Hurst Readiness Exam 4 questions and answers graded A+ 100%

Hurst Readiness Exam 4 questions and answers graded A+ 100% Which client must the nurse assign to a private room? You answered this question Correctly 1. Primiparous client who delivered twins at 28 weeks gestation two days ago 2. Postpartum client on IV Ampicillin and Gentamicin for chorioamnionitis 3. Postpartum client whose 2 hour old infant is being worked up for sepsis 4. Postpartum client 32 hours after delivery with a temperature of 101º F (38.05 ° C) - RationaleStrategies 4. Correct: A temperature of 100.5° F (38.05° C) or greater in a client more than 24 hours postpartum is likely an indication of infection. This client should be kept separate from other mothers and babies. 1. Incorrect: The preterm twins are in the NICU and not in their mother's room (a client with term twins would need a private room because of space considerations). 2. Incorrect: Chorioamnionitis is not contagious. 3. Incorrect: The infant may have an infection and will remain in the NICU. The mother is not infected. Post thyroidectomy, the nurse assesses the client for complications by performing which assessment? You answered this question Correctly 1. Perform blood glucose monitoring every 6 hours 2. Check for a positive Chvostek's 3. Assess swallowing reflex 4. Monitor neck dressings for change in fit and comfort 5. Administer desmopressin per nasal spray for urinary output (UOP) greater than 200 mL/hr - RationaleStrategies 2., 3., & 4. Correct: A positive Chvostek's and Trousseau's is indicative of tetany (low calcium). This can occur when one or more of the parathyroids are accidently removed when the thyroid is removed. A weak, raspy voice, swallowing difficulty, and impaired respiratory status can be caused by nerve injury. Change in fit and comfort of the dressing can indicate possible neck swelling, which can affect the airway. 1. Incorrect: A possible complication of a thyroidectomy is to remove one or more parathyroid glands. The parathyroids' action is to regulate the serum calcium levels. The parathyroid does not regulate the blood glucose levels. 5. Incorrect: The action of desmopressin is to increase the reabsorption of water in the kidney. A decrease in vasopressin, (antidiuretic hormone) is not a complication of a thyroidectomy. A client diagnosed with pancreatitis becomes increasingly restless, confused and has pulled out the NG tube and IV catheter. HR-128/min, BP 96/62. Oxygen saturation = 90%. Skin is cool and clammy to touch. Prioritize the actions that the nurse should take. You answered this question IncorrectlyThe Correct Order Initiate oxygen. Insert another IV line. Obtain blood sugar level. Insert NG tube. Repeat vital sign checks Your Selected Order Repeat vital sign checks Initiate oxygen. Obtain blood sugar level. Insert NG tube. Insert another IV line. - RationaleStrategies First, initiate oxygen. The client is anxious and has tachycardia, signs of hypoxia. The BP is also low, so the client might be bleeding internally. If there is a decreased circulating blood volume then there is less hemoglobin to carry oxygen, so increasing the available oxygen will help the client until the problem is corrected. Second, get the IV started so fluid resuscitation can continue.This increased volume will improve the blood pressure. More volume, more pressure. The IV will also provide a port for needed medications. Third, check the client's blood sugar. Since the pancreas is sick, insulin production can be decreased so glucose can go up. This is next in the priority line of the available options. You have addressed air and circulation, so blood glucose would be next. Fourth, insert the NG tube so that the client can be kept empty and dry and you can prevent aspiration if the client starts vomiting. Last, recheck vital signs to assess effectiveness of your nursing actions. What is the best instruction the nurse should provide when administering acetylsalicylic acid 81 mg to a client experiencing severe, crushing chest pain radiating up the left jaw? You answered this question Correctly 1. Chew the acetylsalicylic acid prior to swallowing. 2. Place the acetylsalicylic acid under the tongue so that it can dissolve. 3. Swallow the acetylsalicylic acid tablet. 4. Insert the acetylsalicylic acid between the cheek and gum for greater absorption. - RationaleStrategies 1. Correct: Acetylsalicylic acid has been shown to decrease mortality and re-infarction rates after MI. The fastest way to get the aspirin into the circulatory system is to have the client chew the acetylsalicylic acid prior to swallowing. 2. Incorrect: Nitroglycerin is administered sublingual (SL) or buccal. Initially acetylsalicylic acid is administered by chewing the tablet or swallowing the tablet. 3. Incorrect: If a solid dose pill is prescribed, the pill should be chewed. Faster absorption is obtained from chewing, rather than swallowing acetylsalicylic acid. 4. Incorrect: Nitroglycerin is administered SL or buccal. Initially acetylsalicylic acid would be chewed to increase the absorption rate. A client who has developed hypovolemic shock is receiving albumin. What assessment finding by the nurse indicates that the albumin has been effective? You answered this question Correctly 1. Swelling in the legs 2. Increase in uninary output 3. Proteinuria 4. Increase in waist measurement - RationaleStrategies 2. Correct: The action of albumin is to increase the serum albumin level. When the albumin level increases there is a shift of fluid from extracellular to intracellular. This action will result in an increase in urinary output. 1. Incorrect: This is a symptom of hypoalbuminemia. There is a shift in the fluid from intracellular to extracellular. This results in the swelling of the legs. 3. Incorrect: Hypoalbuminemia may cause damage to the kidneys. Proteinuria is indicative of renal disease or damage. 4. Incorrect: There may be a increased accumulation of fluid in the abdomen. The ascites is due to the decreased albumin level in the vascular space, which also causes damage to the liver. A nurse is attempting to develop trust with a psychiatric client exhibiting concrete thinking. Which nursing intervention would promote trust in this individual? You answered this question Incorrectly 1. Attend an activity with the client who is reluctant to go alone. 2. Allow the client to break an insignificant rule. 3. Consider client preferences when possible in decisions concerning care. 4. Provide a blanket when the client is cold. 5. Provide food when the client is hungry. - RationaleStrategies 1., 3., 4. & 5. Correct: Trust is demonstrated through nursing interventions that convey a sense of warmth and care to the client. These interventions are initiated simply, concretely, and directed toward activities that address the client's basic needs for physiological and psychological safety and security. Concrete thinking focuses thought processes on specifics, rather than generalities, and immediate issues, rather than eventual outcomes. Examples of nursing interventions that would promote trust in an individual who is thinking concretely include such things as: providing a blanket when the client is cold, providing food when the client is hungry, keeping promises, being honest, providing a written, structured schedule of activities, attending activities with the client if he is reluctant to go alone, being consistent in adhering to unit guidelines, and taking the client's preferences, requests, and opinions into consideration when possible in decisions concerning care. 2. Incorrect: The client should be informed of all rules, simply and clearly, with reasons for certain policies and rules. Be consistent and provide written, structured, scheduled activities. Allowing a client to break a rule would not encourage them to think about the outcomes of their actions. A charge nurse is planning care for several clients on the unit. Which activities can the nurse safely delegate to an unlicensed assistive personnel (UAP)? You answered this question Incorrectly 1. Administer a nebulizer treatment to a client diagnosed with pneumonia. 