NURSING 235 NCLEX prepu practice Exam with Answers

NURSING 235 NCLEX prepu practice Exam with Answers 1. A nurse is teaching a client about type 2 diabetes mellitus. What information would reduce a client's risk of developing this disease? "Maintain weight within normal limits for your body size and muscle mass." The most important factor predisposing to the development of type 2 diabetes mellitus is obesity. Insulin resistance increases with obesity. Cigarette smoking is not a predisposing factor, but it is a risk factor that increases complications of diabetes mellitus. A high-protein diet does not prevent diabetes mellitus, but it may contribute to hyperlipidemia. Hypertension is not a predisposing factor, but it is a risk factor for developing complications of diabetes mellitus. 2. What should the nurse teach a client receiving vitamin D therapy for hypoparathyroidism? Vitamin D is taken to increase absorption of calcium. A client with hypoparathyroidism has a decreased serum calcium level. Variable doses of vitamin D preparations enhance the absorption of calcium from the gastrointestinal tract. This does not cure the client’s hypoparathyroidism. Vitamins A, C, and E are not involved with this process. Vitamin D therapy will not assist in stabilizing potassium. 3. A minister approaches a nurse caring for a client who is a member of the minister’s congregation. The minister inquires as to whether the member has been made aware of his/her diagnosis. Which of the following would be the best response by the nurse? “I understand your concern, but have you asked the client?" The nurse must maintain confidentiality. The minister may mean well but is trying to gather information that is confidential. The nurse should acknowledge the minister’s concern and then suggest asking the client about the reason for hospitalization. This allows the client to share with the minister whatever information the client wants to disclose. The other options are not correct because they do not protect the client’s privacy. Telling the minister that it is not his/her business is not a decision the nurse should be making without discussing the situation with the client. 4. A client experienced a right frontal stroke that left him with short-term memory loss and lack of impulse control. The nurse caring for the client on the previous shift identified him at high risk for falls. While making rounds to begin the shift, a nurse notices the client lying on the floor. The nurse assesses the client and notes no injuries. How should the nurse follow up this incident? Notify the physician, then document the location of the fall, physician notification, any injury, necessary follow-up, and any changes in the care plan needed as a result of the fall. The nurse should notify the physician, then document the facts related to the fall, such as the location of the fall, physician notification, injury if any, necessary follow- up, and any changes in the care plan that occurred as a result of the fall. The nurse shouldn't include any information that places blame on other health care members. The fall must be reported even if the client doesn't suffer an injury. 5. A client seeks medical attention for dyspnea, chest pain, syncope, fatigue, and palpitations. A thorough physical examination reveals an apical systolic thrill and heave, along with a fourth heart sound (S4) and a systolic murmur. Diagnostic tests reveal that the client has hypertrophic cardiomyopathy (HCM). Which nursing diagnosis may be appropriate? Decreased cardiac output Decreased cardiac output is an appropriate nursing diagnosis for a client with HCM because the hypertrophied cardiac muscle decreases the effectiveness of the heart's contraction, decreasing cardiac output. Heart failure may complicate HCM, causing fluid volume excess; therefore, the nursing diagnosis of Risk for deficient fluid volume isn't applicable. Ineffective thermoregulation and Risk for peripheral neurovascular dysfunction are inappropriate because HCM doesn't cause these problems. 6. On admission to the psychiatric unit, a client with major depression reports that a family member is physically abusive and requests that the nurse not release any personal information to anyone. When the allegedly abusive family member calls the unit and demands information about the client's treatment, what is the nurse's best response? "To protect clients' confidentiality, I can't give any information, including whether your relative is receiving treatment here." The client has the right to confidential treatment, and the nurse has a duty to protect his confidentiality. Stating that to protect clients' confidentiality no information will be given is a diplomatic response. Although simply telling the caller that information can't be released protects the client's confidentiality, this response isn't as diplomatic as the first response. Stating that the client isn't accepting phone calls or that the client didn't sign an information form with the caller's name on it divulges the client's whereabouts and status, violating confidentiality. 