Friday, 20 November 2020

Question Of The Day, Medication and I.V. Administration
Q. A 56-year-old client is receiving chemotherapy that has the potential to cause pulmonary toxicity. Which of the following symptoms indicates a toxic response to the chemotherapy?

A. Decrease in appetite.

B. Drowsiness.

C. Spasms of the diaphragm.

D. Cough and shortness of breath.

Correct Answer: D

Reason: Cough and shortness of breath are significant symptoms because they may indicate decreasing pulmonary function secondary to drug toxicity. Decrease in appetite, difficulty in thinking clearly, and spasms of the diaphragm may occur as a result of chemotherapy; however, they are not indicative of pulmonary toxicity.

Thursday, 19 November 2020

Q. Which scenario complies with Health Insurance Portability and Accountability Act of 1996 (HIPAA) regulations?

A. Two nurses in the cafeteria are discussing a client's condition.

B. The health care team is discussing a client's care during a formal care conference.

C. A nurse checks the computer for the laboratory results of a neighbor who has been admitted to another floor.

D. A nurse talks with her spouse about a client's condition.

Correct Answer:  B

Reason: To provide interdisciplinary continuity of care, nurses must share relevant information during client care conferences. Nurses discussing information in the cafeteria may be overheard; this indiscretion violates HIPAA regulations. Looking up laboratory results for a neighbor is a HIPAA violation, as is discussing a client's condition with one's spouse.

Monday, 9 November 2020

Q. A 40-year-old executive who was unexpectedly laid off from work 2 days earlier complains of fatigue and an inability to cope. He admits drinking excessively over the previous 48 hours. This behavior is an example of:

A. alcoholism.

B. a manic episode.

C. situational crisis.

D. depression.

Correct Answer: C

Reason: A situational crisis results from a specific event in the life of a person who is overwhelmed by the situation and reacts emotionally. Fatigue, insomnia, and inability to make decisions are common signs and symptoms. The situational crisis may precipitate behavior that causes a crisis (alcohol or drug abuse). There isn't enough information to label this client an alcoholic. A manic episode is characterized by euphoria and labile affect. Symptoms of depression are usually present for 2 or more weeks.

Thursday, 5 November 2020

Q. During rounds, a nurse finds that a client with hemiplegia has fallen from the bed because the nursing assistant failed to raise the side rails after giving a back massage. The nurse assists the client to the bed and assesses for injury. As per agency policies, the nurse fills out an incident report. Which of the following activities should the nurse perform after finishing the incident report?

A. Attach a copy to the client's records.

B. Highlight the mistake in the client's records.

C. Include the time and date of the incident.

D. Mention the name of the nursing assistant in the client records.

Correct Answer: C

Reason: The nurse should include the date and time of the incident in the incident report, the events leading up to it, the client's response, and a full nursing assessment. To prevent legal issues, the nurse should not attach the copy of the incident report to the client's records. Also to prevent litigation, the mistake should not be highlighted in the client's records. As the client report is a legal document, it should not contain the name of the nursing assistant.

Wednesday, 4 November 2020

Q. The client is receiving an I.V. infusion of 5% dextrose in normal saline running at 125 ml/hour. When hanging a new bag of fluid, the nurse notes swelling and hardness at the infusion site. The nurse should first:

A. Discontinue the infusion.

B. Apply a warm soak to the site.

C. Stop the flow of solution temporarily.

D. Irrigate the needle with normal saline.

Correct Answer: A

Reason: Signs of infiltration include slowing of the infusion and swelling, pain, hardness, pallor, and coolness of the skin at the site. If these signs occur, the I.V. line should be discontinued and restarted at another infusion site. The new anatomic site, time, and type of cannula used should be documented. The nurse may apply a warm soak to the site, but only after the I.V. line is discontinued. Parenteral administration of fluids should not be stopped intermittently. Stopping the flow does not treat the problem, nor does it address the client's needs for fluid replacement. Infiltrated I.V. sites should not be irrigated; doing so will only cause more swelling and pain.

Tuesday, 3 November 2020

Question Of The Day, Basic Physical Care
Q. Communicating with parents and children about health care has become increasingly significant because:

A. Consumers of health care cannot keep up with rapid advances in science.

B. The influence of the media and specialization have increased the complexity of managing health.

C. Nurse educators have recognized the value of communication.

D. Clients are more demanding that their rights be respected.

Correct Answer: B

Reason: Today's health care network includes many specialized areas, such as respiratory therapy, medicine, laboratory, social services, and technical monitoring, to name a few. Due to expanded media coverage of health care issues, parents are more aware of health care issues but cannot understand all the ramifications of possible health care decisions. Because of this expanded media coverage, health care consumers are more aware of advances in the science of health care. Nurses have always recognized the value of communication and that all nurses are teachers. Clients are more aware of their rights through media exposure and information disseminated by health care facilities. However, respect for the client's rights should be the nurse's concern as well and communicating with parents and children should not be impacted by a client's knowledge or demand for those rights.

