NSG 201 Saunders Review Test 2 Questions and Answers,100% CORRECT

NSG 201 Saunders Review Test 2 Questions and Answers 1.ID: 2 The nurse is caring for a woman who is starting medroxyprogesterone injections for birth control. What statements by the client would indicate a need for further teaching? Select all that apply. A. “I may experience some weight gain.” Incorrect B. “I may not have regular periods while taking this medication.” C. “I should return in approximately 6 months for my next injection.” D. “Because it is highly effective, I can use this medication for many years.” E. “Depression is a side effect, and I should let my doctor know if I experience any mood changes.” Incorrect Rationale: Medroxyprogesterone is an injectable progestin given every 3 months to prevent ovulation and pregnancy. It suppresses ovulation for 15 weeks, and therefore, timing of the next injection is very important and should be no longer than exactly 3 months. Although medroxyprogesterone is highly effective, it should not be taken for more than 2 years due to the risk of osteoporosis. Weight gain, irregular periods, and depression are all known side effects. Test-Taking Strategy: Note the strategic words, “need for further teaching.” These words indicate a negative event query and the need to select the incorrect client statements. Specific knowledge about this medication is needed to answer correctly. Remember that it needs to be given every 3 months and should not be taken for more than 2 years due to the risk of osteoporosis. Review: medroxyprogesterone injections Level of Cognitive Ability: Evaluating Client Need: Health Promotion and Maintenance Integrated Process: Teaching and Learning Content Area: Pharmacology: Reproductive Medications Priority Concepts: Client Education, Reproduction HESI Concepts: Sexuality/Reproduction, Teaching and Learning/Patient Education Reference: Rosenjack Burchum, Rosenthal (2016), pp. 760-761. Awarded -1.0 points out of 2.0 possible points. 2.ID: 8 Following thyroid surgery, the nurse notes this response (refer to figure) when taking the client’s blood pressure. On further assessment, which laboratory finding would the nurse expect to find? A. Serum calcium of 8.4 mg/dL (2.1 mmol/L) B. Correct C. Sodium level of 138 mEq/L (138 mmol/L) D. Serum potassium of 5.1 mEq/L (5.1 mmol/L) E. F. Thyroid Stimulating Hormone (TSH) of 1.5 mU/L Incorrect Rationale: Hypocalcemia is characterized by tetany, or sustained muscle contractions. Chvostek’s sign is facial contractions seen after a light tap of the facial nerve in front of the ear. Trousseau’s sign is carpal contraction when a blood pressure cuff is inflated. These two signs are observed in hypocalcemia. Test-Taking Strategy: Focus on the subject, thyroid surgery and the signs of hypocalcemia. Use knowledge of signs of muscle contractions and its association with a low calcium level. Note that hypocalcemia is a known complication after thyroid surgery and serum calcium levels should be closely monitored. Review: hypocalcemia. Level of Cognitive Ability: Synthesizing Client Need: Physiological Integrity Integrated Process: Nursing Process/Analyzing Content Area: Fundamentals of Care: Fluids & Electrolytes Priority Concepts: Cellular Regulation, Fluid and Electrolytes HESI Concepts: Cellular Regulation, Fluids and Electrolytes Reference: Lewis, S., Dirksen, S., Heitkemper, M., & Bucher, L. (2014). Medical-surgical nursing: Assessment and management of clinical problems (9th ed., pp. 298-299). St. Louis: Mosby. Awarded 0.0 points out of 1.0 possible points. 3.ID: 0 The charge nurse on a women’s health unit is making a client room assignment. Which clients would be least appropriate to assign to share a room with a woman who is pregnant? Select all that apply. A. A client with hepatitis B Correct B. A client with herpes zoster Correct C. A client with pyelonephritis Incorrect D. A client with hashimotos thyroiditis Incorrect E. A client with a urinary tract infection Rationale: Viral infections such as hepatitis B and herpes zoster can be very serious for the mother and fetus if exposed and clients with these conditions should not share a room with a pregnant client. Pyelonephritis, hashimotos thyroiditis, and urinary tract infections can all have adverse effects on a pregnant woman, however, these are not contagious conditions, and therefore clients with these conditions can safely room share with a pregnant woman. Test taking strategy: Focus on the strategic words least appropriate and select the clients that should not share a room with a pregnant female. Think about the infectious factors of each disorder in the options to answer correctly. Review: risks of pregnancy Level of Cognitive Ability: Creating Client Need: Safe and Effective Care Environment Integrated Process: Nursing Process/Planning Content Area: Maternity: Antepartum Priority Concepts: Care Coordination, Infection HESI Concepts: Care Coordination, Infection Reference: McKinney, E., James, S., Murray, S., Nelson, K. & Ashwill, J. (2013). Maternal-child nursing (4th ed., pp. 626-628). St. Louis: Elsevier. Awarded -1.0 points out of 2.0 possible points. 4.ID: 4 The home health nurse is caring for an older client recovering from pneumonia. A concerned family member believes that the client is no longer capable of caring for self effectively. The nurse conducts an assessment of the client’s basic activities of daily living (BADLs). What activities would the nurse assess? Select all that apply. A. Eating Correct B. Bathing Correct C. Cooking Incorrect D. Dressing Correct E. Taking medications Incorrect F. Balancing a checkbook Rationale: ADL’s are basic activities that assess functional ability. Daily activities such as eating, bathing, and dressing are considered basic every day needs. Activities such as cooking, taking medication, and balancing a checkbook are considered more complex, instrumental activities. Test-taking Strategy: Focus on the subject, basic activities of daily living. Select the answers that require the most basic care for completion. In addition, specific knowledge of those activities that are basic and those that are instrumental will assist in answering correctly. Review: Activities of Daily Living. Level of Cognitive Ability: Applying Client Need: Physiological Integrity Integrated Process: Nursing Process/Assessment Content Area: Fundamental Skills: Safety Priority Concepts: Functional Ability, Safety HESI Concepts: Functional Ability, Safety References: Giddens, J. (2013). Concepts for nursing practice. (p. 12). St. Louis, MO: Mosby. Potter, P., Perry, A. G., Stockert, P. A., & Hall, A. M. (2013). Fundamentals of nursing. (8th ed., pp. 259-260). St. Louis: Mosby. Awarded 1.0 points out of 3.0 possible points. 5.ID: 8 The nurse is caring for a client who has recently undergone a right-sided mastectomy for stage 3 breast cancer. When giving report to the next shift, what information would be essential to communicate to the oncoming nurse? Select all that apply. A. Elevate the right arm on a pillow. Correct B. Monitor skin color and for the presence of edema. Correct C. Educate that a medical alert bracelet is being worn. Correct D. Ensure the client refrains from any physical activity. Incorrect E. Take blood pressure measurements on the right side only. Incorrect Rationale: After a mastectomy, the nurse must assess for peripheral tissue perfusion. Therefore it is important to assess skin color and for the presence of edema. Elevation of the extremity will decrease venous pressure and decrease edema. A medical alert bracelet should be worn at all times. A medical alert bracelet should be worn to alert others and prevent anyone from using the affected extremity for blood pressure, intravenous (IV punctures), or blood draws because this could increase the likelihood of infection or decreased tissue perfusion. Although the client should avoid heavy lifting, activity should be encouraged and the client should participate in physical therapy unless contraindicated. Test-Taking Strategy: Note the strategic word essential when considering what information should be included in shift change report. Think about what information would be necessary for safe care of the client to help select the correct answer. Also noting the words, any and only in options 4 and 5 will assist in eliminating these options. Review: mastectomy Level of Cognitive Ability: Applying Client Needs: Safe and Effective Care Environment Integrated Process: Communication and Documentation Content Area: Adult Health: Oncology Priority Concepts: Care Coordination, Tissue Integrity HESI Concepts: Care Coordination, Tissue Integrity Reference: Lewis, S., Dirksen, S., Heitkemper, M., & Bucher, L. (2014). Medical-surgical nursing: Assessment and management of clinical problems (9th ed., p. ). St. Louis: Mosby. Awarded -1.0 points out of 3.0 possible points. 