7. A health care provider is legally and ethically required to disclose certain information. Which confidential information should the nurse disclose? A taxi driver’s diagnosis of an uncontrolled seizure disorder to his licensing agency The health care provider may lawfully disclose confidential information about a client when the welfare of others is at stake. The health care provider is required to inform the Department of Motor Vehicles that the taxi driver has an uncontrolled seizure disorder because it’s in the best interest of the public’s and client’s safety. Confidentiality of HIV testing is required. Disclosing a client’s cancer diagnosis to a significant other or pregnancy to a legally separated partner do not affect the welfare of person. 8. The nurse is inspecting the client's abdomen (see the accompanying image). The nurse should document that the client's abdomen: is flat and symmetrical. The client’s abdomen is flat and without abnormalities. There is no aortic pulsation (motion is client’s breathing). There is no hernia; the umbilicus is normal. There are no markings or lines (striae) on this client’s abdomen 9. When developing a long term care plan for the client with multiple sclerosis, the nurse should teach the client to prevent: contractures. Typical complications of multiple sclerosis include contractures, decubitus ulcers, and respiratory infections. Nursing care should be directed toward the goal of preventing these complications. Ascites, fluid overload, and dry mouth are not associated with multiple sclerosis. 10. A nurse is teaching an elderly client about developing good bowel habits. Which statement by the client indicates to the nurse that additional teaching is required? "I need to use laxatives regularly to prevent constipation." The client requires more teaching if he states that he'll use laxatives regularly to prevent constipation. The nurse should teach this client to gradually eliminate the use of laxatives because using laxatives to promote regular bowel movements may have the opposite effect. A high-fiber diet, ample amounts of fluids, and regular exercise promote good bowel health. 11. A client with newly diagnosed chronic obstructive pulmonary disease (COPD) comes to the clinic for a routine examination. The nurse teaches the client strategies for preventing airway irritation and infection. Which statement by the client best indicates that teaching was successful? “I should avoid using powders.” There are many considerations when a client is diagnosed with COPD. A client with COPD should avoid exposure to powders, dust, and smoke from cigarettes, pipes, and cigars. The client should stay away from crowds should avoid aerosol sprays as a precaution. The client should also obtain immunizations against pneumococcal pneumonia as well as influenza. A combination of measures is needed to maintain the client's highest level of respiratory function. 12. A 15-year-old client is 4 cm dilated and 100% effaced and is in active labor with her first baby. The nurse contacts the physician to communicate the findings of fetal heart rate decelerations, thick meconium in the amniotic fluid, and low fetal scalp pH results. What is the most appropriate nursing action at this time? Prepare the client for an assisted or cesarean birth. Fetal heart decelerations, thick meconium, and low fetal scalp pH indicate severe fetal distress. Because the client is a primigravida and in early labor at 4 cm cervical dilatation, it is unlikely that the baby will tolerate further labor and a vaginal birth. It is prudent for the nurse to begin preparing the client for an assisted or operative birth. While changing maternal position and increasing oxygen availability may enhance placental perfusion and fetal oxygenation, these interventions do not meet the immediate fetal needs. There are no implications that a social worker needs to be involved in the care provided at this particular stage. 13. A client is expecting her second child in 6 months. During the psychosocial assessment, she says to the nurse, "I've been through this before. Why are you asking me these questions?" What is the nurse's best response? "Each pregnancy has a unique psychosocial meaning." With each pregnancy, a woman explores a new aspect of the mother role and must reformulate her self-image as a pregnant woman and a mother. The other options don't address the client's feelings. No evidence suggests that a second pregnancy requires more adjustment. Couvade symptoms occur in the father, not the mother. 14. A client is admitted with a diagnosis of diabetic ketoacidosis. An insulin drip is initiated with 50 units of insulin in 100 ml of normal saline solution administered via an infusion pump set at 10 ml/hour. The nurse determines that the client is receiving how many units of insulin each hour? Record your answer using a whole number. 5 To determine the number of insulin units the client is receiving per hour, the nurse must first determine the number of units in each milliliter of fluid (50 units ÷ 100 ml = 0.5 units/ml). Next, multiply the units per milliliter by the rate of milliliters per hour (0.5 units × 10 ml/hr = 5 units). 15. A client is scheduled for an arteriogram. The nurse should explain to the client that the arteriogram will confirm the diagnosis of occlusive arterial disease by: showing the location of the obstruction and the collateral circulation. An arteriogram involves injecting a radiopaque contrast agent directly into the vascular system to visualize the vessels. It usually involves computed tomographic scanning. The velocity of the blood flow can be estimated by duplex ultrasound. The client’s ankle-brachial index is determined, and then the client is requested to walk. The normal response is little or no drop in ankle systolic pressure after exercise. 