Monday, 2 November 2020

Question Of The Day, Respiratory Disorders
Q. A client with a tracheostomy tube coughs and dislodges the tracheostomy tube. The nurse's first action should be to:

A. Call for emergency assistance.

B. Attempt reinsertion of tracheostomy tube.

C. Position the client in semi-Fowler's position with the neck hyperextended.

D. Insert the obturator into the stoma to reestablish the airway.

Correct Answer: B

Reason: The nurse's first action should be to attempt to replace the tracheostomy tube immediately so that the client's airway is reestablished. Although the nurse may also call for assistance, there should be no delay before attempting reinsertion of the tube. The client is placed in a supine position with the neck hyperextended to facilitate reentry of the tube. The obturator is inserted into the replacement tracheostomy tube to guide insertion and is then removed to allow passage of air through the tube.

Saturday, 31 October 2020

Q. A nurse on a rehabilitation unit is caring for a client who sustained a head injury in a motor vehicle accident. She notes that the client has become restless and agitated during therapy; previous documentation described the client as cooperative during therapy sessions. The nurse's priority action should be to:

A. gather assessment data and notify the physician of the change in the client's status.

B. ask the physician to order an antipsychotic medication for the client.

C. consult with the social worker about the possibility of discharging the client from the facility.

D. tell the client that she'll punish him if he doesn't behave.

Correct Answer: A

Reason: A client with a head injury who experiences a change in cognition requires further assessment and evaluation, and the nurse should notify the physician of the change in the client's status. The physician should rule out all possible medical causes of the change in mental status before ordering antipsychotic medications or considering discharging the client from the facility. A nurse shouldn't threaten a client with punishment; doing so is a violation of the client's rights.

Friday, 30 October 2020

Q. Which finding best indicates that a nursing assistant has an understanding of blood glucose meter use?

A. Verbalizing an understanding of blood glucose meter use

B. Documenting a normal blood glucose level

C. Providing documentation of previous certification

D. Demonstrating correct technique

Correct Answer: D

Reason: The best way to validate blood glucose meter use is to allow the nursing assistant to demonstrate correct technique. Verbalizing understanding doesn't demonstrate that the nursing assistant knows proper technique. Documenting a normal blood glucose level and having previous certification don't demonstrate blood glucose meter use.

Thursday, 29 October 2020

Question Of The Day, Gastrointestinal Disorders
Q
. A client with gastroenteritis is admitted to an acute care facility and presents with severe dehydration and electrolyte imbalances. Diagnostic tests reveal the Norwalk virus as the cause of gastroenteritis. Based on this information, the nurse knows that:

A. the client requires an antiviral agent.
B. enteric precautions must be continued.
C. enteric precautions can be discontinued.
D. the client's infection may be caused by droplet transmission.

Correct Answer: B

Reason: The nurse must continue enteric precautions for a client with gastroenteritis caused by the Norwalk virus because this virus is transmitted by the fecal-oral route. No safe and effective antiviral agent is available specifically for treating viral gastroenteritis. The Norwalk virus isn't transmitted by droplets.

Wednesday, 28 October 2020

Q. When assessing a client for early septic shock, the nurse should assess the client for which of the following?

A. Cool, clammy skin.

B. Warm, flushed skin.

C. Increased blood pressure.

D. Hemorrhage.

Correct Answer: B

Reason: Warm, flushed skin from a high cardiac output with vasodilation occurs in warm shock or the hyperdynamic phase (first phase) of septic shock. Other signs and symptoms of early septic shock include fever with restlessness and confusion; normal or decreased blood pressure with tachypnea and tachycardia; increased or normal urine output; and nausea and vomiting or diarrhea. Cool, clammy skin occurs in the hypodynamic or cold phase (later phase). Hemorrhage is not a factor in septic shock.

Tuesday, 27 October 2020

Question Of The Day, The Neonate
Q. Just after delivery, a nurse measures a neonate's axillary temperature at 94.1° F (34.5° C). What should the nurse do?

A. Rewarm the neonate gradually.

B. Rewarm the neonate rapidly.

C. Observe the neonate hourly.

D. Notify the physician when the neonate's temperature is normal.

Correct Answer: A

Reason: A neonate with a temperature of 94.1° F is experiencing cold stress. To correct cold stress while avoiding hyperthermia and its complications, the nurse should rewarm the neonate gradually, observing closely and checking vital signs every 15 to 30 minutes. Rapid rewarming may cause hyperthermia. Hourly observation isn't frequent enough because cold stress increases oxygen, calorie, and fat expenditure, putting the neonate at risk for anabolic metabolism and possibly metabolic acidosis. A neonate with cold stress requires intervention; the nurse should notify the physician of the problem as soon as it's identified.

Monday, 26 October 2020

Q. A client is experiencing an early postpartum hemorrhage. Which item in the client's care plan requires revision?

A. Inserting an indwelling urinary catheter

B. Fundal massage

C. Administration of oxytocics

D. Pad count

Correct Answer: D

Reason: By the time the client is hemorrhaging, a pad count is no longer appropriate. Inserting an indwelling urinary catheter eliminates the possibility that a full bladder may be contributing to the hemorrhage. Fundal massage is appropriate to ensure that the uterus is well contracted, and oxytocics may be ordered to promote sustained uterine contraction.