2. Obtain vital signs on a postoperative client who required naloxone 5 minutes ago. 3. Report a urinary output (UOP) less than 50 ml/hr on a post-op client. 4. Assist a client with obtaining a clean catch urine sample. 5. Remove an indwelling urinary catheter from a client. - RationaleStrategies 3., & 4. Correct: A UAP can report the amount of UOP but cannot interpret it. A clean catch urine sample is a noninvasive procedure. The UAP can assist the client to obtain the clean catch urinary sample. Both activities are the right person and right task of delegation. 1. Incorrect: A UAP cannot administer medications. This is the wrong task for an UAP. 2. Incorrect: The client received naloxone to reverse the action of an opioid medication. A UAP should not be assigned to obtain vital signs on an unstable client. This is the wrong person to perform removal of an indwelling urinary catheter. 5. Incorrect: A UAP cannot remove an indwelling urinary catheter. Which interventions should the nurse initiate to lessen acid reflux in a client diagnosed with gastroesophagel reflux disease (GERD)? You answered this question Correctly 1. Provide small, frequent meals. 2. Avoid carbonated beverages. 3. Administer omeprazole as prescribed. 4. Assist with smoking cessation. 5. Place in left lateral position for 2 hours after eating. - RationaleStrategies 1., 2., 3., & 4. Correct: All of these actions are correct to help alleviate dyspepsia. When a client has GERD, the stomach's contents reflux into the esophagus. Small frequent meals will decrease possible reflux by decreasing the stomach content. Smoking can relax the lower muscle of the esophagus. Drinking a carbonated drink may cause the stomach to expand. Both smoking and drinking a carbonated drink increase the potential of reflux. The action of omeprazole is to reduce the acid that is produced in the stomach. 5. Incorrect: The client should be positioned with the head of the bed (HOB) elevated for 2-3 hours after eating. This position will decrease the potential for esophageal reflux. A nurse from the neonatal unit is transferred to the adult medical-surgical unit. Which client should the charge nurse assign to the neonatal nurse? You answered this question Incorrectly 1. Undergoing surgery for placement of a central venous catheter. 2. Diagnosed with leukemia, hospitalized for induction of high-dose chemotherapy. 3. Receiving IV heparin for left leg thrombosis. 4. Admitted with a cerebrovascular accident. - RationaleStrategies 1. Correct: This is the most stable client to give to the nurse who was transferred from the neonatal unit. A neonatal nurse cares for central lines daily in this specialty area and can transfer this knowledge to the adult client. 2. Incorrect: This is not a good client for a neonatal nurse because knowledge of lab values, chemotherapy precautions, protective isolation and chemotherapy drugs is required for the nurse in order to care for this client. 3. Incorrect: This is not the best client for a neonatal nurse because thrombosis problems are not commonly seen in the nursery. Monitoring clotting factors and being aware of signs and symptoms of pulmonary emboli are essential for safe care of this client. 4. Incorrect: This client is very unstable and requires skilled observation and assessment using the Glasgow Scale. This level of assessment is not utilized in a neonatal unit. The nurse is providing care to a client who has a large abdominal dressing. Which intervention is most likely to reduce the risk of skin irritation due to frequent dressing changes? You answered this question Correctly 1. Use a paper tape for adhering the dressing. 2. Use tape sparingly. 3. Secure the dressing with Montgomery straps. 4. Change the dressing only if it becomes saturated with drainage. - RationaleStrategies 3. Correct: Montgomery straps will allow the dressing to be held in place without the use of tape. The adhesive on the ends of the straps is the only adhesive used. 1. Incorrect: Paper tape may be less irritating; however, with repeated changes, skin irritation is more likely. Montgomery straps will decrease the repeated tape changes. 2. Incorrect: Use of the tape should be sufficient to secure the dressing and applied in a way to allow mobility if placed over a joint. There still is an increase of skin irritation from applying the tape. 4. Incorrect: The soiled dressing is a medium for bacteria growth. The dressing should be changed as ordered or required. A newborn in a neonatal unit is to receive penicillin G benzathine 50,000 units/kg intramuscularly (IM). The newborn weighs 6 lbs (2.7 kg). The dispensed dose is 25,000 units per 1 mL. What should the nurse do? You answered this question Incorrectly 1. Administer the drug intravenously (IV) since a large volume is required. 2. Choose three A client with a history of increasing dyspnea over the past week comes to the emergency department. After arterial blood gases (ABGs) are drawn, which information would be important for the nurse to document? You answered this question Correctly 1. The client had not been NPO prior to the test. 2. The client was on 2 L of oxygen by nasal canula. 3. Lung sounds are wet. 4. Client is sitting in upright position. - RationaleStrategies 2. Correct: The fact that the client is on 2 L/min of oxygen will affect the analysis of the ABG results. If the client is on oxygen, the partial pressure of oxygen (PO2) will be elevated due to the increased inhaled oxygen. 1. Incorrect: Whether the client has eaten or been NPO will not affect the evaluation of the ABG results. 3. Incorrect: An assessment of the client's lung sounds must be performed for a client with a history of dyspnea. This assessment will not directly affect the ABGs result. 4. Incorrect: The client's position will not directly affect the evaluation of the ABG results. injection sites and give the medication as prescribed. 3. Consult with the pharmacy for a different medication concentration. 4. Read the available drug information to determine how to administer the medication. - RationaleStrategies 3. Correct: The nurse must consult with the pharmacy to receive further instructions. The dose is greater than the allowed volume to be given IM, which warrants clarification by the pharmacy. 1. Incorrect: Since the drug is prescribed IM, the route should not be changed to IV administration because this violates the prescription as written. 2. Incorrect: The dose is greater than the allowed volume to be given IM, which warrants clarification by the pharmacy. You want to avoid having to give three injections. 4. Incorrect: The concern is not drug information or administration; it is the concentration, which can only be provided by the pharmacy. A nurse is preparing to conduct a presentation on barriers to therapeutic communication with clients from a culture other than the nurse's culture. Which points should the nurse include in the presentation? You answered this question Incorrectly 1. Lack of knowledge about a client's culture is a major barrier to therapeutic communication. 2. Follow cultural beliefs when caring for all clients of that particular culture. 3. Ethnocentrism facilitates therapeutic communication. 4. Do not touch the client until you know what the cultural belief is about touching. 5. Adapt care to client's cultural needs and preferences. - RationaleStrategies 1., 4. & 5. Correct: Nurses must understand and take into consideration the cultural differences of their clients. Some cultures do not approve of touching or shaking hands. By assessing the client's culture preference, the nurse is able to provide individualized care. 2. Incorrect: Do not stereotype all clients of a certain culture. Ask questions. Allow for individuality. To provide culturally competent care, the nurse must recognize individual preferences within the client's culture. 