16. The nurse is preparing a teaching plan about increased exercise for a female client who is receiving long-term corticosteroid therapy. What type of exercise is most appropriate for this client? Walking The best exercise for females who are on long-term corticosteroid therapy is a low-impact, weightbearing exercise such as walking or weight lifting. Floor exercises do not provide for the weightbearing. Stretching is appropriate but does not offer sufficient weightbearing. Running provides for weightbearing but is hard on the joints and may cause bleeding. 17. A nurse administers albuterol, as ordered, to a client with emphysema. Which finding indicates that the drug is producing a therapeutic effect? Respiratory rate of 22 breaths/minute In a client with emphysema, albuterol is used as a bronchodilator. A respiratory rate of 22 breaths/minute indicates that the drug has achieved its therapeutic effect because fewer respirations are required to achieve oxygenation. Albuterol has no effect on pupil reaction or urine output. It may cause a change in the heart rate, but this is an adverse, not therapeutic, effect. 18. A neonate is experiencing respiratory distress and is using a neonatal oxygen mask. An unlicensed assistive personnel has positioned the oxygen mask as shown. The nurse is assessing the neonate and determines that the mask: is appropriate for the neonate. The correct size covers the nose but not the eyes. The mask is too large if it covers the neonate’s eyes. Masks that are too small may pinch the nose. Masks should fit snugly against the cheeks and chin. It is not necessary to cover the mask with a soft cloth. If the mask fits snugly, it will not be as likely to rub the skin. 19. A nurse is caring for a client with end-stage heart failure who is awaiting a heart transplant. The client tells the nurse that he thinks he's going to die before a donor heart is found. He also tells the nurse that he hasn't been attending a church but wants to talk with a priest. What action should the nurse take? Contact the clergy member who is assigned to the transplant team. Each multidisciplinary transplant team has a clergy person assigned. The nurse should contact that person and request that he visit the client. It isn't appropriate for the nurse to ask her priest to see the client. Telling the client that he has nothing to worry about because donors are typically found offers false reassurance. Telling the client that it doesn't matter if he attends a church invalidates the client's concern. 20. A nurse is providing instruction to a 38-year-old male client undergoing treatment for anxiety and insomnia. The practitioner has prescribed lorazepam 1 mg/po/tid. The nurse determines that teaching has been effective when the client states: “I’ll avoid coffee.” Lorazepam is a benzodiazepine used to treat various forms of anxiety and insomnia. Caffeine is contraindicated because it is a stimulant and increases anxiety. A client taking lorazepam should avoid alcoholic beverages. Clients taking certain antipsychotic medications should avoid sunlight. Salt intake has no effect on lorazepam. 21. In a care conference, the social worker is asking if a psychosocial assessment has been completed. Which areas would the nurse report on as part of this assessment? Health habits, family relationships, affect, and thought patterns A psychosocial assessment involves assessment of health habits, family relationships, emotional responses, and thought patterns. These areas are important to assess to determine how the client is coping with illness. It is also important to identify the support systems of the client. Each of the other choices includes physical assessment factors, not just psychosocial factors. 22. A client with type I diabetes mellitus is scheduled to have surgery. The client has been nothing-by-mouth (NPO) since midnight. In the morning, the nurse notices the client’s daily insulin has not been prescribed. Which action should the nurse do first? Obtain the client's blood glucose at the bedside. The nurse should contact the health care provider and clarify whether the client’s usual insulin dose should be given before surgery; having the blood glucose level is objective information that the health care provider may need to know before making a final decision as to the insulin dosage. The nurse should not assume that the usual insulin dose is to be given. It is not appropriate for the nurse to defer decision making on this issue until after surgery. 23. A day-shift nurse on the pediatric neurologic unit has just received a report from the previous shift. Which infant should the nurse assess first? A restless infant with a high-pitched cry who was transferred from the intensive care unit (ICU) the previous evening An infant's restlessness and high-pitched cry can indicate increased intracranial pressure (ICP). Because the infant was transferred from the ICU the previous night, assessing for increased ICP should be a nursing priority. The infant with a pulse of 140-160 bpm exhibits normal parameters. Although the nurse must assess a low-grade fever on the third postoperative day, this stable infant isn't the priority at this time. Decreased respirations are indicative of increased intracranial pressure, but this infant's respirations of 38 breaths per minute would not be a priority concern. 