Sunday, 25 October 2020

Q. A nurse is using Doppler ultrasound to assess a pregnant woman. When should the nurse expect to hear fetal heart tones?

A. 7 weeks' gestation

B. 11 weeks' gestation

C. 17 weeks' gestation

D. 21 weeks' gestation

Correct Answer: B

Reason: Using Doppler ultrasound, fetal heart tones may be heard as early as the 11th week of pregnancy. Using a stethoscope, fetal heart tones may be heard between 17 and 20 weeks' gestation.

Friday, 23 October 2020

Question Of The Day, Mood, Adjustment, and Dementia Disorders
Q. Family members of a client with bipolar disorder tell a nurse that they are concerned that the client is becoming manic. The nurse knows that the manic phase is marked by:

A. flight of ideas and inflated self-esteem.

B. increased sleep and greater distractibility.

C. decreased self-esteem and increased physical restlessness.

D. obsession with following rules and maintaining order.

Correct Answer: A

Reason: The manic phase of bipolar disorder is characterized by recurrent episodes of a persistently euphoric and expansive or irritable mood. This phase is diagnosed if the client experiences four of the following signs and symptoms for at least 1 week: flight of ideas; inflated self-esteem; unusual talkativeness; increased social, occupational, or sexual activity; physical restlessness; a decreased need for sleep; increased distractibility; and excessive involvement in activities with a high potential for painful but unrecognized consequences. Obsession with following rules and maintaining order characterizes obsessive-compulsive disorder.

Tuesday, 20 October 2020

Question Of The Day, Toddler
Q. When performing a physical assessment on an 18-month-old child, which of the following would be best?

A. Have a parent hold the toddler.

B. Assess the ears and mouth first.

C. Carry out the assessment from head to toe.

D. Assess motor function by having the child run and walk.

Correct Answer: A

Reason: The best strategy for assessing a toddler is to have the parent hold the toddler. Doing so is comforting to the toddler. Assessment should begin with noninvasive assessments first while the child is quiet. Typically these include assessments of the cardiac and respiratory systems. The ears and throat are typically examined last. Using a head-to-toe approach is more appropriate for an older child. For a toddler, assessment should begin with noninvasive assessments first while the child is quiet. Having a toddler run and be active may make it difficult to settle the child down after the physical exertion.

Friday, 16 October 2020

Q. The nurse observes that the right eye of an unconscious client does not close completely. Which nursing intervention is most appropriate?

A. Have the client wear eyeglasses at all times.

B. Lightly tape the eyelid shut.

C. Instill artificial tears once every shift.

D. Clean the eyelid with a washcloth every shift.

Correct Answer: B

Reason: When the blink reflex is absent or the eyes do not close completely, the cornea may become dry and irritated. Corneal abrasion can occur. Taping the eye closed will prevent injury. Having the client wear eyeglasses or cleaning the eyelid will not protect the cornea from dryness or irritation. Artificial tears instilled once per shift are not frequent enough for preventing dryness.

Tuesday, 13 October 2020

Question Of The Day, Neurosensory Disorders
Q. A nurse, a licensed practical nurse (LPN), and a nursing assistant are caring for a group of clients. The nurse asks the nursing assistant to check the pulse oximetry level of a client who underwent laminectomy. The nursing assistant reports that the pulse oximetry reading is 89%. The client Kardex contains an order for oxygen application at 2 L/min should the pulse oximetry level fall below 92%. The nurse is currently assessing a postoperative client who just returned from the postanesthesia care unit. How should the nurse proceed?

A. Immediately go the client's room and assess vital signs, administer oxygen at 2 L/minute, and notify the physician.

B. Ask the nursing assistant to notify the physician of the low pulse oximetry level.

C. Ask the LPN to obtain vital signs and administer oxygen at 2 L/min to the client who underwent laminectomy.

D. Complete the assessment of the new client before attending to the client who underwent laminectomy.

Correct Answer: C

Reason: Because it's important to get more information about the client with a decreased pulse oximetry level, the nurse should ask the LPN to obtain vital signs and administer oxygen as ordered. The nurse must attend to the newly admitted client without delaying treatment to the client who is already in her care. The nurse can effectively do this by delegating tasks to an appropriate health team member such as an LPN. The nurse doesn't need to immediately attend to the client with a decreased pulse oximetry level; she may wait until she completes the assessment of the newly admitted client. The physician doesn't need to be notified at this time because an order for oxygen administration is already on record.

Friday, 9 October 2020

Question Of The Day, Oncologic Disorders
Q. A young man with early-stage testicular cancer is scheduled for a unilateral orchiectomy. The client confides to the nurse that he is concerned about what effects the surgery will have on his sexual performance. Which of the following responses by the nurse provides accurate information about sexual performance after an orchiectomy?