6.ID: 6 A client informs the nurse that she has recently started taking the herbal supplement black cohosh for her menopausal symptoms. When reviewing the client’s medical record, what finding would warrant the need for follow-up? Refer to chart. H i s t o r y a n d P h y s i c a l Laboratory Results M e di c at io n s R e n a l I n Thyroid Stimulating Hormone (TSH) 2.45 mIU/L Gl ipi zi de 5 m g s u f f i c i e n c y or al on ce da ily H e a r t f a i l u r e B-type natriuretic peptide (BNP) 204 pg/ml Si m va st at in 4 0 m g on ce da ily A. TSH result B. BNP result C. Heart failure D. Glipizide prescription Correct Rationale: Black cohosh is an herbal product used to treat hot flashes, irritability, and palpitations. It potentiates insulin, oral hypoglycemic agents, and anti- hypertensive agents. Therefore, follow-up would be necessary if the client was taking glipizide, a sulfonlyrea oral hypoglycemic agent. The TSH result is a normal finding. The BNP result would be expected with a known diagnosis of heart failure and additionally would not be affected by black cohosh. Test-Taking Strategy: Note the strategic words need for follow-up when considering what information provided in the chart is important. The options of heart failure and the BNP result are comparable or alike options, and therefore should be eliminated. Next, note that the TSH level is normal to eliminate this option. Review: interactions associated with black cohosh Level of Cognitive Ability: Synthesizing Client Needs: Safe and Effective Care Environment Integrated Process: Nursing Process: Analysis Content Area: Fundamental of Care: Safety Priority Concepts: Clinical Judgment, Safety HESI Concepts: Clinical Decision-Making/Clinical Judgment, Safety References: Hodgson, B., & Kizior, R. (2015). Saunders nursing drug handbook 2015. (p. 1317 ). St. Louis: Saunders. Lewis, S., Dirksen, S., Heitkemper, M., & Bucher, L. (2014). Medical-surgical nursing: Assessment and management of clinical problems (9th ed., p. 1285). St. Louis: Mosby. Awarded 1.0 points out of 1.0 possible points. 7.ID: 5 A client is admitted to hospital for treatment of a respiratory infection. The client was treated with an intravenous (IV) course of ampicillin and is ready to be discharged home on oral antibiotics. What information present in the chart would warrant the nurse to provide further teaching? Hist ory and Phy sica l Labo rator y and Diag nosti c Findi ngs Medi catio ns Ane Ches t X- Ray: norg esti mate mia cons olida tion in left uppe r lobe and ethin yl estra diol oral once daily Poly Cys Pota Metf tic ssiu ormi Ova m n rian level 500 Syn of mg dro 4.5 oral me meq/ twice (PC L daily OS) A. Anemia B. Potassium result C. Chest X-ray result Incorrect D. Norgestimate and ethinyl estradiol prescription Correct Rationale: Broad-spectrum antibiotics such as ampicillin are commonly used to treat upper respiratory infections. These medications can decrease the effectiveness of oral contraceptive medications and the client should be advised to use alternative birth control options. Anemia has no impact on the use of ampicillin. The chest x-ray results, although abnormal, are expected with a respiratory infection. Serum potassium level is within normal limits. PCOS and the use of metformin is not affected by the oral antibiotic. Test-Taking Strategy: Focus on the strategic words, provide further teaching. Use knowledge of board spectrum antibiotics to answer correctly. Remember that antibiotics can cause a decrease in the effectiveness of oral contraceptive pills. Review: broad spectrum antibiotics. Level of Cognitive Ability: Synthesizing Client Needs: Physiological Integrity Integrated Process: Nursing Process: Analysis Content Area: Fundamentals of Care: Safety Priority Concepts: Client Education, Safety HESI Concepts: Safety, Teaching and Learning/Patient Education Reference: Rosenjack Burchum, Rosenthal (2016), pp. 1022, 1024. Awarded 0.0 points out of 1.0 possible points. 8.ID: 4 The charge nurse is making a client assignment for the upcoming shift. In order to create a safe assignment, the charge nurse plans to assign those clients requiring airborne precautions amongst different nurses. Which clients should be assigned to different nurses? Select all that apply. A. A client with measles. Correct B. A client with C. difficle. C. A client with influenza. Incorrect D. A client with pneumonia. E. A client with tuberculosis. Correct Rationale: Airborne precautions are used for those clients that are diagnosed with or suspected to have a condition spread through airborne transmission. Measles and tuberculosis are transmitted via airborne transmission. A client with influenza should be placed on droplet precautions. A client with C. difficile should be placed in contact and enteric precautions and a client with pneumonia only requires standard precautions. Test Taking Strategy: Focus on the subject of the question, airborne contact precautions. Think about how each disease identified in the options is transmitted in order to help select the correct option. Review: all types of transmission-based precautions Level of Cognitive Ability: Creating Client Needs: Safe and Effective Care Environment Integrated Process: Nursing Process/Planning Content Area: Fundamentals of Care: Infection Control Priority Concepts: Care Coordination, Infection HESI Concepts: Care Coordination, Infection References: Ignatavicius, D. M., & Workman, L. (2013). Medical-surgical nursing: Patient-centered collaborative care. (7th ed. p. 440). St. Louis, MO: W.B. Saunders Company. Perry, A., Potter, P., & Ostendorf, W. (2014). Clinical nursing skills & techniques (8th ed., p. 173). St. Louis: Mosby. Awarded 1.0 points out of 2.0 possible points. 9.ID: 0 The nurse at an outpatient clinic is performing a health assessment on a 67 year-old client. Her health history includes chronic obstructive pulmonary disorder (COPD) and diabetes mellitus and she currently has no complaints. On assessment, the client tells the nurse that she has not received any vaccinations other than a tetanus vaccine four years ago. Which routine vaccinations should be recommended given the client’s age? Select all that apply. A. Tetanus vaccine Incorrect B. Shingles vaccine Correct C. Influenza vaccine Correct D. Rotavirus vaccine Incorrect E. Pneumococcal vaccine Correct Rationale: The Centers for Disease Control (CDC) recommends that a healthy individual over the age of 65 years old should receive the shingles vaccine, an annual influenza vaccine, and a pneumococcal vaccine. Rotavirus is given to infants and the client is not due for a tetanus booster. Test-Taking Strategy: Focus on the data in the question and recall the recommended immunization schedule. Also focus on the client’s age to assist in answering. Review: immunization schedules Level of Cognitive Ability: Applying Client Needs: Health Promotion and Maintenance Integrated Process: Nursing Process: Implementation Content Area: Developmental Stages: Health Assessment/Physical Exam Priority Concepts: Health Promotion, Immunity HESI Concepts: Health Promotion, Immunity Reference: Ignatavicius, D. M., & Workman, L. (2013). Medical-surgical nursing: Patient-centered collaborative care. (7th ed. p. 16). St. Louis, MO: W.B. Saunders Company. Awarded -1.0 points out of 3.0 possible points. 