24. During the immediate postpartum period, the nurse is caring for a primipara who gave birth to a postterm neonate after an oxytocin induction. When developing the client’s plan of care, which problem should the nurse expect to assess for frequently? Uterine atony uterine atony is more common in clients who have received oxytocin during labor because the uterine muscle becomes fatigued and does not contract effectively to compress the vessels at the placental site. Respiratory depression, not typically associated with oxytocin induction, may occur with narcotic overdose or excessive magnesium sulfate administration. Increased pulse rate and hypertension are not typically associated with oxytocin induction during labor 25. When preparing discharge instructions for a client after an abdominal hysterectomy, the nurse should first: assess the client's available social supports. Assessment is the first step in planning client education. Assessing social support resources is a key aspect of discharge planning that begins when the client is admitted to the hospital. It is imperative to know what assistance and support the client has at home. Assessment includes obtaining data about any family or home responsibilities the client is concerned with during the recovery period. It is within the scope of nursing practice to provide discharge instructions. A social worker is not needed at this time. The nurse should assess the client’s needs before determining whether using a video or reading instructions to the client is appropriate. 26. A nurse is caring for a client that received a colostomy 2 days ago. Which is the priority intervention? Assess the drainage from the stoma. Assessing the stoma is important because of the potential for surgical site infection. Teaching on irrigation and dietary planning should be performed before discharge. The client should be encouraged to look at the stoma, but this is not the priority. 27. A nurse is preparing to administer an I.V. containing dextrose 10% in ¼ normal saline solution to a 6-month-old infant. The nurse should select which tubing to safely administer the solution? I.V. tubing with a volume-control chamber Because infants have a small circulating blood volume, inadvertent administration of extra I.V. fluid can cause fluid volume excess. To prevent this from occurring, I.V. tubing with a volume-control chamber should always be used for infants and children to closely regulate the amount of fluid infused. The volume-control chamber should be filled only with enough I.V. fluid for the next two 2 hours. A microdrip chamber that allows for 60 drops/ml (as opposed to a macrodrip chamber, which allows for 10 to 20 drops/ml, depending on the manufacturer) should be used to infuse the smaller amounts of I.V. fluids an infant needs. A filter is typically used only for the administration of total parenteral nutrition and certain blood products. Standard I.V. tubing for adults should be avoided for infants because of the inability to closely regulate the amount of fluid infused. 28. A client in the emergency department is diagnosed with a communicable disease. When complications of the disease are discovered, the client is admitted to the hospital and placed in respiratory isolation. Which infection warrants airborne isolation? Measles Measles warrants airborne isolation, which aims to prevent transmission of disease by airborne nuclei droplets. Other infections necessitating respiratory isolation include varicella and tuberculosis. The mumps call for droplet isolation; impetigo, contact isolation; and cholera, enteric isolation. 29. The nurse observes a family member of a client who is on contact precautions enter and exit the client's room without performing hand hygiene. What is the nurse's most appropriate action? Offer to show family members how to perform hand hygiene using soap and water or alcohol rub. The nurse should address the family member's oversight and promote infection control, but in a way that is nonconfrontational. Offering to show the family members how to perform hand hygiene achieves these goals. Moving signage may not result in a behavior change. Speaking about hospital-acquired infections may not result in improved hand hygiene. 30. A healthy client comes to the clinic for a routine examination. When auscultating his lower lung lobes, the nurse should expect to hear which type of breath sound? Vesicular Vesicular breath sounds are soft, low-pitched sounds normally heard over the lower lobes of the lung. They're prolonged on inhalation and shortened on exhalation. Bronchial breath sounds are loud, high-pitched sounds normally heard next to the trachea; discontinuous, they're loudest during expiration. Tracheal breath sounds are harsh, discontinuous sounds heard over the trachea during inhalation or exhalation. Bronchovesicular breath sounds are medium-pitched, continuous sounds that occur during inhalation or exhalation. They're best heard over the upper third of the sternum and between the scapulae. 