A. "Most impotence resolves in a couple of months."

B. "You could have early ejaculation with this type of surgery."

C. "We will refer you to a sex therapist because you will probably notice erectile dysfunction."

D. "Because your surgery does not involve other organs or tissues, you'll likely not notice much change in your sexual performance."

Correct Answer: D

Reason: Although there may not be a big change in sexual function with a unilateral orchiectomy, the loss of a gonad and testosterone may result in decreased libido and sterility. Sperm banking may be an option worth exploring if the number and motility of the sperm are adequate. Remember, the population most affected by testicular cancer is generally young men ages 15 to 34, and in this crucial stage of life, sexual anxieties may be a large concern.

Thursday, 8 October 2020

Q. Before discharge, which instruction should a nurse give to a client receiving digoxin (Lanoxin)?

A. "Take an extra dose of digoxin if you miss one dose."

B. "Call the physician if your heart rate is above 90 beats/minute."

C. "Call the physician if your pulse drops below 80 beats/minute."

D. "Take digoxin with meals."

Correct Answer: B

Reason: The nurse should instruct the client to notify the physician if his heart rate is greater than 90 beats/minute because cardiac arrhythmias may occur with digoxin toxicity. To prevent toxicity, the nurse should instruct the client never to take an extra dose of digoxin if he misses a dose. The nurse should show the client how to take his pulse and tell him to call the physician if his pulse rate drops below 60 beats/minute — not 80 beats/minute, which is a normal pulse rate and doesn't warrant action. The client shouldn't take digoxin with meals; doing so slows the absorption rate.

Wednesday, 7 October 2020

Q. The neonate of a client with type 1 diabetes is at high risk for hypoglycemia. An initial sign the nurse should recognize as indicating hypoglycemia in a neonate is:

A. peripheral acrocyanosis.

B. bradycardia.

C. lethargy.

D. jaundice.

Correct Answer: C

Reason: Lethargy in the neonate may be seen with hypoglycemia because of a lack of glucose in the nerve cells. Peripheral acrocyanosis is normal in the neonate because of immature capillary function. Tachycardia — not bradycardia — is seen with hypoglycemia. Jaundice isn't a sign of hypoglycemia.

Tuesday, 6 October 2020

Q. The nurse is assessing a client at her postpartum checkup 6 weeks after a vaginal delivery. The mother is bottle feeding her baby. Which client finding indicates a problem at this time?

A. Firm fundus at the symphysis.

B. White, thick vaginal discharge.

C. Striae that are silver in color.

D. Soft breasts without milk.

Correct Answer: A

Reason: By 4 to 6 weeks postpartum, the fundus should be deep in the pelvis and the size of a nonpregnant uterus. Subinvolution, caused by infection or retained placental fragments, is a problem associated with a uterus that is larger than expected at this time. Normal expectations include a white, thick vaginal discharge, striae that are beginning to fade to silver, and breasts that are soft without evidence of milk production (in a bottle-feeding mother).

Saturday, 3 October 2020

Question Of The Day: Psychotic Disorders
Q. A client has refused to take a shower since being admitted 4 days earlier. He tells a nurse, "There are poison crystals hidden in the showerhead. They'll kill me if I take a shower." Which nursing action is most appropriate?

A. Dismantling the showerhead and showing the client that there is nothing in it

B. Explaining that other clients are complaining about the client's body odor

C. Asking a security officer to assist in giving the client a shower

D. Accepting these fears and allowing the client to take a sponge bath

Correct Answer: D

Reason: By acknowledging the client's fears, the nurse can arrange to meet the client's hygiene needs in another way. Because these fears are real to the client, providing a demonstration of reality by dismantling the shower head wouldn't be effective at this time. Explaining that other clients are complaining about his body odor or asking a security officer to assist in giving the client a shower would violate the client's rights by shaming or embarrassing him.

Thursday, 1 October 2020

Question Of The Day, Foundations of Psychiatric Nursing
Q. A nurse is instructing a client with bipolar disorder on proper use of lithium carbonate (Eskalith), the drug's adverse effects, and symptoms of lithium toxicity. Which client statement indicates that additional teaching is required?

A. "I can still eat my favorite salty foods."

B. "When my moods fluctuate, I'll increase my dose of lithium."

C. "A good blood level of the drug means the drug concentration has stabilized."

D. "Eating too much watermelon will affect my lithium level."

Correct Answer: B

Reason: A client who states that he'll increase his dose of lithium if his mood fluctuates requires additional teaching because increasing the dose of lithium without evaluating the client's laboratory values can cause serious health problems, such as lithium toxicity, overdose, and renal failure. Clients taking lithium don't need to limit their sodium intake. A low-sodium diet causes lithium retention. A therapeutic lithium blood level indicates that the drug concentration has stabilized. The client demonstrates effective teaching by stating his lithium levels will be affected by foods that have a diuretic effect, such as watermelon, cantaloupe, grapefruit juice, and cranberry juice.

Tuesday, 29 September 2020

Q. A child, age 3, is brought to the emergency department in respiratory distress caused by acute epiglottiditis. Which clinical manifestations should the nurse expect to assess?