3. Incorrect: Ethnocentrism is the belief that one's own culture and traditions are better than those of another. It blocks therapeutic communication by allowing the nurse's biases and prejudices to negatively influence the nursing care of the client. A woman, diagnosed with an ectopic pregnancy, asks the nurse the purpose of receiving methotrexate. What is the best reply for the nurse to make? You answered this question Correctly 1. "Methotrexate will stop your bleeding." 2. "It will destroy fetal cells that got into your blood so that antibodies will not be formed." 3. "This medication will stop the growth of the embryo to save your fallopian tube." 4. "Cervical dilation is expected after receiving this medication." - RationaleStrategies 3. Correct: The medical management of an ectopic pregnancy is to prescribe methotrexate. The action of methotrexate is to stop the growth of the embryo in the fallopian tube. The embryo is reabsorbed and the fallopian tube can be saved. 1. Incorrect: Methotrexate does not stop bleeding. It will stop the growth of the embryo so that the fallopian tube can be saved. 2. Incorrect: RhoGam is given to destroy fetal cells that got into mom's blood so that antibodies are not formed. This is done when mom is Rh negative. 4. Incorrect: Methotrexate does not cause cervical dilation. This medication will prevent damage to the fallopian tube by halting the growth of the embryo. A child is being admitted to the hospital with a diagnosis of acute glomerulonephritis. In performing the history and physical, what would be a priority assessment that the nurse should include when questioning the child and caregivers? You answered this question Correctly 1. Types of contact sports played 2. Amount of acetaminophen intake 3. Recent sore throat 4. Recent exposure to salmonella - RationaleStrategies 3. Correct: Acute post-streptococcal glomerulonephritis (APSGN) results from a group A beta-hemolytic streptococci infection that originates typically in the throat (strep throat) or the skin (impetigo). The strep bacterial infection can cause the filtering units of the kidneys (glomeruli) to become inflamed and results in a decreased ability of the kidneys to filter the urine. The disorder may develop 1-2 weeks after an untreated throat infection or 3-4 weeks after a skin infection. 1. Incorrect: Glomerulonephritis is not associated with trauma over the kidney region, so questioning about contact sports would not be relevant to glomerulonephritis. 2. Incorrect: Excessive acetaminophen intake can cause liver damage but is not associated with glomerulonephritis. 4. Incorrect: Salmonella is not an organism that is linked to the development of glomerulonephritis. Group A beta-hemolytic streptococci is the causative organism for acute glomerulonephritis. A client with dementia has been admitted to the medical floor. The family informs the nurse that the client tends to wander at night. When planning client safety goals, which action by the nurse would take priority? You answered this question Correctly 1. Place client with a roommate who is able to notify staff when client wanders. 2. Discuss safety goals with family, encouraging them to spend time with client. 3. Designate an unlicensed assistive personnel (UAP) to sit with the client through the night. 4. Reorient the client every shift regarding floor policies and safety procedures. - RationaleStrategies 3. Correct: The family specifically informed the nurse that the client wanders at night. When preparing care plan safety goals, the nurse understands the priority is to ensure client safety and have staff personnel to stay with the client during those hours of wandering. This action does not require a licensed nurse; therefore, a unlicensed assistive personnel UAP is the most appropriate staff to sit with the client. 1. Incorrect: It is neither ethical nor legal to expect another client to be accountable for a roommate's behavior or whereabouts. 2. Incorrect: The nurse would indeed discuss plans for client safety with the family and encouraging the family to spend time with the client can be helpful. However, this does not release the staff from the responsibility for the client's safety. 4. Incorrect: This client is known to have dementia and re-explaining policies and safety procedures every shift would not ensure this client's compliance, understanding or safety. In what position should the nurse place a client post liver biopsy? You answered this question Incorrectly 1. Left Sims' 2. Reverse Trendelenburg 3. Semi-Fowler's 4. Right Lateral Decubitus - RationaleStrategies 4. Correct: Right lateral decubitus is defined as lying on the right side. The client is placed on the right side post liver biopsy to reduce bleeding by compressing the liver capsule to the puncture site. 1. Incorrect: Left Sims' position is left side with knee and thigh drawn upward. Being placed on the left side would not decrease the chances of bleeding at the insertion site. This is the proper position for administration of an enema. 2. Incorrect: Reverse Trendelenburg is when the bed is tilted with head upward. This is an incorrect placement post liver biopsy. This position would not compress the liver capsule to the puncture site. 3. Incorrect: Semi- Fowler's is head of bed approximately 30 degrees and is an incorrect position post liver biopsy. This position would not apply pressure from liver capsule to the puncture site. The nurse is caring for a client with hypothyroidism. Which dietary consideration is most important for the nurse to teach this client? You answered this question Correctly 1. Increase carbohydrate intake. 2. Decrease fluid intake. 3. Avoid shellfish. 4. Increase fiber. - RationaleStrategies 4. Correct: A symptom of hypothyroidism is constipation due to the decreased mobility of the intestinal tract. Client's with hypothyroidism should increase their dietary fiber to prevent constipation. 1. Incorrect: No, they need fewer calories, not more. Their metabolism is slowed. A client with hypothyroidism may gain weight due to decreased metabolism. The client should decrease their intake of carbohydrates. 2. Incorrect: To decrease constipation the client should increase fluid intake. When the client is hydrated the stool will be softer. 3. Incorrect: Avoiding shellfish is not a consideration unless there is an iodine allergy. The nurse is instructing a client on achieving relaxation using deep breathing exercises. Which statement by the client indicates to the nurse that further teaching is necessary? You answered this question Correctly 1. "I can perform deep breathing exercises anywhere and at any time that I feel tension and anxiety." 2. "I should sit or lie in a comfortable position, making sure my back is straight." 3. "I will inhale slowly and deeply through my mouth focusing on my chest expansion." 4. "When I have inhaled in as much as possible, I will hold my breath for a few seconds before exhaling." - RationaleStrategies 3. Correct: The proper method is to inhale slowly and deeply through the nose, allowing the abdomen to expand. The chest should be moving only slightly. 1. Incorrect: This statement demonstrates successful teaching. To relieve anxiety, deep breathing exercises can be initiated as needed. Inhaling slowly and deeply through the nose can be performed anytime, and no additional equipment is needed. 2. Incorrect: This statement demonstrates successful teaching. To initiate deep breathing exercises, the client should sit or lie down in a comfortable position. Maintaining a straight back will facilitate breathing deeply into the lungs. 4. Incorrect: This statement demonstrates successful teaching. Holding your breath after inhaling is a technique that assists the client to control their breathing pattern. The client has control over themselves by repeating the deep breathing exercise. The nurse is caring for an adolescent client diagnosed with depression. The client is prescribed fluoxetine. What is the best response by the nurse when the client says, "What will this medicine do to me?" You answered this question Correctly 1. It will increase the level of serotonin in the brain. 