31. The nurse advises a client recovering from a myocardial infarction to decrease fat and sodium intake. Which foods should the nurse instruct the client to avoid? Select all that apply. Pepperoni pizza, Bacon, Cheese, Soft drinks Foods high in sodium include cheese, processed meats such as pepperoni and bacon, and soft drinks. Bacon and cheese also have a high fat content. 32. During the evening shift on the day of a client’s bowel resection surgery, the nasogastric (NG) tube drains 500 mL of green-brown fluid. The nurse should: record the amount of drainage on the client’s chart. Because peristalsis has not been reestablished, this amount of gastric drainage would be expected. The green-brown color would also be expected. The appropriate nursing action is to chart the amount and color of output and continue monitoring the client. There is no need to notify the health care provider or to provide additional IV fluids. A patent NG tube does not require irrigation. 33. The nurse is instructing a client about skin care while receiving radiation therapy to the chest. What should the nurse instruct the client to do? Wash the area with tepid water and mild soap. Clients receiving radiation experience dryness or redness in the area of the radiation. The nurse instructs the client to wash the area with soap and water and keep the area dry. The client does not apply lotion, shave, or cover the area. 34. Which night clothes would the nurse recommend for an infant with atopic dermatitis? one-piece cotton pajamas with long sleeves. Atopic dermatitis results in pruritus. The infant’s skin should be covered as completely as possible to keep him from scratching himself. Cotton is the preferred material because it allows the skin to breathe and moisture to evaporate. A short-sleeved shirt would be inappropriate because the infant could scratch the uncovered arms, exacerbating the condition. Flannel may be too warm, causing the child to perspire, which will aggravate the condition. Because atopic dermatitis is commonly associated with allergies, wool garments should be avoided. 35. A nurse is caring for a client with cirrhosis. The nurse assesses the client at noon and discovers that the client is difficult to arouse. The client's morning ammonia level is 110 mcg/dl. The nurse should suspect which situation? The client's hepatic function is decreasing. The decreased level of consciousness caused by an increased serum ammonia level indicates hepatic disfunction. If the client didn't take his morning dose of lactulose, he wouldn't have elevated ammonia levels and decreased level of consciousness this soon. These assessment findings are not indicative of reduced renal filtration. 36. A client who is very depressed exhibits psychomotor retardation, a flat affect, and apathy. The nurse observes the client to be in need of grooming and hygiene. Which nursing action is most appropriate? stating to the client that it is time for him to take a shower The client with depression is preoccupied, has decreased energy, and cannot make decisions, even simple ones. Therefore, the nurse presents the situation, “It is time for a shower,” and assists the client with personal hygiene to preserve his dignity and self-esteem. Explaining the importance of good hygiene to the client is inappropriate because the client may know the benefits of hygiene but is too fatigued and preoccupied to pay attention to self-care. Asking the client if he is ready for a shower is not helpful because the client with depression commonly cannot make even simple decisions. This action also reinforces the client’s feeling about not caring about showering. Waiting for the family to visit to help with the client’s hygiene is inappropriate and irresponsible on the part of the nurse. The nurse is responsible for making basic decisions for the client until the client can make decisions for himself. 37. A client with type 1 diabetes mellitus is conscious but confused, weak, diaphoretic, and is having heart palpitations. What is the nurse’s priority action? Provide 15 to 20 grams of a fast-acting oral carbohydrate The client is exhibiting signs of hypoglycemia. Since the client is conscious, the first intervention is to give a fast-acting oral carbohydrate, such as orange juice, hard candy, or honey. If the client becomes unconscious, the nurse would administer IM or subQ glucagon or dextrose 50% IV if access is available. Administering insulin wouldn’t be appropriate because the client is experiencing hypoglycemia 38. A client tells the nurse about having numbness from the back of the left buttock to the dorsum of the foot and big toe. The client is scheduled to undergo a laminectomy, and the operative consent form states “a left lumbar laminectomy of L3–L4.” What should the nurse do next? Call the surgeon. surgery. The client’s comments indicate radiculopathy of L4–L5, but the informed consent form states L3–L4. Radiculopathy of L3–L4 involves pain radiating from the back to the buttocks to the posterior thigh to the inner calf. The nurse must act as a client advocate and not ask the client to sign the consent until the correct procedure is identified and confirmed on the consent. The nurse has no legal authority or responsibility to change the consent. The history is a source of information, but when the client is coherent and the history is contradictory, the health care provider (HCP) should be contacted to clarify the