10.ID: 5 The nurse at a long-term care facility is conducting a medication review of a newly admitted older client with dementia, hypertension, diabetes mellitus, and depression. Which medication prescription would warrant the need to contact the health care provider? Select all that apply. A. Lisinopril 10 mg orally once daily. B. Furosemide 20mg orally once daily. C. Fluoxetine 20 mg orally once daily. Correct D. Metformin 500mg orally twice daily. E. Cyclobenzaprine 5mg every 8 hours as needed. Correct Rationale: A close review of medications is necessary for safe care of any client client but because the aging process affects physiological functioning, medication prescriptions for the older client need to be carefully monitored. The use of fluoxetine and cyclobenzaprine are considered inappropriate in the older client according to the Beers criteria and should not be used. All other medications listed would be appropriate. Test-Taking Strategy: Focus on the subject of this question, appropriate medication use in the elderly population. Think about physiological changes that occur with aging when selecting the correct option. Also, specific knowledge of medications in the Beers criteria and the classifications of the medications in the options will assist in answering correctly. Review: Beers criteria Level of Cognitive Ability: Synthesizing Client Needs: Safe and Effective Care Environment Integrated Process: Nursing Process/Analysis Content Area: Fundamental of Care: Medications and Administration Priority Concepts: Collaboration, Safety HESI Concepts: Collaboration, Safety References: Ignatavicius, D. M., & Workman, L. (2013). Medical-surgical nursing: Patient-centered collaborative care. (7th ed. p. 20-21). St. Louis, MO: W.B. Saunders Company. Lewis, S., Dirksen, S., Heitkemper, M., & Bucher, L. (2014). Medical-surgical nursing: Assessment and management of clinical problems (9th ed., p. 74). St. Louis: Mosby. American Geriatrics Society Updated Beers Criteria for Potentially Inappropriate Medication Use in Older Adults, The American Geriatrics Society 2012 Beers Criteria Update Expert Panel; ia_JAGS.pdf Awarded 1.0 points out of 2.0 possible points. 11.ID: 3 The nurse is assisting in the examination of a five year old child who was removed from an abusive home. The social worker alerts the nurse that there is a history of violence in the child’s home, which has resulted in the removal of the child and siblings. Which behaviors should the nurse expect the child to express? Select all that apply. A. Smiling during the exam. B. Blaming the abuser for the injury. C. A need to find and protect a sibling. Correct D. Feeling guilty for causing the abuse to occur. Correct E. Aggressive behavior towards the nurse and health care provider. Correct Rationale: In homes where intimate partner violence (IPV) occurs, children are exposed to that violence at the very least and often become additional recipients of that violence. IPV usually predates abuse of the child. Younger children seem to have more behavioral problems when exposed to intra-family violence. For instance, they often have problems with anxiety, depression, and aggression. They often experience many fears and worries that are developmentally inappropriate. Expressing the need to find and protect a sibling is an example of worry that is developmentally inappropriate for a five year old child. Guilt is another aspect that abused children frequently struggle with, as children often blame themselves for abuse. The nurse would expect the child to portray aggressive behaviors out of fear. Due to the history of violence that this child has been subjected to, the nurse would not expect the child to smile and be receptive to the exam, or blame the abuser for the injury. Another issue of concern that the nurse should be aware of is post-traumatic stress disorder (PTSD). Associated features of PTSD may be more detrimental than the violence itself. Test-Taking Strategy: Focus on the subject, “behaviors of an abused child”. Determine which behaviors an abused child would show during interaction with the nurse. Eliminate options 1 and 2, because the child is likely to be afraid and unsure of the nurse and exam. Review: Behaviors of the abused child. Level of Cognitive Ability: Analyzing Client Needs: Psychosocial Integrity. Integrated Process: Nursing Process/Assessment Content Area: Leadership/Management Giddens Concepts: Caregiving, Interpersonal Violence HESI Concepts: Developmental/Family Dynamics, Violence References: Giddens, J. (2013). Concepts for nursing practice. (1st ed., p. 353). St. Louis: Mosby. Hockenberry, M, & Wilson, D. (2015). Wong’s nursing care of infants and children (10th ed. pp. 565-566). St Louis: Mosby. Awarded 3.0 points out of 3.0 possible points. 12.ID: 9 The nurse is examining an infant with burns that are suspicious for child abuse. Which findings should the nurse report as highly suspicious for abuse? (Select all that apply). A. A burn mark on the child’s finger. B. Circular burn marks on the infant’s buttocks. Correct C. A bright pink coloring on the infant’s cheeks. D. A dark brown marking on the infant’s lower back. Incorrect E. A stocking pattern of burn marks on the infant’s feet and legs. Correct Rationale: Examination findings for interpersonal violence range from subtle to obvious. Some may manifest as old or new injuries that may seem mild to more significant and may not raise concern. For this reason, it is critical to consider the history in relation to injuries seen. The nurse should also maintain a high degree of awareness for injuries that are not typically seen in the context of day- to-day living—such as unusual patterns of bruising or burn marks. Findings during the physical assessment that would raise suspicion for the nurse are circular burns or burns that occur in a stocking pattern. A burn mark to the finger should be questioned, but is not highly suspicious for child abuse. Bright pink coloring to the checks is typically normal in infants. Dark brown markings located on the lower back or buttocks are known as Mongolian spots. Test-Taking Strategy: Focus on the subject, “highly suspicious signs of child abuse”. Note the word “highly” nad determine which signs are indicative of abuse. Eliminate options 1, 3 and 4 because these findings do not necessarily indicate that child abuse has occurred.. Review: Child Abuse Level of Cognitive Ability: Analyzing Client Needs: Psychosocial Integrity Integrated Process: Nursing Process/Assessment Content Area: Leadership/Management Giddens Concepts: Clinical Judgment, Interpersonal Violence. HESI Concepts: Clinical Decision-Making/Clinical Judgment, Violence Reference: Giddens, J. (2013). Concepts for nursing practice. (1st ed., p. 354). St. Louis: Mosby. Hockenberry, M, & Wilson, D. (2015). Wong’s nursing care of infants and children (10th ed. p. 562). St Louis: Mosby. Awarded 1.0 points out of 2.0 possible points. 