2. It will decrease the production of noradrenaline. 3. It will lower your level of the brain hormone norepinephrine. 4. It will balance blood glucose and dopamine levels in your head. - RationaleStrategies 1. Correct: The action of fluoxetine is to increase the level of serotonin in the central nervous system. There is a correlation between a low level of serotonin and depression. The action of the drug should be explained to the adolescent in a manner that will be understood. 2. Incorrect: Fluoxetine does not selectively decrease the production of noradrenaline in the brain. 3. Incorrect: This action does not relate to fluoxetine. Fluoxetine may actually increase the level of norepinephrine in the brain. 4. Incorrect: This action does not relate to fluoxetine. Fluoxetine does not effect the balance of blood glucose and dopamine in the brain. A client is in the surgical suite to have a left total knee replacement. Prior to the surgeon initiating the first incision, what should the circulating nurse remind the surgical team to perform? You answered this question Correctly 1. Surgical scrub 2. Time-out 3. Sponge and instrument count 4. Inspection of the surgical site - RationaleStrategies 2. Correct: Time-out, done immediately before the procedure, is a final verbal verification of the correct client, procedure, site, and implant. Time-out is active communication among all members of the surgical/procedural team, initiated by a member of the team before surgery. 1. Incorrect: Surgical scrub should be done before entering the surgical suite. 3. Incorrect: The scrub nurse does instrument and sponge counts numerous times before, during, and after the procedure. 4. Incorrect: Simple inspection of the surgical site is not enough. The team must verbally communicate what is to be done, on what limb. Additionally, the limb should be marked as "This knee" or "yes". The nurse is teaching a newly diagnosed diabetic about proper foot care. Which statements by the nurse are correct? You answered this question Incorrectly 1. Cut the toenails in a rounded fashion. 2. Wash the feet with warm water and betadine. 3. Wear appropriate fitting shoes at all times. 4. View the bottom of the feet daily. 5. Protect feet from hot and cold. - RationaleStrategies 3., 4., & 5. Correct: Shoes should be worn at all times to prevent injury. The client may step on something and not know that the foot has been injured. Inspection should be done daily, since many diabetics cannot feel if their feet have been injured. Feet may not be sensitive to hot and cold, which could cause injury. 1. Incorrect: Toe nails should be cut straight across to avoid an ingrown toenail. Additionally any skin cuts on the toes may result in infection. 2. Incorrect: Do not put harsh chemicals, such as betadine, on the feet. Betadine will dry the skin which may lead to cracks in the skin. This creates potential portals for infection to occur. Based on the Parkland formula, the primary healthcare provider has determined that a burn victim needs 9,250 mL of LR intravenously over the first 24 hours. How many milliliters of LR should the nurse administer over the first eight hours? Round answer to The nurse is teaching the client about benzodiazepines. Which comments by the client indicate adequate understanding of the drug effects/side effects? You answered this question Incorrectly 1. I should not drive my car until I see how the medication affects me. 2. I can expect my reaction time to be slowed in the beginning. 3. I may need to double the dose if I continue to be anxious. 4. I must be careful to take the medication for a limited time. 5. There is a risk for dependence on this medication. - RationaleStrategies 1., 2., 4. & 5. Correct: Benzodiazepines slow reaction time and may affect general alertness. The client should not operate machinery until effects of the medication are observed, and client can drive safely. Benzodiazepine medications are usually prescribed for short periods of time. Benzodiazepines are frequently abused. Clients develop tolerance and dependence on the drugs. 3. Incorrect: The client should not self-regulate dosage. There is a potential for tolerance and dependence to develop. Dosage should be monitored carefully by the primary healthcare provider. the nearest whole number. You answered this question IncorrectlyEnter the answer for the question below. - RationaleStrategies Based on the Parkland formula the fluid resuscitation of a burn victim means that ½ of the fluid should be given within the first 8 hours. For this client 4,625 mL needs to be administered within the first 8 hours. The remaining ½ of the fluid is divided over the remaining 16 hours. A nurse is teaching a client about the prescription aripiprazole discmelt. The nurse documents that teaching has been effective when the client makes which statement? You answered this question Incorrectly 1. "If I start to have shakiness and sweating I need to call my primary healthcare provider at once." 2. "I must be certain to take this medication with food to eliminate vomiting." 3. "If I miss a dose of medication, I need to take an extra dose to make up for the missed dose." 4. "I will allow the tablet to dissolve in my mouth." - RationaleStrategies 4. Correct: Discmelt is an orally disintegrating tablet. Since this tablet is formulated to dissolve on the tongue, the tablet should not be swallowed. 1. Incorrect: Hyperglycemia can occur. Signs/symptoms include polydipsia, polyphasia, polyuria. Hyperglycemia is a potential adverse reaction of aripiprazole discmelt. The symptoms listed are indicative of hypoglycemia. 2. Incorrect: Can be taken with or without food. Aripiprazole can be taken with or without food. Taking the medication with food does not increase or decrease side effects. 3. Incorrect: Skip the missed dose if it is almost time for the next scheduled dose. Do not take extra medication to make up for missed dose. The unit charge nurse is responsible for reporting all healthcare associated infections. Which client condition needs to be reported? You answered this question Correctly 1. A client diagnosed with Clostridium Difficile while receiving intravenous (IV) antibiotics. 2. A client admitted with Methicillin-Resistant Staphylococcus aureus (MRSA) in a wound. 3. A client with ulcerative colitis exhibiting diarrhea. 4. A client with a fever of 99.1º F (37.2° C) two days post gastrectomy. - RationaleStrategies 1. Correct: Clostridium Difficile is a spore forming bacterium that has significant healthcare associated infections (HAI) potential. Clients with intravenous catheters are at a higher risk for HAI. 2. Incorrect: This client was admitted with MRSA already present which indicates that this is a community acquired infection. The client did not acquire a healthcare associated infection. 3. Incorrect: Clients with ulcerative colitis have diarrhea. Diarrhea in this instance does not indicate a possible healthcare associated infection. 4. Incorrect: Low grade fever may occur after surgery. The temperature of 99.1° F (37.2° C) does not indicate a HAI at this time. The public health nurse is planning to participate in local forums regarding the placement of a factory that is known to produce pollution through discharge of chemical by-products into the air. What actions demonstrate ethical nursing practice in the public health arena? You answered this question Correctly 1. Speaking up for the underrepresented, such as the poor and uneducated persons. 2. Encouraging community leaders to accept placement of the factory. 3. Requesting that forums be held throughout the community at various times of the day or evening. 4. Asking for information regarding the health status of people in other factory locations. 