situation. Ultimately, it is the surgeon’s responsibility to identify the site of surgery specified on the surgical consent form. 39. A client is at risk for excess fluid volume. Which nursing intervention ensures the most accurate monitoring of the client's fluid status? Weighing the client daily at the same time each day Increased fluid volume leads to rapid weight gain — 2.2 lb (1 kg) for each liter of fluid retained. Weighing the client daily at the same time and in similar clothing provides more objective data than measuring fluid intake and output, which may be inaccurate because of omitted measurements such as insensible losses. Changes in vital signs are less reliable than daily weight because these changes usually are subtle during early stages of fluid retention. Weight gain is an earlier sign of excess fluid volume than crackles, which represent pulmonary edema. The nurse should plan to detect fluid accumulation before pulmonary edema occurs. 40. A client at 28 weeks gestation is admitted to the maternity unit in preterm labor. The client asks the nurse if there is anything that can be done to stop the preterm labor. Which one of the following is the most appropriate response from the nurse? "A cerclage may be performed depending on the competency of your cervix.” A cerclage is a surgical procedure where a stitch is placed by the physician in the cervix to prevent a spontaneous abortion or premature birth. The physician would have to determine the competency of the cervix, cervical dilation, and placement of the amniotic sac to determine whether the procedure is an option to stop progression of the birth. This is a potential option for the family. A 28-week fetus is considered viable and responding about confirming the viability of the fetus is not therapeutic at this time. Coordinating other family members to come into the hospital for support is an important response, but not the first response from the nurse. 41. A client is being discharged with a prescription for enoxaparin. What will the nurse document to address that medication teaching occurred? Select all that apply. The client’s response to teaching, The client knows the time for the next dose, The client can select a site for injection, The client knows adverse effects such as bleeding, bloody or black stools. The nurse has a legal duty to do teaching with the client including reporting adverse effects such as bleeding, bloody or black stools. The nurse will document client’s ability to select site for injection and the client’s response to teaching as well as confirming the next scheduled dose with client. The client’s ability to pay for the medication is not part of the teaching obligation. 42. The nurse is educating a woman with type 2 diabetes from France who speaks English as a second language. What behavior(s) alerts the nurse to a possible lack of communication of the educational material? Select all that apply. asking questions about shopping, laughing at some of the brochures, looking away from the speaker Some of the behaviors which indicate that the client is not understanding the nurse’s teaching are: asking inappropriate questions to change the subject, laughing to disguise embarrassment, and looking away from the speaker. Taking notes and writing down medical terms are positive behaviors indicating that the client is engaged in learning. 43. A client in the postanesthesia care unit with a left below-the-knee amputation has pain in the left big toe. What should the nurse do first? Give the client the prescribed opioid analgesic. The nurse’s first action should be to administer the prescribed opioid analgesic to the client because this phenomenon is phantom sensation and interventions should be provided to relieve it. Pain relief is the priority. Phantom sensation is a real sensation. It is incorrect and inappropriate to tell a client that it is impossible to feel the pain. Although it does relieve the client’s apprehensions to be told that phantom sensations are a real phenomenon, the client needs prompt treatment to relieve the pain sensation. Usually phantom sensation will go away. However, showing the client that the toes are not there does nothing to provide the client with relief. 44. An infant is diagnosed with a congenital hip dislocation. On assessment, the nurse expects to note: Ortolani's sign In a child with a congenital hip dislocation, assessment typically reveals Ortolani's sign, asymmetrical thigh and gluteal folds, limited hip abduction, femoral shortening, and Trendelenburg's sign. 45. A client with colon cancer is having a barium enema. The nurse should instruct the client to take which type of medication after the procedure is completed? Laxative After a barium enema, a laxative is ordinarily prescribed. This is done to promote elimination of the barium. Retained barium predisposes the client to constipation and fecal impaction. Anticholinergic drugs decrease gastrointestinal motility. Antacids decrease gastric acid secretion. Demulcents soothe mucous membranes of the gastrointestinal tract and are used to treat diarrhea. 