13.ID: 1 The nurse is volunteering at a local health fair to educate the public on primary prevention of stress. Which interventions would be the most appropriate for the nurse to recommend to the public, in order to reduce stress levels? Select all that apply. A. Finding a source of pleasure. Correct B. Developing a positive attitude. Correct C. Counseling for chronic anxiety. Correct D. Engaging in stressful situations. E. Learning relaxation and deep breathing exercises. Correct Rationale: Primary prevention refers to activities that prevent or decrease the probability of occurrence of an injury, physical or mental illness, or health- threatening situation in an individual or family, or an event or illness in the population by combating harmful forces and by strengthening the capacity of individuals to withstand these forces. It would be most appropriate for the nurse to suggest finding a source of pleasure, whether it is spending time with family or talking a walk each day. Developing a positive attitude, seeking counseling for chronic anxiety and utilizing relaxation and deep breathing exercises are also ways to combat stress. The nurse should recommend that individuals stay away from stressful situations, in order to decrease their overall levels of stress. Test-Taking Strategy: Focus on the strategic words, “most appropriate”. In this scenario, the most appropriate action is to assist the public in reducing stress levels. Eliminate option 4, because this would lead to an increase in stress levels. Review: Stress reduction. Level of Cognitive Ability: Applying Client Needs: Health Promotion and Maintenance Integrated Process: Teaching and Learning Content Area: Leadership/Management Giddens Concepts: Health Promotion, Stress HESI Concepts: Teaching and Learning/Patient Education, Stress and Coping Reference: Giddens, J. (2013). Concepts for nNursing Practice. (1st ed., p 354). St. Louis: Mosby. Lewis, S., Dirksen, S., Heitkemper, M., & Bucher, L. (2014). Medical-surgical nursing: Assessment and management of clinical problems (9th ed., pp. 92-94). St. Louis: Mosby. Awarded 2.0 points out of 4.0 possible points. 14.ID: 4 The nurse is assisting a family with end-of-life care for their child. Which actions by the nurse would be the most appropriate? Select all that apply. A. Acknowledging the emotions of the family members. Correct B. Taking time to listen to the family talk about their child. Correct C. Limiting communication with the family, to allow grieving. D. Reminding the family that their feelings and emotions are normal. Correct E. Gently reminding the family that they must focus on their remaining children. Rationale: Chronic and terminal conditions involve the loss of health and result in grief. Grief is a normal psychophysiological process that occurs in response to a specific loss. As adjustment to the condition progresses, many parents experience chronic sorrow related to the unending nature of the child's condition and the ongoing feelings of loss. It is important that the nurse take the time to listen to the family as they talk about their child. The nurse should also acknowledge the emotions of the family members and remind them that their feelings and emotions are normal. Not acknowledging the family members feelings are often triggers for grief. It would be inappropriate, or even hurtful, to the family if the nurse limited communications or suggested that the family focus on the remaining children. During this time, family members need therapeutic and caring support from the nurse. Test-Taking Strategy: Focus on the strategic words, “most appropriate”. Determine which nursing actions would be the most beneficial to the family in their time of need. Eliminate options 3 and 5, because these actions may be upsetting to the family and may not provide the support that the family needs. Review: End-of-life Care. Priority Nursing Tip: The grief experience is unique to each person. Be supportive to the client and family at all times. Prepare by practicing therapeutic communication. Level of Cognitive Ability: Applying Client Needs: Psychosocial Integrity Integrated Process: Nursing Process/Planning Content Area: Leadership/Management Giddens Concepts: Communication, Palliation. HESI Concepts: Reference: Hockenberry, M, & Wilson, D. (2015). Wong’s nursing care of infants and children (10th ed. pp. 807-809). St Louis: Mosby. Awarded 2.0 points out of 3.0 possible points. 15.ID: 1 A pregnant client has a history of depression and has been noncompliant with treatment in the past. What actions by the nurse would be the most appropriate? Select all that apply. A. Respect the client's decisions. Correct B. Maintain a hopeful, caring relationship with the client. Correct C. Discuss the noncompliance with the client, if the client brings it up. D. Provide education to the client about depression and treatment options. Correct E. Ask the client what methods of managing the depression have worked in the past. Correct Rationale: Women are at risk for developing a psychiatric disorder between the ages of 18 and 45 years—the childbearing years. Women who have serious mental disorders may be engaging in sexual activities that can result in pregnancy. The pregnant woman may have a history of disorder in mood, anxiety, substance use, schizophrenia, personality, or development and may be noncompliant with treatment for the disorder. Assessment throughout pregnancy and the postpartum period is critical to the mother's and the baby's health. The nurse should strive to maintain respect for the client's decisions at all times, even though the nurse may not agree with the client's decisions. Maintaining a hopeful and caring relationship with the client, allows for the establishment of trust. The nurse should provide education when the client is open to learning, and utilize teachable moments whenever possible. In order to create a plan of care that works, the nurse should ask the client what methods of depression management have been successful in the past. It would not be effective for the nurse to avoid discussion of depression unless the client's brings up the topic. The nurse should recognize the need for education and begin assessing the client's readiness to learn. Test-Taking Strategy: Focus on the strategic words, “most appropriate.”Think about the components of a therapeutic relationship and methods to deal with noncompliance. Determine which actions by the nurse would be the most appropriate to maintain a therapeutic relationship with the client. Eliminate option 3, because this action would not be beneficial to the client. Review: Depression. Level of Cognitive Ability: Applying Client Needs: Psychosocial Integrity Integrated Process: Nursing Process/Implementation Content Area: Mental Health Giddens Concepts: Adherence, Caregiving, HESI Concepts: Reference: Lowdermilk, D., Perry, S., Cashion, K., & Alden, K. (2016). Maternity & Women’s Health Care (11th ed., pp. 748-749). St. Louis: Elsevier. Awarded 2.0 points out of 4.0 possible points. 16.ID: 0 The nurse is caring for a client who is in labor and preparing for birth. The nurse has been advised that the pregnancy is the result of a rape. Which statements by the nurse would be the most appropriate? Select all that apply. A. "You are safe here." Correct B. "We have done this many times before." Incorrect C. "Just relax; we know what we are doing." D. "You are in labor and preparing to give birth to your baby." Correct E. "You do not need to be concerned about anything because your baby is ok." Correct Rationale: In order to create a comfortable environment for the client, the nurse should maintain a calm environment and use words that will comfort the client. The nurse should let the client know that the environment is safe and that safety will be maintained at all times. The client should be updated on what is happening, and letting the client know what to expect, what examinations are occurring, and the reason why. The nurse should refrain from making vague statements, and instead should personalize care to the needs of the client. If the pregnancy is a result of rape, the woman may be extremely ambivalent about the baby. If the rape occurred some time ago, the experience of pregnancy with prenatal examinations can trigger memories of the original trauma. It is important to know that she may avoid prenatal examinations because of the anxiety triggered by bodily touch and vaginal examinations. Test-Taking Strategy: Focus on the strategic words, “most appropriate.” Use therapeutic communication techniques. Eliminate options 2 and 3, because these statements could increase the anxiety level of the client and are nontherapeutic. Review: rape syndrome. Level of Cognitive Ability: Applying Client Needs: Psychosocial Integrity Integrated Process: Nursing Process/Implementation Content Area: Maternity Giddens Concepts: Communication, Professionalism HESI Concepts: Reference: Lowdermilk, D., Perry, S., Cashion, K., & Alden, K. (2016). Maternity & Women’s Health Care (11th ed., pp. 742-743). St. Louis: Elsevier. Awarded 1.0 points out of 3.0 possible points. 