5. Requesting information from individuals in areas where the factories are currently located. - RationaleStrategies 1., 3., 4. & 5. Correct: Many times factories are placed in communities where people are not aware of the hazards. The underrepresented and poor need the nurse as their advocate. Forums encourage wider participation of all community members and give the community more information about the consequences of the pollution. The public health nurse advocates for the health of the entire community. Individuals in the communities where factories are located could give first-hand information about health or other issues related to the factory placement. Printed reports, depending on the source, may contain false information. 2. Incorrect: More information is needed at this time. Placement should be determined by what is best for the community as a whole. The nurse is interested in protecting the public's health. Which pediatric client should the nurse see first? You answered this question Incorrectly 1. Six year old with a femur fracture. 2. Two year old with a fever of 102 ° F (38.8 ° C) 3. Three year old with wheezes in right lower lobe. 4. Two year old whose gastrostomy tube came out. - RationaleStrategies 3. Correct: The child having respiratory difficulty should be seen first. This is an example of using Maslow to set priorities. Airway will always be first followed by breathing and circulation. This client is not stable. 1. Incorrect: This client will need to be seen, but not prior to a client with an immediate vital function problem such as airway and breathing. From the information given, all we know is that the child has a fracture so we have to assume the client is stable. 2. Incorrect: This client will need to be assessed, but not prior to a client with an immediate vital function problem such as airway and breathing. The temperature is elevated but there is no information to cause the nurse to think the situation is life threatening. 4. Incorrect: The tube has come out and needs to be replaced so that feeding can be resumed. You have time before this client is in any distressed so this is not your priority client. An elderly client arrives in the emergency department (ED) after a fall. What assessment findings would lead the nurse to suspect that the client has a fractured right hip? You answered this question Incorrectly 1. Severe pain in the right hip and groin. 2. Inability to bear weight on the right leg. 3. Right leg slightly longer in length than the left leg. 4. External rotation of right lower leg. 5. Bruising and swelling around the right hip. - RationaleStrategies 1., 2., 4., & 5. Correct: Pain in the affected hip, often severe, is one of the main signs of a hip fracture. This pain may radiate to the groin area. The pain and bone injury generally prevent the client from being able to bear weight on the affected leg. The client will often assume a position in which the leg on the injured side is held in a still and externally rotated position (the foot and knee turns outward). Discoloration and swelling can be an indication of a hip fracture in some clients. 3. Incorrect: A client who has a hip fracture often appears to have shortening of the extremity on the affected side. This is a result of the location of the break and the positioning of the body in response to the injury and pain. The nurse will be admitting a client from the operating room following a left total pneumonectomy for adenocarcinoma. Which type of chest drainage should the nurse anticipate that the client will have? You answered this question Incorrectly 1. Bilateral chest tubes. 2. One chest tube on the operative side 3. Two chest tubes on the operative side 4. No chest drainage will be necessary. - RationaleStrategies 4. Correct: A total pneumonectomy means the excision of the entire lung. A drainage tube is not inserted, since the fluid and air must accumulate in the thoracic space. This is to prevent mediastinal shift to the left. 1. Incorrect: A total pneumonectomy is removal of entire lung. The presence of fluid and air in the left thoracic cavity decreases the incidence of left mediastinal shift. 2. Incorrect: The entire lung is removed. The left thoracic space should fill with fluid and air to prevent mediastinal shift. The insertion of a chest tube is not warranted. 3. Incorrect: Entire lung is removed and no chest drainage is needed. The insertion of two chest tubes is not required. Fluid and air should fill the left pleural space to reduce the risk of a mediastinal shift. A client has returned to the burn unit after an escharotomy of the forearm. What is the priority nursing intervention? You answered this question Correctly 1. Roll sterile q-tip over the wound 2. Elevate the affected arm 3. Ask the client to rate pain level 4. Assess bilateral radial pulses - RationaleStrategies 4. Correct: An escharotomy is an incision of the eschar of a burned arm to decrease the tension in the proximal tissue. This will result in increased circulation to the proximal tissue. The assessment of bilateral radial pulses needs to be compared for adequate circulation. 1. Incorrect: This is an intervention for a forearm with a graft. 2. Incorrect: After an escharotomy elevating the affected arm is an appropriate intervention. The evaluation of the circulation in the arm should be performed first. 3. Incorrect: Pain is also an indicator of adequate circulation. The assessment of distal pulses first will provide a more concise assessment of the circulation in both arms. The nurse is planning daily activities for a client who has a diagnosis of schizophrenia. The client tends to spend most of the time in bed and is very uncomfortable when other clients are in the day area of the unit. What activity would be most therapeutic for this client? You answered this question Correctly 1. Watching TV with two other clients in the day room. 2. Watching TV alone in a conference room. 3. Spending time in brief one on one interactions with the nurse. 4. Sitting in the day-room away from other clients. - RationaleStrategies 3. Correct: The interaction with the nurse can keep the conversation reality based and provide interaction with someone. Clients with schizophrenia may be very withdrawn and need the presence of the nurse. 1. Incorrect: The client is very uncomfortable around the other clients. This action could be appropriate as the client's condition begins to stabilize. 2. Incorrect: The client needs interaction with others. Time with others allows the client to stay reality based. When alone, there may be more time for delusional thought or auditory hallucinations. 4. Incorrect: The nurse can assess the thought processes of the client and offer acceptance of the client. Sitting away from other clients is not recommended therapeutic intervention for this client. An elderly client is admitted to the floor with vomiting and diarrhea for three days. She is receiving IV fluids at 200 mL/hr via pump. What is the priority nursing action? You answered this question Incorrectly 1. Intake and output every shift. 2. Lung assessments every 2-4 hours. 3. Vital signs every shift. 4. IV site assessment every 2-4 hours. - RationaleStrategies 2. Correct: The IV is infusing at 200 mL/hr which is a rapid infusion rate for an elderly client. The lungs should be assessed every 2-4 hours to evaluate for potential fluid volume excess (FVE). 1. Incorrect: Input and Output (I&O) are important, but are a less priority than lung assessment in the elderly client. 3. Incorrect: Vital signs should probably be more frequent than every shift on the elderly client with dehydration. In addition, the cliet's IV rate is 200 mL/hr which may result in FVE. 4. Incorrect: The site should be monitored but will not be priority over lung assessment in the elderly client. The nurse is caring for a client with hyperparathyroidism. The nurse will monitor the client for which complications? You answered this question Correctly 1. Kidney stones 2. Diarrhea 3. Osteoporosis 4. Tetany 5. Fluid volume deficit - RationaleStrategies 1. & 3. Correct: Yes, because too much calcium in the blood equals too much calcium in the urine and increased risk of kidney stones. Increased parathyroid hormone (PTH) is pulling the calcium from the bones, leaving them weak. 2. Incorrect: A clinical manifestation of hyperpararthyroidism is constipation. Diarrhea is not a clinical manifestation of hyperparathyroidism. 