A. Severe sore throat, drooling, and inspiratory stridor

B. Low-grade fever, stridor, and a barking cough

C. Pulmonary congestion, a productive cough, and a fever

D. Sore throat, a fever, and general malaise

Correct Answer: A

Reason: A child with acute epiglottiditis appears acutely ill and clinical manifestations may include drooling (because of difficulty swallowing), severe sore throat, hoarseness, a high temperature, and severe inspiratory stridor. A low-grade fever, stridor, and barking cough that worsens at night are suggestive of croup. Pulmonary congestion, productive cough, and fever along with nasal flaring, retractions, chest pain, dyspnea, decreased breath sounds, and crackles indicate pneumococcal pneumonia. A sore throat, fever, and general malaise point to viral pharyngitis.

Friday, 25 September 2020

Q. A nurse is caring for a client who required chest tube insertion for a pneumothorax. To assess for pneumothorax resolution, the nurse can anticipate that the client will require:

A. monitoring of arterial oxygen saturation (SaO2).

B. arterial blood gas (ABG) studies.

C. chest auscultation.

D. a chest X-ray.

Correct Answer: D

Reason: Chest X-ray confirms diagnosis by revealing air or fluid in the pleural space. SaO2 values may initially decrease with a pneumothorax but typically return to normal within 24 hours. ABG studies may show hypoxemia, possibly with respiratory acidosis and hypercapnia but these are not necessarily related to a pneumothorax. Chest auscultation will determine overall lung status, but it's difficult to determine if the chest has reexpanded sufficiently.

Thursday, 24 September 2020


Q.
When caring for a client after a closed renal biopsy, the nurse should?

A. Maintain the client on strict bed rest in a supine position for 6 hours.

B. Insert an indwelling catheter to monitor urine output.

C. Apply a sandbag to the biopsy site to prevent bleeding.

D. Administer I.V. opioid medications to promote comfort.

Correct Answer: A

Reason: After a renal biopsy, the client is maintained on strict bed rest in a supine position for at least 6 hours to prevent bleeding. If no bleeding occurs, the client typically resumes general activity after 24 hours. Urine output is monitored, but an indwelling catheter is not typically inserted. A pressure dressing is applied over the site, but a sandbag is not necessary. Opioids to control pain would not be anticipated; local discomfort at the biopsy site can be controlled with analgesics.

Monday, 21 September 2020

Q. A client has a herniated disk in the region of the third and fourth lumbar vertebrae. Which nursing assessment finding most supports this diagnosis?

A. Hypoactive bowel sounds

B. Severe lower back pain

C. Sensory deficits in one arm

D. Weakness and atrophy of the arm muscles

Correct Answer: B

Reason: The most common finding in a client with a herniated lumbar disk is severe lower back pain, which radiates to the buttocks, legs, and feet — usually unilaterally. A herniated disk also may cause sensory and motor loss (such as footdrop) in the area innervated by the compressed spinal nerve root. During later stages, it may cause weakness and atrophy of leg muscles. The condition doesn't affect bowel sounds or the arms.

 

Friday, 18 September 2020

Q. The American Cancer Society recommends routine screening to detect colorectal cancer. Which screening test for colorectal cancer should a nurse recommend?

A. Carcinoembryonic antigen (CEA) test after age 50

B. Proctosigmoidoscopy after age 30

C. Annual digital examination after age 40

D. Barium enema after age 20

Correct Answer: C

Reason: The American Cancer Society recommends an annual digital examination after age 40 for the purpose of detecting colorectal cancer. The CEA test is performed on clients who have already been treated for colorectal cancer. It helps monitor a client's response to treatment as well as detect metastasis or recurrence. Proctosigmoidoscopy is recommended every 3 to 5 years for people older than age 50. Barium enema isn't a screening test.

Thursday, 17 September 2020

Q. A client with a past medical history of ventricular septal defect repaired in infancy is seen at the prenatal clinic. She is complaining of dyspnea with exertion and being very tired. Her vital signs are 98, 80, 20, BP 116/72. She has + 2 pedal edema and clear breath sounds. As the nurse plans this client's care, which of the following is her cardiac classification according to the New York Heart Association Cardiac Disease classification?

A. Class I.

B. Class II.

C. Class III.

D. Class IV.

Correct Answer: B

Reason: According to the New York Heart Association Cardiac Disease classification, this client would fit under Class II because she is symptomatic with increased activity (dyspnea with exertion). The New York Heart Association Cardiac Disease Classification identifies Class II clients as having cardiac disease and a slight limitation in physical activity. When physical activity occurs, the client may experience angina, difficulty breathing, palpations, and fatigue. All of the client's other symptoms are within normal limits.

Wednesday, 16 September 2020

Q. A client's gestational diabetes is poorly controlled throughout her pregnancy. She goes into labor at 38 weeks and gives birth. Which priority intervention should be included in the care plan for the neonate during his first 24 hours?

A. Administer insulin subcutaneously.
B. Administer a bolus of glucose I.V.
C. Provide frequent early feedings with formula.
D. Avoid oral feedings.