17.ID: 3 The nurse is attending an educational session on substance abuse during pregnancy. Which statements by the nurse indicate that the education has been effective? Select all that apply. A. "Substance abuse generally has no effect on the fetus." Incorrect B. "Social stigma, labeling, and guilt are barriers to treatment." Correct C. "Pregnant women often do not seek help for fear of losing their child." Correct D. "Most pregnant women end up receiving treatment for their addictions." Incorrect E. "In some states, pregnant women who abuse substances may face criminal charges." Correct Rationale: Substance abuse refers to the continued use of substances despite related problems in physical, social, or interpersonal areas. Recurrent abuse results in failure to fulfill major role obligations, and there may be substance- related legal problems. Any use of alcohol or illicit drugs during pregnancy is considered abuse. There are serious damaging effects of alcohol and illicit drugs on pregnant clients and their fetuses. Alcohol and other drugs easily pass from a mother to her fetus through the placenta. Therefore it is important for pregnant clients to seek treatment. It is important that the nurse have a clear understanding of the effects of substance abuse during pregnancy. The nurse should understand the barriers that prevent treatment, such as social stigma, labeling, and guilt. The nurse should know that many pregnant clients avoid treatment out of fear of losing their child. In some states, pregnant clients may face criminal charges for their use of drugs while pregnant. Nurses should recognize that substance abuse has a direct effect on the health and well-being of both the mother and fetus, and that less than 10% of pregnant substance abusers actually receive treatment for their addiction. Test-Taking Strategy: Focus on the strategic word, “effective” and the subject, education was effective. Determine which statements by the nurse indicate that the nurse has an understanding of the effect of substance abuse during pregnancy. Eliminate options 1 and 4, because these statements are incorrect, meaning that the nurse needs more education. Review: Substance abuse during pregnancy. Level of Cognitive Ability: Evaluating Client Needs: Physiological Integrity Integrated Process: Nursing Process/Evaluation Content Area: Maternity Giddens Concepts: Addiction, Reproduction HESI Concepts: Addiction, Sexuality/Reproduction Reference: Lowdermilk, D., Perry, S., Cashion, K., & Alden, K. (2016). Maternity & Women’s Health Care (11th ed., pp. 751-752). St. Louis: Elsevier. Awarded -1.0 points out of 3.0 possible points. 18.ID: 0 The nurse is assessing a client who is two days post-partum, and preparing to be discharged from the health care facility. Which interventions would be the most appropriate for the nurse to perform? Select all that apply. A. Assess the client for risk factors of depression. Correct B. Determine if a follow-up after discharge is necessary. C. Provide a listing of community resources to the client and family. Correct D. Spend time observing the interactions between the client and infant. Correct E. Educate the client and family on the signs of post-partum depression. Correct Rationale: Even though the prevalence of post-partum depression is fairly well established, it often remains undetected because women are hesitant to report symptoms of depression to their health care providers or to seek help from a mental health provider. It is important that the nurse take time to adequately assess the client and prepare the family for discharge. The nurse should always plan to follow-up with the client after discharge, whether by discharge phone calls or home visit. The nurse should also assess the client for risk factors of depression before discharge, so that proper interventions can be made. Providing a list of community resources to the client and family may help in decreasing the the client and family’s anxiety in obtaining help when needed. The nurse should educate the client and family on signs of post-partum depression and where to get help. The nurse should also spend some time observing interactions between the client and infant, and performing any interventions that may be necessary. Test-Taking Strategy: Focus on the strategic words, “most appropriate”. Determine which interventions would be the most appropriate, or most likely to help the client. Eliminate option 2 because follow-up after discharge is always necessary. Review: Nursing interventions for post-partum depression. Level of Cognitive Ability: Applying Client Needs: Psychosocial Integrity Integrated Process: Nursing Process/Implementation Content Area: Maternity Giddens Concepts: Caregiving, Client Education HESI Concepts: Caregiving, Teaching and Learning/Patient Education Reference: Lowdermilk, D., Perry, S., Cashion, K., & Alden, K. (2016). Maternity & Women’s Health Care (11th ed., pp. 749, 751). St. Louis: Elsevier. Awarded 3.0 points out of 4.0 possible points. 19.ID: 0 The nurse on a post-partum floor is assessing a client for signs of post-partum depression. Which statements would be the most appropriate for the nurse to make, in order to assess the client for depression? Select all that apply. A. "How are things going for you today?" Correct B. "Do you have anyone to help you at home?" Correct C. "Can you tell me how you are feeling today?” Correct D. "I'm sure you're so happy with your new baby". E. "It is not very common to feel sad after giving birth". Rationale: To recognize symptoms of post-partum depression as early as possible, the nurse should be an active listener and demonstrate a caring attitude. Nurses cannot depend on women volunteering unsolicited information about their depression or asking for help. The nurse should observe for signs of depression and ask appropriate questions to determine moods, appetite, sleep, energy, and fatigue levels, and ability to concentrate. The nurse should make an effort to engage in conversation with the client, in order to gain an understanding of how the client is feeling. Asking if the client feels sad, how things are going, and inquiring if the client has help at home, are good ways to engage the client in conversation and determine if there is evidence of depression. Assuming that the client feels happy or making general statements are not ways that the nurse can effectively assess for post-partum depression. Test-Taking Strategy: Focus on the strategic words, “most appropriate”. Determine which statements would assist the nurse in assessment of the post- partum client. Eliminate option 4 because it makes an assumption about the client. Eliminate option 5, because this is a general statement and not a question aimed at assessing the client. Options 4 and 5 are non-therapeutic statements. Review: Nursing assessment for post-partum depression. Level of Cognitive Ability: Applying Client Needs: Psychosocial Integrity Integrated Process: Nursing Process/Assessment Content Area: Maternity. Giddens Concepts: Clinical Judgment, Communication HESI Concepts: Clinical Decision-Making/Clinical Judgment, Communication Reference: Lowdermilk, D., Perry, S., Cashion, K., & Alden, K. (2016). Maternity & Women’s Health Care (11th ed., pp. 747-748). St. Louis: Elsevier. Awarded 2.0 points out of 3.0 possible points. 