46. A 1-month-old infant in the neonatal intensive care unit is dying. His parents request that a nurse give the infant an opioid analgesic. The infant's heart rate is 68 beats/minute and his respiratory rate is 18 breaths/minute. He is on room air; oxygen saturation is 92%. The nurse's response to the parents' request should be based on the fact that: providing an analgesic during the last days and hours is an ethically appropriate nursing action. The nurse's action should be based on the fact that all clients, regardless of age, have the right to die with dignity and to be free of pain. Assisted suicide requires some action on the part of the client, which isn't possible in the case a 1-month-old infant. The parent's decision doesn't eliminate the nurse's ethical obligation to the infant and to the nursing profession. Withholding the opioid analgesic isn't appropriate because it isn't known that administering the drug would hasten death in this case. 47. The client asks the nurse if surgery is needed to correct a hiatal hernia. Which reply by the nurse would be most accurate? "Hiatal hernia symptoms can usually be successfully managed with diet modifications, medications, and lifestyle changes." Most clients can be treated successfully with a combination of diet restrictions, medications, weight control, and lifestyle modifications. Surgery to correct a hiatal hernia, which commonly produces complications, is performed only when medical therapy fails to control the symptoms. 48. A client with pancreatitis returns from an endoscopic retrograde cholangiopancreatography (ERCP). Which assessment would be of most concern to the nurse? Poor gag reflex A poor gag reflex may lead to inability of the client to handle oral secretions and lead to decreased oxygen saturation. Upper abdominal pain is expected from the injection of CO2 to visualize the duodenum. Retrograde amnesia is expected from conscious sedation and a sore throat is expected from the endoscope being inserted during the procedure. 49. A client with a deep vein thrombosis has heparin sodium infusing at 1,500 units/hour. The concentration of heparin is 25,000 units/500 mL. If the infusion remains at the same rate for a full 12 hour shift, how many milliliters of fluid will infuse? Record your answer using a whole number. 360 25,000 u/500 ml = 50 units/ml. 1 ml/50 units x 1500 units/hour = 30 ml/hour x 12 hours = 360 ml 50. The nurse is planning care for a client with osteomyelitis. The client is taking an antibiotic, but the infection has not resolved. The nurse should advise the client to: eat a diet high in protein and vitamins C and D. The goal of care for this client is healing and tissue growth while the client continues on long-term antibiotic therapy to clear the infection. A diet high in protein and vitamins C and D promotes healing. Herbal supplements may potentiate bleeding (e.g., ginkgo, ginger, tumeric, chamomile, kelp, horse chestnut, garlic, and dong quai) and have not been proven through research to promote healing. Frequent passive motion will increase circulation but may also aggravate localized bone pain. It is not appropriate to advise the client to change antibiotics as treatment may take time. 51. During a prenatal visit, the client has told the nurse that she intends to give birth at a spiritual retreat center that is distant from population centers or health care facilities. What is the nurse's best response? "It sounds like you have given this a lot of consideration. What is it about giving birth there that will be special for you?" Asking about what the woman hopes to gain or experience is an empathic and therapeutic way of initiating dialogue about this client's decision. Offering a warning will likely sever any follow-up discussion. Ultimately, clients do not need permission to enact a care plan. Acknowledging that nonhospital births are increasingly common is appropriate, but it is helpful to follow a statement with a question. 52. A nurse is caring for a client declared brain dead following a motor vehicle accident. When the nurse enters the client's room, his spouse and family are talking with friends about the possibility of organ donation. Which statement by the nurse reflects an ethical practice dilemma? "If you're thinking about organ donation, my sister is waiting for a kidney transplant. She'd be an excellent recipient. I can give you her phone number." The nurse demonstrates unethical behavior when she discusses personal information with the client's family and suggests her sister as an organ recipient. Offering to find resources, answer questions, and provide support to the client's family are within the scope of nursing practice. 53. What is a crucial goal of therapeutic communication when helping the client deal with personal issues and painful feelings? conveying client respect and acceptance even if not all of the client's behaviors are tolerated The nurse is required to set limits on inappropriate behavior while conveying respect and acceptance of that person. Doing so conveys to the client that he is worthy without posing any harm or embarrassment to the client. Touch is a complex issue that must be used cautiously. Touch may be misinterpreted or misperceived by a client who has been abused or who has perceptual or thought disturbances. Mutual sharing reflects a social friendship, not a therapeutic one. Total confidentiality is not desirable. For example, treatment team members and insurance companies need selected information to ensure quality services. 