4. Incorrect: Tetany is a clinical manifestation of hypoparathyroidism. 5. Incorrect: Fluid volume deficit (FVD) is not a clinical manifestation of hyperparathyroidism. When assessing a client's testes, which finding would indicate to the nurse the need for further investigation? You answered this question Correctly 1. Rope like area located at the top of the back of a testicle. 2. Right testicle is slightly larger than the left testicle. 3. Lump the size of a piece of rice. 4. Nonpalpable lymph nodes in groin. - RationaleStrategies 3. Correct: The most common symptoms of testicular cancer are a painless enlargement of one testis and the appearance of a palpable small hard lump on the front or side of the testicle.. 1. Incorrect: This is a normal finding. The epididymis feels soft, rope like, and is slightly tender to pressure, and is located at the top of the back part of each testicle. 2. Incorrect: It is normal for one testicle to be slightly larger than the other for most males. 4. Incorrect: Lymph node in the groin are not normally palpable. A nurse has received the following arterial blood gas results on a client with a post bowel resection: pH 7.48; PCO2 30; HCO3 24. Which acid/base imbalance is the client experiencing? You answered this question Correctly 1. Metabolic alkalosis 2. Metabolic acidosis 3. Respiratory alkalosis 4. Respiratory acidosis - RationaleStrategies 3. Correct: The pH is high, indicating alkalosis. The PCO2 is low, which coordinates with a high pH, indicating a lung problem. This client is in respiratory alkalosis, not acidosis. The bicarbonate is normal. 1. Incorrect: The bicarbonate is normal. In metabolic alkalosis, the bicarbonate will be increased. A pH of 7.48 is an alkalosis. 2. Incorrect: Normal pH is 7.35-7.45. Anything less than 7.35 is an acidosis. Anything greater than 7.45 is an alkalosis. 4. Incorrect: The pH is high, indicating alkalosis. The PCO2 is low, which coordinates with a high pH, indicating a lung problem: Respiratory alkalosis, not acidosis. The bicarbonate is normal. During evening rounds, the nurse discovers that a violent client with a history of threats against a former girlfriend cannot be located. The client's window is open and personal belongings missing. Based on recent threats of violence against the girlfriend, what is the nurse's initial action? You answered this question Incorrectly 1. Look for the client quietly to maintain confidentiality. 2. Notify the local police to organize a search party. 3. Initiate the missing client protocol. 4. Complete an "Against Medical Advice" (AMA) form on the client's elopement. - RationaleStrategies 3. Correct. Since the client is missing and is considered to be a risk to himself or others, the missing client protocol is immediately implemented. A organized and escalating search for the client will occur. 1. Incorrect. Although HIPAA is very precise on the issue of confidentiality, privacy is waived in specific, extreme situations that involve the life of a client, staff, or family. While the nurse may alert staff members to help search the building or facility grounds, this is not the initial action of the nurse. 2. Incorrect. Although local police may eventually be asked to assist in locating the client, this decision will be made by the facility's administrative personnel. However, this is not the initial action under the stated circumstances. 4. Incorrect. An Against Medical Advice (AMA) form is signed by a client who decides to leave a facility without treatment, against the advice of the primary healthcare provider. That form does not apply in this situation since the client has already left. This event falls under the category of elopement. The nurse is planning health promotion strategies for a single parent of young children who is trying to increase personal physical activity level but expresses a lack of time. Which interventions would help the client get more regular physical activity into the day? You answered this question Incorrectly 1. Suggest walking up and down steps at home several times each morning and evening. 2. Suggest parking further away from the grocery store and work. 3. Walk with the children in the evening instead of watching TV with them. 4. Suggest waking one hour earlier in the morning to go to the gym. 5. Suggest walking for 30 minutes with a buddy each afternoon before leaving work. - RationaleStrategies 1., 2. & 3. Correct: This plan will allow the parent to stay home without adding further time demands to the day. Parking farther away is one plan to get more steps into the day without increasing time demands drastically. Walking with the children allows the parent to spend quality time with the children as well as offers them a good example. 4. Incorrect: Being a single parent, this plan would not be feasible. The demands of getting the children out earlier could impact the time schedule for the day in a negative way. 5. Incorrect: This plan would only increase time demands and possibly financial demands if the children have to be cared for by someone else at an extra charge each day. The nurse is caring for a client in an outpatient clinic. The client is being treated with warfarin for prevention of a stroke due to atrial fibrillation. The international normalized ratio (INR) was noted to be 4.6. What should the nurse do? You answered this question Incorrectly 1. Inform the primary healthcare provider immediately. 2. Instruct the client to continue medication as ordered. 3. Inform the client to watch for signs of bleeding. 4. Inform the client to return to the clinic per routine monitoring schedule. 5. Take no action as this value is within target range. - RationaleStrategies 1. & 3. Correct: The primary healthcare provider should be notified. The value of 4 is above the usual target range of 2-3. The client has a potential for decreased clotting and bleeding. The client should be told to watch for signs of bleeding. 2. Incorrect: The medication dosage is likely to be reduced. 4. Incorrect: The client should not leave the clinic until the primary healthcare provider has been notified. Further action is indicated and may include changing the usual warfarin dosage. 5. Incorrect: The normal range for a INR is 2-3. When a client is prescribed warfarin, the INR should increase to a therapeutic target range. The value of 4.6 is greater than the usual target range. The nurse is administering the prescribed Mantoux tuberculin skin test to a client. The nurse does not observe the tense blister-like formation at the injection site. Which action should the nurse take? You answered this question Incorrectly 1. Chart the injection site response as the only action. 2. Administer another Mantoux tuberculin skin test at a different site. 3. Circle the area, wait 48 to 72 hours, and assess for a reaction. 4. Call the primary healthcare provider. - RationaleStrategies 2. Correct: If there is not a wheal of at least 6 mm in diameter after the solution is injected , the test should be administered again. The nurse would need to administer another Mantoux tuberculin skin test in another area about 5-6 cm from the original injection site. 1. Incorrect: The Mantoux tuberculin skin test is an intradermal injection. The expected outcome after the injection of the medication is a tense blister-like formation at the injection site. The absence of the tense blister-like formation is an indicator that the injection was given too deep. 3. Incorrect: The Mantoux tuberculin skin test was not administered correctly. A wheal of 5-6 mm did not occur after the injection was given. The test would need to be done again. 