20.ID: 0 The nurse manager is educating a group of nursing students on the educational needs of bariatric clients post-surgery. Which statement by one of the nursing students indicates that the teaching has been effective? Select all that apply. A. "The client should be encouraged to keep follow-up appointments." Correct B. "During weight loss, the client may become depressed or even anxious." Correct C. "Clients should be provided with a list of available community resources." Correct D. "It is not necessary for clients to adhere to a community-based treatment plan." E. "Clients are followed by a surgeon and dietician for a few months after the surgery." Incorrect Rationale: Obesity is a chronic, lifelong problem. Diets, medication therapy, exercise, and behavior modification can produce short-term weight losses with reasonable safety. However, most who do lose weight often regain the weight. Treatment of obesity should focus on the long-term reduction of health risks and medical problems associated with obesity, improving quality of life, and promoting a health-oriented lifestyle. The nurse manager knows that teaching has been effective when the student states that post-surgical clients should keep follow-up appointments. The client may also become depressed or anxious during this time, and experience a "hibernation period." Clients should receive a list of community resources that are available specifically to them. Clients should be educated about the importance of adhering to a community- based treatment plan, which will give them access to information and support. The client should understand that they will be followed by both a surgeon and dietician for a few years after surgery. Test-Taking Strategy: Focus on the strategic word, “effective.” Determine which statements are correct, indicating that the student has an understanding of the topic. Eliminate options 4 and 5, because these statements are not correct regarding the educational needs of bariatric clients. These statements indicate that further education is needed. Review: Education of the bariatric client Level of Cognitive Ability: Evaluating Client Needs: Psychosocial Integrity Integrated Process: Nursing Process/Evaluation Content Area: Adult Health Giddens Concepts: Client Education, Health Promotion HESI Concepts: Health, Wellness, and Illness – Health Promotion, Teaching and Learning/Patient Education Reference: Ignatavicius, D & Workman, M. (2013). Medical-surgical nursing: Patient-centered collaborative care. (7th ed., p. 1356). Philadelphia: Saunders. Awarded 1.0 points out of 3.0 possible points. 21.ID: 0 The nurse is monitoring a client who is receiving a blood transfusion. The blood has been infusing for 15 minutes. The nurse interprets which assessment findings as a possible allergic reaction? Select all that apply. A. Increased pallor Correct B. New onset of hypertension Incorrect C. The client reports feeling nervous D. Palpation of a rapid, thready pulse Correct E. A change in the client’s level of fatigue Rationale: Nursing actions during transfusions aim at prevention or early recognition of transfusion reactions. Reactions include palpation of a rapid thready pulse, and increased pallor or cyanosis. These findings should alert the nurse to a possible reaction. It is important that the nurse immediately stop the blood infusion if a reaction is suspected. Findings such as hypertension, nervousness, or a change in fatigue level do not typically indicate an allergic reaction. However, the nurse should continue to monitor these symptoms and intervene as necessary. Test-Taking Strategy: Focus on the subject, “possible allergic reaction to blood.” Determine which assessment findings indicate the possibility of an allergic reaction. Think about how the client might react in a reaction. and use knowledge of the assessment findings in a reaction to answer correctly. Review: Blood Administration. Level of Cognitive Ability: Synthesizing Client Needs: Safe and Effective Care Environment Integrated Process: Nursing Process/Assessment Content Area: Blood Administration Giddens Concepts: Clinical Judgment, Safety HESI Concepts: Clinical Decision-Making/Clinical Judgment, Safety Reference: Ignatavicius, D., & Workman, M. (2016). Medical-surgical nursing: Patient-centered collaborative care. (8th ed., p. 823). St. Louis: Saunders. Awarded 0.0 points out of 2.0 possible points. 22.ID: 8 The nurse is assessing the client for placement of a midline catheter. Which factors would prompt the nurse to select a different type of catheter for this client? Select all that apply. A. Dialysis fistula on the right arm Incorrect B. The use of vesicant medications Correct C. The need for long-term antibiotics Incorrect D. Client history of bilateral mastectomy with lymphedema Correct E. The need for parenteral therapy with osmolarity greater than 600 mOsm/L (600 mmol/kg) F. Correct Rationale: An infusion catheter, also known as a vascular access device (VAD), is a plastic tube placed in a blood vessel to deliver fluids and medications. The specific type and purpose of the therapy determine whether the infusion can be given safely through peripheral veins or if the large central veins of the chest are needed. Midline catheters are placed in the peripheral circulation. Fluids and medications infused through a midline catheter should have a pH between 5 and 9 and a final osmolarity of less than 600 mOsm/L(600 mmol/kg). The pH and osmolarity outside these parameters increase the risk for complications like nurse would choose another type of catheter if the client will be given any vesicant medications, because leakage of these medications could damage surrounding tissue. The nurse should also avoid use of a midline catheter if the client has had a bilateral mastectomy with lymphedema, or if the client requires parenteral therapy that has an osmolarity greater than 600 mOsm/L (600 mmol/kg). Test-Taking Strategy: Focus on the subject, “contraindications for use of a midline catheter.” Think about the anatomical location of this type of catheter to answer correctly. Review: Use of midline catheters. Level of Cognitive Ability: Analyzing Client Needs: Safe and Effective Care Environment Integrated Process: Nursing Process/Assessment Content Area: Intravenous Therapy Giddens Concepts: Clinical Judgment, Safety HESI Concepts: Clinical Decision-Making/Clinical Judgment, Safety Reference: Ignatavicius, D., & Workman, M. (2016). Medical-surgical nursing: Patient-centered collaborative care. (8th ed., pp. 192-193). St. Louis: Saunders. Awarded -1.0 points out of 3.0 possible points. 23.ID: 8 The nurse is caring for a client who has been diagnosed with rheumatoid arthritis. The health care provider has just started the client on methotrexate, to manage symptoms. When creating the plan of care for this client, which adverse effects should the nurse monitor for? Select all that apply. A. Increased thirst Incorrect B. Elevated blood pressure C. Elevation of liver enzymes Correct D. A decrease in the platelet count E. An increase in white blood cells (WBC) Rationale: Methotrexate, an immunosuppressive medication, administered in a low, once-a-week dose (generally 25 mg or less per week) is a possible treatment for rheumatoid arthritis. When creating the plan of care, the nurse should monitor for certain adverse effects, and be prepared to treat them. The nurse should assess for an elevation in liver enzymes and a decrease in platelet count. Increased thirst and elevated blood pressure are not adverse effects of methotrexate. The client would experience a decrease in the WBC count, not an increase, during methotrexate therapy. Test-Taking Strategy: Focus on the subject, “adverse effects of methotrexate.” Recalling that this medication is an immunosuppressant will assist in answering correctly. Review: adverse effects of methotrexate Level of Cognitive Ability: Creating Client Needs: Physiological Integrity Integrated Process: Nursing Process/Planning Content Area: Pharmacology Giddens Concepts: Care Coordination, Clinical Judgment HESI Concepts: Care Coordination, Clinical Decision-Making/Clinical Judgment Reference: Ignatavicius, D., & Workman, M. (2016). Medical-surgical nursing: Patient-centered collaborative care. (8th ed., p. 308). St. Louis: Saunders. Awarded -1.0 points out of 2.0 possible points. 