54. A 4-year-old has just returned from surgery. He has a nasogastric (NG) tube in place and is attached to intermittent suction. The child says to the nurse, "I'm going to throw up." What should the nurse do first? Irrigate the NG tube to ensure patency. The nurse should first irrigate the NG tube because if the tube isn't draining properly or is kinked, the child will experience nausea. There's no reason to notify the physician immediately because a nurse should be able to handle the situation. Giving the child an antiemetic doesn't really address the problem. Encouraging the mother to calm the child is always a good intervention but isn't the first thing to do in this case. 55. During the initial assessment of a child admitted to the pediatric unit with osteomyelitis of the left tibia, when assessing the area over the tibia, which is an expected finding? increased warmth Findings associated with osteomyelitis commonly include pain over the area, increased warmth, localized tenderness, and diffuse swelling over the involved bone. The area over the affected bone is red. 56. The nurse is caring for an infant admitted with a severe respiratory infection. The nurse is explaining the risk of airway obstruction and the need for frequent respiratory assessments to the parents. Which of the following statements by the nurse is most appropriate regarding the risk of airway obstruction? “The infant’s larger tongue and smaller oral cavity increase the risk of airway obstruction.” The relatively larger tongue and smaller oral cavity of a child means that the tongue is more likely to obstruct the airway and increase resistance to airflow than in an adult. A flattened rib wall, thin chest wall, and rapid respiratory rate are all accurate descriptions of a pediatric population but they do not potentially put the child at the greatest risk for airway obstruction. 57. A client arrives to the emergency department with suspected appendicitis. The admitting nurse performs an assessment. Order the following steps according to the sequence in which they are performed. All options must be used. Obtain a health history. Inspect the abdomen, noting the shape, contours, and any visible peristalsis or pulsations. Auscultate bowel sounds in all four quadrants. Percuss all four abdominal quadrants. Gently palpate all four quadrants, saving the painful area for last. The first step in the data collection process is to obtain a health history. Then, the nurse would visually inspect the abdomen. Of the three remaining steps, it is important to auscultate before percussing or palpating the client’s abdomen. Touching or palpating the abdomen before listening may actually change the bowel sounds, leading to faulty data. 58. After an amniotomy, which client goal should take the highest priority? The client will maintain adequate fetal tissue perfusion. Amniotomy increases the risk of umbilical cord prolapse, which would impair the fetal blood supply and tissue perfusion. Because the fetus's life depends on the oxygen carried by that blood, maintaining fetal tissue perfusion takes priority over goals related to increased knowledge, infection prevention, and pain relief. 59. A client’s chest tube accidentally disconnects from the drainage tube. The nurse should first: clamp the chest tube. When a chest tube becomes disconnected, the nurse should take immediate steps to prevent air from entering the chest cavity, which may cause the lung to collapse. Therefore, when a chest tube is accidentally disconnected from the drainage tube, the nurse should either double clamp the chest tube as close to the client as possible or place the open end of the tube in a container of sterile water or saline solution. The nurse can then notify the health care provider. First priority must be given to clamping the chest tube. Covering the disconnected chest tube with a dressing does not prevent air from entering the chest cavity. Reconnecting the tube may allow air to enter the chest cavity. 60. The nurse in an inpatient psychiatric adult unit is assigned care for a group of clients. Which client would the nurse see first during morning rounds? A client admitted to the hospital for agitation and paranoia The client admitted to the hospital for agitation and paranoia needs to have the most immediate assessment. The nurse must establish whether the client is a danger to himself/herself or to others on the unit. The client to be discharged is the most stable and can be assessed at a later time. The client with depression who refused his/her medication is a concern, but there is no indication of acute safety concerns. The client with dementia who has not communicated would not be outside the normal course when the environment of a client with advanced dementia is changed. The nurse must do a further cognitive and neurologic exam. 61. The nurse is performing a complete neurological assessment on an older adult client. Which question by the nurse would best assess cerebral function? "Have you noticed a change in your memory?" To assess cerebral function, the nurse should ask about the client's level of consciousness, orientation, memory, and other aspects of mental status. Questions about muscle strength help evaluate the client's motor system. Questions about coordination help her assess cerebellar function. Questions about eyesight help the nurse evaluate the cranial nerves associated with vision.