Correct Answer: C

Reason: The neonate of a mother with gestational diabetes may be slightly hyperglycemic immediately after birth because of the high glucose levels that cross the placenta from mother to fetus. During pregnancy, the fetal pancreas secretes increased levels of insulin in response to this increased glucose amount that crosses the placenta from the mother. However, during the first 24 hours of life, this combination of high insulin production in the neonate coupled with the loss of maternal glucose can cause severe hypoglycemia. Frequent, early feedings with formula can prevent hypoglycemia. Insulin shouldn't be administered because the neonate of a mother with gestational diabetes is at risk for hypoglycemia. A bolus of glucose given I.V. may cause rebound hypoglycemia. If glucose is given I.V., it should be administered as a continuous infusion. Oral feedings shouldn't be avoided because early, frequent feedings can help avoid hypoglycemia.

Tuesday, 15 September 2020

Q. After being treated with heparin therapy for thrombophlebitis, a multiparous client who delivered 4 days ago is to be discharged on oral warfarin (Coumadin). After teaching the client about the medication and possible effects, which of the following client statements indicates successful teaching?

A. "I can take two aspirin if I get uterine cramps."
B. "Protamine sulfate should be available if I need it."
C. "I should use a soft toothbrush to brush my teeth."
D. "I can drink an occasional glass of wine if I desire."

Correct Answer: C

Reason: Successful teaching is demonstrated when the client says, "I should use a soft toothbrush to brush my teeth." Heparin therapy can cause the gums to bleed, so a soft toothbrush should be used to minimize this adverse effect. Use of aspirin and other nonsteroidal anti-inflammatory medications should be avoided because of the increased risk for possible hemorrhage. Protamine sulfate is the antidote for heparin therapy. Vitamin K is the antidote for warfarin excess. Alcohol can inhibit the metabolism of oral anticoagulants and should be avoided.

Monday, 14 September 2020

Q. A nurse is assessing a woman in labor. Her cervix is dilated 8 cm. Her contractions are occurring every 2 minutes. She's irritable and in considerable pain. What type of breathing should the nurse instruct the woman to use during the peak of a contraction?

A. Deep breathing
B. Shallow chest breathing
C. Deep, cleansing breaths
D. Chest panting

Correct Answer: B

Reason: Shallow chest breathing is used during the peak of a contraction during the transitional phase of labor. Deep breathing can cause a woman to hyperventilate and feel light-headed, with numbness or tingling in her fingers or toes. A deep, cleansing breath taken at the beginning and end of each breathing exercise can help prevent hyperventilation. Chest panting may be used to prevent a woman from pushing before the cervix is fully dilated. 

Saturday, 12 September 2020

Question Of The Day, Substance Abuse, Eating Disorders, Impulse Control Disorders
Q. A client with a history of polysubstance abuse is admitted to the facility. He complains of nausea and vomiting 24 hours after admission. The nurse who assesses the client notes piloerection, pupillary dilation, and lacrimation. The nurse suspects that the client is going through withdrawal from which substance?

A. Alcohol
B. Cannabis
C. Cocaine
D. Opioids

Correct Answer: D

Reason: Piloerection, pupillary dilation, and lacrimation are specific to opioid withdrawal. A client with alcohol withdrawal would show elevated vital signs. There is no real withdrawal from cannabis. Symptoms of cocaine withdrawal include depression, anxiety, and agitation.

Friday, 11 September 2020

Question Of The Day, Psychotic Disorders
Q. The nurse should assess the client who is taking risperidone (Risperdal) 1 mg, orally twice a day for:

A. Insomnia.
B. Headache.
C. Anxiety.
D. Orthostatic hypotension.



Correct Answer: D

Reason: Significant orthostatic hypotension is associated with risperidone (Risperdal) therapy. The nurse should monitor the client's blood pressure sitting and standing and teach the client interventions to manage this adverse effect to prevent risk of injury. Although insomnia, headache, and anxiety are possible adverse effects of risperidone therapy, they are of less immediate concern than orthostatic hypotension.

Thursday, 10 September 2020

Q. Which statement about somatoform pain disorder is accurate?

A. The pain is intentionally fabricated by the client to receive attention.
B. The pain is real to the client, even though the pain may not have an organic etiology.
C. The pain is less than would be expected as a result of the underlying disorder the client identifies.
D. The pain is what would be expected as a result of the underlying disorder the client identifies.

Correct Answer: B

Reason: In a somatoform pain disorder, the client has pain even though a thorough diagnostic workup reveals no organic cause for it. The nurse must recognize that the pain is real to the client. By refusing to believe that the client is in pain, the nurse impedes the development of a therapeutic trust-based relationship. While somatoform pain offers the client secondary gains, such as attention or avoidance of an unpleasant activity, the pain isn't intentionally fabricated by the client. Even if a pathologic cause of the pain can be identified, the pain is usually in excess of what the pathologic cause would normally be expected to produce.