4. Incorrect: There is no need to call the primary healthcare provider. The primary healthcare provider prescribed the test. The injection should be administered to create a 5-6 mm wheal. A quality assurance (QA) manager plans to evaluate performance improvement regarding the implementation of fall precautions for at risk clients. What steps should the QA manager include in this evaluation? You answered this question Incorrectly 1. Chart review for fall precaution documentation. 2. Direct observation of unit staff. 3. Poll staff to identify what fall precautions are implemented for at risk clients. 4. Identify at risk clients on unit. 5. Make unannounced visits to the unit for evaluating staff performance. - RationaleStrategies 1., 2., 4 & 5. Correct: The QA manager is responsible for evaluating performance improvement plans to ensure that staff are providing appropriate care. The QA manager can do chart reviews to see if staff are documenting fall precaution for a client. Direct observation of unit staff will let the QA manager know if staff are performing proper precautions while caring for clients. The first step is to identify what clients are at risk for falls and then see if the staff have identified these clients as at risk as well. Monitoring should be at unpredictable intervals, so staff do not comply just for a scheduled evaluation. 3. Incorrect: Asking the staff does not ensure that they follow through. The charge nurse has received report from the emergency department about a client diagnosed with Cushing's disease being admitted to the unit. Which client in a semiprivate room would be appropriate for the charge nurse to have this client share? You answered this question Correctly 1. Client who has leukemia. 2. Client diagnosed with gastroenteritis. 3. Client who has a fractured hip. 4. Client diagnosed with bronchitis. - RationaleStrategies 3. Correct: The client with Cushing's disease could go in the room with the client who has a fractured hip, as this client does not have an infection. 1. Incorrect: Both of these clients are immunocompromised and should not share a room with each other. 2. Incorrect: The client with gastroenteritis poses a risk of infection to the client with Cushing's disease because this client is immunosuppressed. 4. Incorrect: The client with bronchitis poses a risk of infection to the client with Cushing's disease. RationaleStrategies 2. Correct: As the lens becomes less flexible, the near point of focus gets further away. This condition, presbyopia, usually begins in the 40s. Reading glasses to magnify objects are required. 1. Incorrect: Anomia (cannot name objects) is an early sign of Alzheimer's disease. Anomia is not a normal assessment of a 65 year old client. 3. Incorrect: Blood pressure (BP) reading of 156/88 is not within normal BP range. The normal blood pressure range for the 65 to 79 year old is 140/90 or less. 4. Incorrect: Apraxia means client cannot perform purposeful movement. We would not expect to assess this in a healthy 65 year old. A client has been admitted to the medical unit and placed on airborne precautions for suspected pulmonary tuberculosis (TB). The nurse will assess for which signs and symptoms? You answered this question Incorrectly 1. Weight gain 2. Fatigue 3. Hemoptysis 4. Diaphoresis during sleep 5. Anorexia - RationaleStrategies 2., 3., 4. & 5. Correct: Feeling tired all the time, loss of appetite, fever, coughing up blood, and night sweats are the most common signs and symptoms of active TB. 1. Incorrect: A symptom of TB is a decreased desire for food. This will result in weight loss rather than weight gain. A client received a leg cast that was applied following fracturing the left femur. What assessment finding would be a priority for the nurse to report to the primary healthcare provider? You answered this question Correctly 1. Reports of a feeling of warmness under the cast after application. 2. Pain not relieved by elevation, cold packs, and pain medication. 3. Reports of itching under the cast not relieved by cool air. 4. Slight swelling of the toes of the affected extremity. - RationaleStrategies 2. Correct: Pain that is disproportionate to the injury, becomes severe, and/or is not relieved by elevation, cold packs, and pain medication could indicate a complication such as compartment syndrome. Failure to detect this could lead to neurovascular damage and possible amputation. 1. Incorrect: Due to the drying process of the cast material, it is normal for the cast to feel warm. The primary healthcare provider would not need to be notified. The warm feeling should subside. 3. Incorrect: A common complaint is itching under the cast. The cast material may cause irritation to the skin. Cool air under the cast may help to relieve this. The primary healthcare provider would not need to be notified at this time. 4. Incorrect: Some swelling is expected initially due to the damage of the tissue around the fracture which may result in dependent swelling of the toes. This compromised circulation should be relieved by elevation. The primary healthcare provider would not need to be notified at this time. Which finding should a nurse expect when assessing a healthy 65 year old client? You answered this question Correctly 1. Anomia 2. Presbyopia 3. BP 156/88 4. Apraxia - The nurse in the outpatient clinic performs an assessment on a client who takes propranolol for management of palpitations associated with mitral valve prolapse. Which statement by the client should be reported immediately to the primary healthcare provider? You answered this question Correctly 1. "My resting pulse was 60 this morning." 2. "I feel a little short of breath when walking." 3. "I have lost 5 pounds in the last 2 weeks." 4. "My blood pressure (BP) was lower this visit than last time." - RationaleStrategies 2. Correct: Propranolol is a non-selective beta blocker so it blocks sites in the heart and in the lungs. The shortness of breath could be the result of the adverse reactions of bronchospams or heart failure. This statement requires immediate investigation by the primary healthcare provider. 1. Incorrect: A side effect of propranolol is bradycardia. The client should be taught to contact their primary healthcare provider if their pulse is <50 beats per minute (bpm). A pulse rate of 60 bpm is acceptable. 3. Incorrect: Losing weight is not a side effect of propranolol. Weight loss regimen may be encouraged for hypertension. Losing 5 pounds in 2 weeks is within the acceptable range. 4. Incorrect: The therapeutic effect of propranolol is to reduce BP. If the client is asymptomatic, decreased BP is no big deal. A client is seen in the clinic for recurrent unexplained, vague stomach pain over the past 5 years. EGD, colonoscopy, gallbladder ultrasound, and lab results have revealed no physical reason for the symptoms. The client tells the nurse, "The doctor thinks the pain in my stomach is psychosomatic. But the pain is so bad some times that I can't function!" What is the nurse's most appropriate response? You answered this question Correctly 1. "The pain you feel is real." 2. "The primary healthcare provider is right. Your pain is not real." 3. "Let me get you an appointment with the psychiatrist." 4. "Don't worry. Everything will be ok." - RationaleStrategies 1. Correct: Pain is real even if it is psychological pain. The client is experiencing anxiety, or stress through stomach pain. The nurse should use therapeutic communication technique that is client centered and empowers the client. 2. Incorrect: This is a example of nontherapeutic communication. The response is confrontational and does not address how the client feels. 3. Incorrect: This nontherapeutic communication of changing the subject ignores the client's feelings. This action invalidates the client. 4. Incorrect: This is a nontherapeutic communication technique, because the response is trite, with false reassurance. The nurse can not know if everything will be ok for the client. A client calls the clinic to ask the nurse if it would be okay to take the herbal medication kava-kava to help reduce anxiety. What is the nurse's best response? You answered this question Correctly 1. "Why do you want to take kava-kava?" 2. "I really doubt your primary healthcare provider will approve you taking kava-kava." 3. "Kava-kava can cause liver damage, so we need to consult your healthcare provider." 