24.ID: 8 The nurse is creating a plan of care for a client with chronic pain. Which alternative therapies should the nurse add into the plan, to increase the client’s comfort? Select all that apply. A. Providing therapeutic massage Correct B. Play soft music during rest times Correct C. Assist with a warm, soothing bath Correct D. Educate the client to plan for rest time Correct E. Increase the client’s dosage of pain medication Rationale: With chronic pain, the client cannot depend solely on medications for relief. The nurse should offer alternative therapies to the client when appropriate. These treatments include using therapeutic massage, a warm soothing bath and soft music during rest times. The client should be educated to plan for rest times in between activities. Increasing the client’s pain medication may be appropriate, but it is not considered an alternative treatment. Test-Taking Strategy: Focus on the subject, “using alternative therapies in client care. ” Determine which treatments are considered alternative. Eliminate option 5, because this is a pharmacological therapy and not considered an alternative therapy. Review: Alternative therapies for pain Level of Cognitive Ability: Creating Client Needs: Physiological Integrity Integrated Process: Nursing Process/Planning Content Area: Pain Giddens Concepts: Client Education, Pain HESI Concepts: Teaching and Learning/Patient Education, Pain References: Ignatavicius, D., & Workman, M. (2016). Medical-surgical nursing: Patient-centered collaborative care. (8th ed., pp. 48, 294-295). St. Louis: Saunders. Perry, A., Potter, P., & Ostendorf, W. (2014). Clinical nursing skills & techniques (8th ed., p. 366). St. Louis: Mosby. Awarded 2.0 points out of 4.0 possible points. 25.ID: 2 The nurse is caring for a client who has had a myocardial infarction. After administering intravenous morphine sulfate, which interventions should the nurse take? Select all that apply. A. Monitor the client’s blood pressure Correct B. Monitor the client’s respiratory rate Correct C. Determine the client’s oxygen saturation Correct D. Ask the client to obtain a urine specimen Incorrect E. Prepare the client for cardiac catheterization Rationale: Intravenous morphine sulfate (1 to 2 mg) is often prescribed to reduce myocardial oxygen demand by triggering blood vessel dilation. The nurse should be prepared to monitor the client’s status. After administering morphine sulfate, the nurse should monitor the client’s respiratory rate, oxygen saturation, and blood pressure. The nurse would not prepare the client for the cardiac catheterization unless specifically indicated by the health care provider. While a urine specimen may be needed, it is not the most important intervention after administration of the medication. Test-Taking Strategy: Focus on the subject, nursing interventions after the administration of morphine sulfate. Think about the physiological action and adverse effects of morphine to answer correctly. Review: morphine sulfate Level of Cognitive Ability: Synthesizing Client Needs: Physiological Integrity Integrated Process: Nursing Process/Implementation Content Area: Pharmacology Giddens Concepts: Caregiving, Safety HESI Concepts: Caregiving, Safety Reference: Gahart, B., & Nazareno, A. (2015). 2015 Intravenous medications (31st ed., pp. 841-842). St. Louis: Mosby. Awarded 1.0 points out of 3.0 possible points. 26.ID: 5 The nurse is caring for a client with known chronic kidney disease (CKD), who is taking digoxin. When assessing the client, which signs/symptoms would alert the nurse to the possibility of digoxin toxicity? Select all that apply. A. Anorexia Correct B. Muscle aches Incorrect C. Visual changes Correct D. Sudden ear pain E. Nausea and vomiting Correct Rationale: Clients with CKD are particularly at risk for digoxin toxicity because the medication is excreted by the kidneys. The symptoms include confusion, visual changes, gastrointestinal (GI) disturbances such anorexia, nausea, and vomiting. Muscle aches and sudden ear pain is not indicative of digoxin toxicity. Test-Taking Strategy: Focus on the subject, “signs/symptoms of digoxin toxicity.” It is necessary to know what these manifestations are in order to answer correctly. Remember that GI disturbances and visual disturbances are manifestations. Review: digoxin toxicity. Level of Cognitive Ability: Analyzing Client Needs: Physiological Integrity Integrated Process: Nursing Process/Assessment Content Area: Pharmacology-Cardiovascular Medications Giddens Concepts: Clinical Judgment, Safety HESI Concepts: Clinical Decision-Making/Clinical Judgment, Safety Reference: Ignatavicius, D., & Workman, M. (2016). Medical-surgical nursing: Patient- centered collaborative care. (8th ed., pp. 661-662). St. Louis: Saunders. Awarded 1.0 points out of 3.0 possible points. 27.ID: 3 The nurse is creating a plan of care for a client who was admitted with an infection. The nurse has been informed that the client will need a peripherally inserted central catheter (PICC) line placed, and in the next few days will be discharged home. Which information about the PICC line should the nurse include in the plan of care? Select all that apply. A. Avoid heavy lifting once Correct B. Keep the extremity immobile C. How to care for the PICC line Correct D. Reason for PICC line placement Correct E. How to get dressed with the PICC line Correct Rationale: A peripherally inserted central catheter (PICC) is a catheter inserted through a vein of the antecubital fossa (inner aspect of the bend of the arm) or the middle of the upper arm. PICCs should be inserted early in the course of therapy before the veins of the extremity have been damaged from multiple venipunctures and infusions. The nurse should plan to educate the client on how to care for the PICC line, how to get dressed and perform other activities of daily living, and the reason for the PICC line placement. The nurse should also educate the client to avoid heavy lifting because this can lead to muscle contraction, which can cause catheter dislodgment. Test-Taking Strategy: Focus on the subject, “client education about a PICC line.” Think about the anatomical location of a PICC line and what is important for a client to know. Noting the word “immobile” in option 2 will assist in elimination this option because immobility of the extremity is unnecessary. Review: PICC Lines. Level of Cognitive Ability: Creating Client Needs: Safe and Effective Care Environment Integrated Process: Teaching and Learning Content Area: Intravenous Administration Giddens Concepts: Client Education, Teaching and Learning HESI Concepts: Teaching and Learning/Patient Education, Safety References: Ignatavicius, D., & Workman, M. (2016). Medical-surgical nursing: Patient-centered collaborative care. (8th ed., pp. 193-194). St. Louis: Saunders. Perry, A., Potter, P., & Ostendorf, W. (2014). Clinical nursing skills & techniques (8th ed., p. 708). St. Louis: Mosby. Awarded 3.0 points out of 4.0 possible points. 