Wednesday, 9 September 2020

Q. A nurse notices that a client with obsessive-compulsive disorder washes his hands for long periods each day. How should the nurse respond to this compulsive behavior?

A. By setting aside times during which the client can focus on the behavior
B. By urging the client to reduce the frequency of the behavior as rapidly as possible
C. By calling attention to or trying to prevent the behavior
D. By discouraging the client from verbalizing his anxieties

Correct Answer: A

Reason: The nurse should set aside times during which the client is free to focus on his compulsive behavior or obsessive thoughts. The nurse should urge the client to reduce the frequency of the compulsive behavior gradually, not rapidly. She shouldn't call attention to the behavior or try to prevent it. Trying to prevent the behavior may frighten and hurt the client. The nurse should encourage the client to verbalize his anxieties to help distract attention from his compulsive behavior. 

Tuesday, 8 September 2020

Question Of The Day, Foundations of Psychiatric Nursing
Q. A 28-year-old client with an Axis I diagnosis of major depression and an Axis II diagnosis of dependent personality disorder has been living at home with very supportive parents. The client is thinking about independent living on the recommendation of the treatment team. The client states to the nurse, "I don't know if I can make it in an apartment without my parents." The nurse should respond by saying to the client:

A. "You're a 28-year-old adult now, not a child who needs to be cared for."
B. "Your parents won't be around forever. After all, they are getting older."
C. "Your parents need a break, and you need a break from them."
D. "Your parents have been supportive and will continue to be even if you live apart."

Correct Answer: D

Reason: Some characteristics of a client with a dependent personality are an inability to make daily decisions without advice and reassurance and the preoccupation with fear of being alone to care for oneself. The client needs others to be responsible for important areas of his life. The nurse should respond, "Your parents have been supportive of you and will continue to be supportive even if you live apart," to gently challenge the client's fears and suggest that they may be unwarranted. Stating, "You're a 28-year-old adult now, not a child who needs to be cared for," or "Your parents need a break, and you need a break from them," is reprimanding and would diminish the client's self-worth. Stating, "Your parents won't be around forever; after all they are getting older," may be true, but it is an insensitive response that may increase the client's anxiety.

Monday, 7 September 2020

Question Of The Day: School-age Child
Q. An 8-year-old child is suspected of having meningitis. Signs of meningitis include:

A. Cullen's sign.
B. Koplik's spots.
C. Kernig's sign.
D. Chvostek's sign.

Correct Answer: C


Reason: Signs and symptoms of meningitis include Kernig's sign, stiff neck, headache, and fever. To test for Kernig's sign, the client is in the supine position with knees flexed; a leg is then flexed at the hip so that the thigh is brought to a position perpendicular to the trunk. An attempt is then made to extend the knee. If meningeal irritation is present, the knee can't be extended and attempts to extend the knee result in pain. Cullen's sign is the bluish discoloration of the periumbilical skin caused by intraperitoneal hemorrhage. Koplik's spots are reddened areas with grayish blue centers that are found on the buccal mucosa of a client with measles. Chvostek's sign is elicited by tapping the client's face lightly over the facial nerve, just below the temple. A calcium deficit is suggested if the facial muscles twitch.

Friday, 4 September 2020

Question Of The Day, The Nursing Process
Q. A group of nurses has established a focus group and pilot study to examine the potential application of personal data assistants (PDAs) in bedside care. This study is a tangible application of:

A. Nursing informatics.
B. Electronic medical records.
C. Telemedicine.
D. Computerized documentation

Correct Answer: A

Reason: Nursing informatics is a specialty that integrates nursing science, computer science, and information science to manage and communicate data, information, and knowledge in nursing practice. A specific application of nursing informatics is the use of PDAs in the clinical setting. The devices are less likely to be used to perform documentation or to constitute client records. Telemedicine involves the remote provision of care.

Thursday, 3 September 2020

Q. Twenty-four hours after a bone marrow aspiration, the nurse evaluates which of the following as an appropriate client outcome?

A. The client maintains bed rest.
B. There is redness and swelling at the aspiration site.
C. The client requests morphine sulfate for pain.
D. There is no bleeding at the aspiration site.



Correct Answer: D

Reason: After a bone marrow aspiration, the puncture site should be checked every 10 to 15 minutes for bleeding. For a short period after the procedure, bed rest may be ordered. Signs of infection, such as redness and swelling, are not anticipated at the aspiration site. A mild analgesic may be ordered. If the client continues to need the morphine for longer than 24 hours, the nurse should suspect that internal bleeding or increased pressure at the puncture site may be the cause of the pain and should consult the physician.

Wednesday, 2 September 2020

Q. When giving an I.M. injection, the nurse should insert the needle into the muscle at an angle of:

A. 15 degrees.
B. 30 degrees.
C. 45 degrees.
D. 90 degrees.



Correct Answer: D

Reason: When giving an I.M. injection, the nurse inserts the needle into the muscle at a 90-degree angle, using a quick, dartlike motion. A 15-degree angle is appropriate when administering an intradermal injection. A 30-degree angle isn't used for any type of injection. The nurse may use a 45- or 90-degree angle when giving a subcutaneous injection.