4. "Do not take Kava-kava for more than a year without a primary healthcare provider's supervision." - RationaleStrategies 3. Correct: Kava-kava can cause liver damage. It is recommended that if if taking kava-kava the client should be under the direct supervision of a primary healthcare provider. 1. Incorrect: The client has already answered that: anxiety. This question will put the client on the defensive. This is an example of nontherapeutic communication technique asking for explanations. 2. Incorrect: Judgmental response. This will put the client on the defensive. This is an example of the nontherapeutic communication technique of an aggressive response. 4. Incorrect: You should not take this drug for longer than 3 months without a primary healthcare provider's supervision. There have been recent reports that kava-kava causes liver damage. A home care nurse is preparing to perform venipuncture to draw blood. As the nurse gathers supplies, the client begins to experience palpitations, trembling, nausea, shortness of breath and a feeling of losing control. What should be the nurse's first action? You answered this question Incorrectly 1. Hug the client to provide support. 2. Take the client to the emergency department for sedation. 3. Decrease stimuli in the room. 4. Teach the client deep breathing exercises. - RationaleStrategies 3. Correct: The nurse should remain calm and quiet by the client. A stimulating environment may increase the client's level of anxiety. 1. Incorrect: Hugging a client is moving into the client;s personal space. Hugging may confine the person and intensify feelings. The nurse should use touch cautiously. 2. Incorrect: Panic attacks usually last minutes, rarely longer. The client is not exhibiting symptoms at this time that would warrant administration of a sedative. 4. Incorrect: This is good; however, you need to wait until the panic attack is over. The client must be ready to learn prior to initiating teaching. The nurse should wait until the symptoms resolve for learning to occur. What is most important for the nurse to have at the client's bedside when inserting a large orogastric tube for rapid gastric lavage? You answered this question Incorrectly 1. Emesis basin 2. Portable x-ray machine 3. Oxygen 4. Suction equipment - RationaleStrategies 4. Correct: Insertion of a large orogastric tube designed for rapid lavage often causes gagging and vomiting, so suction equipment should be readily available to reduce the risk of aspiration. Maintaining the client's airway is the priority. 1. Incorrect: You would need an emesis basin because of the chance of vomiting, but suction equipment is the priority due to aspiration. 2. Incorrect: An x-ray is the preferred method to check initial placement, once the tubing is inserted. Suction equipment is the priority when inserting the tube due to risk of aspiration. 3. Incorrect: There are no key words in the question to suggest the client needs oxygen at this time. The nurse is caring for a client with renal failure. The client has a 24 hour intake of 2500 mL and a 24 hour urinary output of 200 mL. What is the priority nursing assessment? You answered this question Correctly 1. Assess for dependent edema. 2. Monitor for cardiac arrhythmias. 3. Auscultate breath sounds. 4. Monitor sodium and potassium levels - RationaleStrategies 3. Correct: The nurse is "worried" about fluid volume excess. In fluid volume excess (FVE), the number one concern is heart failure with resultant pulmonary edema. In FVE, you can stress the heart so much that the heart begins to fail. With heart failure, the cardiac output decreases. With decreased cardiac output, there is decreased forward flow out of the heart. With decreased forward flow there is back flow. Back flow from the left ventricle results in fluid accumulation in the lungs. The best assessment for heart failure is to auscultate lung sounds. 1. Incorrect: Inspecting for dependent edema does not address the biggest problem/concern in FVE. The nurse is "worried" about pulmonary edema. This client will probably have edema, but it is not more important than breath sounds. 2. Incorrect: After evaluating the output versus the input amounts, the lungs should be assessed to evaluate the pressure of FVE. Cardiac arrhythmias are a possibility, due to the stress on the heart due to FVE. 4. Incorrect: Electrolytes may be abnormal due to FVE. The number one concern is FVE and pulmonary edema. A parent tells the clinic nurse, "My child has just been diagnosed with attentiondeficit/hyperactivity disorder (ADHD). What will be done to help my child?" How should the nurse best respond to the parent? You answered this question Correctly 1. The primary healthcare provider will want to start your child on a central nervous system (CNS) depressant in order to decrease hyperactivity and improve attention. 2. You will need to admit your child to the psychiatric behavioral unit so that group therapy can be initiated. 3. Children are often placed on central nervous system stimulants that improve behavior associated with ADHD. 4. The standard of care for children with ADHD includes central nervous system stimulants along with behavior and family therapy. - RationaleStrategies 4. Correct: Multimodal treatment of ADHD is the standard of care for children. There is a lot to be gained by supporting medication treatment with appropriate educational, psychosocial, and family interventions. 1. Incorrect: Central nervous system (CNS) depressants are not appropriate therapy for ADHD. Central nervous stimulants are recommended to manage ADHD symptoms. 2. Incorrect: Children with ADHD are not generally hospitalized. Outpatient behavior therapy is recommended to assist the client to substitute positive behaviors with nonproductive behaviors. 3. Incorrect: Central nervous system stimulants are given to children with ADHD. This is a true statement, but the standard of care also includes behavior and family therapy. Which client requires immediate intervention by the nurse? You answered this question Correctly 1. Client diagnosed with Crohn's disease reporting frequent bloody diarrhea and abdominal cramping. 2. Client with renal calculi who reports no pain relief from ketorolac administered 30 minutes ago. 3. Client with a fractured femur reporting sharp chest pain of 4/10. 4. Client admitted with cholelithiasis reporting right-sided abdominal pain of 8/10. - RationaleStrategies 3. Correct: Sharp chest pain after a fractured femur could indicate a pulmonary embolus (PE) or a fat embolus and requires immediate intervention by the nurse. 1. Incorrect: This is not the most life-threatening problem. The client with suspected PE or fat embolus takes priority, although this client would be closely monitored for fluid and electrolyte imbalances. 2. Incorrect: This is not the most life-threatening problem. The client with suspected PE or fat embolus takes priority. Just remember, pain never killed anybody. 4. Incorrect: This is not the most lifethreatening problem. The client with suspected PE or fat embolus takes priority. Although this client's pain does not need to be ignored, it doesn't take priority over someone with an embolus. A child was diagnosed with attention-deficit/hyperactivity disorder (ADHD) in the clinic one week ago. Today the child's mother calls the clinic to tell the nurse, "My child has not been able to sleep since being put on methyphenidate." What is the best response for the nurse to make? You answered this question Correctly 1. "I will discuss this with the primary healthcare provider. A different medication may be prescribed." 2. "The insomnia will get better over time. Just wait it out." 3. "To prevent insomnia, give your child the last daily dose at least 6