28.ID: 6 On assessment of a client with a normal saline intravenous (IV) infusion, the nurse notes that the IV site has infiltrated. Which actions by the nurse would be appropriate? Select all that apply. A. Stop the IV infusion Correct B. Elevate the extremity Correct C. Apply a warm compress to the IV site Correct D. Apply a sterile dressing if weeping occurs Correct E. Restart a new IV below the current IV site Rationale: Complications from IV therapy can be minor and limited or life- threatening. It is important for the nurse to frequently monitor the client’s IV site for signs of complications such as infiltration. If infiltration occurs, there are steps the nurse can take to prevent further damage to the tissue involved. These steps include stopping the IV infusion immediately, elevating the extremity to reduce swelling, and applying a warm compress to the IV site after the IV has been removed (per agency procedure). If weeping occurs from the IV site, the nurse can apply a sterile dressing to control the weeping and prevent infection. If the client requires a new IV, the nurse should place the IV in the opposite extremity. Test-Taking Strategy: Focus on the subject, “interventions for IV infiltration.” Think about what the effects on skin integrity are when infiltration occurs. Determine which actions are appropriate to prevent further damage to skin tissue. Eliminate option 5, because this action may increase the risk of damage to tissue. Review: IV Infiltration. Level of Cognitive Ability: Analyzing Client Needs: Physiological Integrity Integrated Process: Nursing Process/Implementation Content Area: Intravenous Administration Giddens Concepts: Health Care Quality, Tissue Integrity HESI Concepts: Quality Improvement/Health Care Quality, Tissue Integrity Reference: Ignatavicius, D., & Workman, M. (2016). Medical-surgical nursing: Patient-centered collaborative care. (8th ed., p. 204). St. Louis: Saunders. Awarded 2.0 points out of 4.0 possible points. 29.ID: 0 The nurse has been assigned a client who is receiving enalapril therapy. After receiving report and looking at the client’s chart, which action should the nurse take first? A. Obtain a blood pressure Correct B. Perform a full physical assessment C. Administer the client’s morning medications D. Order the client’s breakfast tray to be delivered at 0800 Incorrect Rationale: Enalapril is an angiotensin-converting enzyme (ACE) inhibitor that is used to treat hypertension. Therefore, after receiving report and gathering information from the client’s chart, the nurse should first obtain a blood pressure on the client. This will enable the nurse to make decisions about which step to take next, in order to provide safe client care. All other actions can safely wait until the nurse has obtained the client’s blood pressure. Test-Taking Strategy: Focus on the strategic word, “first” and focus on the name of the medication. Recalling that medications that end with the letters –pril are ACE inhibitors and that these medications are used to trest hypertension will assist in answering correctly. The remaining options can safely wait until the blood pressure has been obtained. Review: enalapril Level of Cognitive Ability: Synthesizing Client Needs: Safe and Effective Care Environment Integrated Process: Nursing Process/Implementation Content Area: Leadership/Management: Prioritizing Giddens Concepts: Care Coordination, Safety HESI Concepts: Care Coordination, Safety Reference: Lilley, L., Rainforth Collins, S., Harrington, S., & Snyder J. (2014). Pharmacology and the nursing process (7th ed., pp. 356, 362-363). St. Louis: Mosby. Awarded 0.0 points out of 1.0 possible points. 30.ID: 0 The nurse is preparing to administer bumetanide to a client. What information is the priority for the nurse to obtain prior to administering this medication? A. The client’s current weight B. The client’s potassium level Correct C. The time of the client’s last meal D. The time of the last bumetanide administration Rationale: Bumetanide is a loop diuretic that causes the kidneys to excrete potassium, which can lead to hypokalemia. Therefore it should be the nurse’s highest priority to obtain the client’s potassium level prior to administering the potassium. While the other options are important in the care of the client, the potassium level is the highest priority for client safety and well-being. Test-Taking Strategy: Note the strategic word, priority. Recalling that bumetanide is a diuretic will assist in answering the question. Remember that most diuretics cause hypokalemia. Review: bumetanide Level of Cognitive Ability: Analyzing Client Needs: Physiology Integrity Integrated Process: Nursing Process/Assessment Content Area: Leadership/Management: Prioritizing. Giddens Concepts: Clinical Judgment, Fluid and Electrolyte Balance HESI Concepts: Clinical Decision-Making/Clinical Judgment, Fluids and Electrolytes Reference: Ignatavicius, D., & Workman, M. (2016). Medical-surgical nursing: Patient-centered collaborative care. (8th ed., p. 165). St. Louis: Saunders. Awarded 1.0 points out of 1.0 possible points. 31.ID: 9 Which clients are at high risk for venous thromboembolism (VTE)? Select all that apply. A. A 35 year-old with intractable nausea B. A 88 year-old admitted with confusion Correct C. A 28 year-old recovering from a paralytic ileus Incorrect D. A 45 year-old recovering from a total hysterectomy Correct E. A 45 year-old in a motor vehicle accident who sustained multiple fractures Correct Rationale: Clients at risk for VTE include those with prolonged immobility such as those with multiple fractures, those recovering from a surgical procedure, such as a total hysterectomy, obese clients, and those with advancing age. Nausea and paralytic ileus alone do not increase the risk for VTE. Test-Taking Strategy: Focus on the subject of the question, clients at risk for a VTE. Think about the pathophysiology associated with VTE and about conditions that could impact circulation and blood flow to answer this question correctly. Review: Venous thromboembolism Level of Cognitive Ability: Analyzing Client Needs: Physiological Integrity Integrated Process: Nursing Process: Assessment Content Area: Adult Health: Cardiovascular Giddens Concepts: Clotting, Perfusion HESI Concepts: Clotting, Perfusion References: Ignatavicius, D., & Workman, M. (2013). Medical-surgical nursing: Patient-centered collaborative care. (7th ed., p. 663). St. Louis: Saunders. Lewis, S., Dirksen, S., Heitkemper, M., & Bucher, L. (2014). Medical-surgical nursing: Assessment and management of clinical problems (9th ed., p. 848). St. Louis: Mosby. Awarded 1.0 points out of 3.0 possible points. 32.ID: 4 The nurse in the emergency department is caring for a client just brought in with partial thickness burns to 50% of the body. What actions should the nurse implement as part of the care plan? Select all that apply. A. Elevate extremities Correct B. Administer tetanus vaccine for prophylaxis Correct C. Assess airway patency and provide oxygen as needed Correct D. Provide the client with a large glass of water to stay hydrated Incorrect E. Keep burns uncovered to allow for cooling air to reach the wounds Rationale: Immediate care for a burn is critical. Ensure in the first hour after a burn that the client’s extremities are elevated to prevent edema. Administer a prophylactic dose of tetanus, assess the airway to ensure patency, and administer oxygen as needed. Water should not be provided to the client because the client should remain NPO; initiate fluid rehydration with IV fluids instead. Lastly, cover he client with a blanket to help maintain body temperature. Test-Taking Strategy: Focus on the subject, care for the client with burns. Also, use the ABC – airway, breathing, circulation strategy to include activities that support the airway and promote circulation. Review: immediate burn care Level of Cognitive Ability: Creating Client Needs: Physiological Integrity Integrated Process: Nursing Process: Planning Content Area: Critical Care: Emergency Situations/Management Giddens Concepts: Thermoregulation, Tissue Integrity HESI Concepts: Thermoregulation, Tissue Integrity Reference: Ignatavicius, D., & Workman, M. (2013). Medical-surgical nursing: Patient-centered collaborative care. (7th ed., p. 520). St. Louis: Saunders. Awarded 0.0 points out of 3.0 possible points. 33.ID: 6 The nurse caring for an 8 month old child at the pediatrician’s office is reviewing medication instructions with the father. The client has otitis media and has been prescribed amoxicillin 250 mg three times daily. The medication comes as a liquid suspension of 500 mg/10 mL. The nurse would advise the father to give how many milliliters per dose? Fill in the blank and round answer to the nearest whole number. milliliters Correct Correct Responses A. 5 Rationale: First, calculate the dose needed, which is 250 mg or 5 mL. The father shou