Tuesday, 1 September 2020

Q. A primiparous woman has recently delivered a term infant. Priority teaching for the patient includes information on:

A. Sudden infant death syndrome (SIDS)
B. Breastfeeding
C. Infant bathing
D. Infant sleep-wake cycles



Correct Answer: B

Reason: Breastfed infants should eat within the first hour of life and approximately every 2 to 3 hours. Successful breastfeeding will likely require sustained support, encouragement, and instruction from the nurse. Information on SIDS, infant bathing, and sleep-wake cycles are also important topics for the new parent, but they can be covered at any time prior to discharge.

Wednesday, 26 August 2020

Question Of The Day, Gastrointestinal Disorders
Q. A nurse is caring for a client with cholelithiasis. Which sign indicates obstructive jaundice?

A. Straw-colored urine
B. Reduced hematocrit
C. Clay-colored stools
D. Elevated urobilinogen in the urine



Correct Answer: C

Reason: Obstructive jaundice develops when a stone obstructs the flow of bile in the common bile duct. When the flow of bile to the duodenum is blocked, the lack of bile pigments results in a clay-colored stool. In obstructive jaundice, urine tends to be dark amber (not straw-colored) as a result of soluble bilirubin in the urine. Hematocrit levels aren't affected by obstructive jaundice. Because obstructive jaundice prevents bilirubin from reaching the intestine (where it's converted to urobilinogen), the urine contains no urobilinogen.

Tuesday, 25 August 2020

Question Of The Day: Oncologic Disorders
Q. A client who is undergoing radiation therapy develops mucositis. Which of the following interventions should be included in the client's plan of care?

A. Increase mouth care to twice per shift.
B. Provide the client with hot tea to drink.
C. Promote regular flossing of teeth.
D. Use half-strength hydrogen peroxide on mouth ulcers.

Correct Answer: C

Reason: Mucositis is an inflammation of the oral mucosa caused by radiation therapy. It is important that the client with mucositis receive meticulous mouth care, including flossing, to prevent the development of an infection. Mouth care should be provided before and after each meal, at bedtime, and more frequently as needed. Extremes of temperature should be avoided in food and drink. Half-strength hydrogen peroxide is too harsh to use on irritated tissues.

Monday, 24 August 2020

Q. A client is recovering from an acute myocardial infarction (MI). During the first week of the client's recovery, the nurse should stay alert for which abnormal heart sound?

A. Opening snap
B. Graham Steell's murmur
C. Ejection click
D. Pericardial friction rub


Correct Answer: D

Reason: A pericardial friction rub, which sounds like squeaky leather, may occur during the first week following an MI. Resulting from inflammation of the pericardial sac, this abnormal heart sound arises as the roughened parietal and visceral layers of the pericardium rub against each other. Certain stenosed valves may cause a brief, high-pitched opening snap heard early in diastole. Graham Steell's murmur is a high-pitched, blowing murmur with a decrescendo pattern; heard during diastole, it indicates pulmonary insufficiency, such as from pulmonary hypertension or a congenital pulmonary valve defect. An ejection click, associated with mitral valve prolapse or a rigid, calcified aortic valve, causes a high-pitched sound during systole.

Saturday, 22 August 2020

Q. A nurse is preparing to perform a postpartum assessment on a client who gave birth 5 hours ago. Which precaution should the nurse plan to take for this procedure?

A. Washing the hands
B. Washing the hands and wearing latex gloves
C. Washing the hands and wearing latex gloves and a barrier gown
D. Washing the hands and wearing latex gloves, a barrier gown, and protective eyewear

Correct Answer: B

Reason: During a postpartum assessment, the nurse is likely to come into contact with the client's blood or body fluids, especially when examining the perineal region. Therefore, the nurse must wear latex gloves; hand washing alone would neither provide adequate protection nor comply with universal precautions. The nurse should wear a barrier gown and protective eyewear in addition to latex gloves only when anticipating splashing of blood or body fluids such as during childbirth. Splashing isn't likely to occur during a postpartum assessment.

Friday, 21 August 2020

Q. A client who has been in the latent phase of the first stage of labor is transitioning to the active phase. During the transition, the nurse expects to see which client behavior?

A. A desire for personal contact and touch
B. A full response to teaching
C. Fatigue, a desire for touch, and quietness
D. Withdrawal, irritability, and resistance to touch

Correct Answer: D

Reason: During the transition to the active phase of the first stage of labor, increased pain typically makes the client withdrawn, irritable, and resistant to touch. During the latent phase (the early part of the first stage of labor), when contractions aren't intensely painful, the client typically desires personal contact and touch and responds to teaching and interventions. Fatigue, a desire for touch, and quietness are common during the third and fourth stages of labor.

Thursday, 20 August 2020

Q. A client who's 7 weeks pregnant comes to the clinic for her first prenatal visit. She reports smoking 20 to 25 cigarettes per day. When planning the client's care, the nurse anticipates informing her that if she doesn't stop smoking, her fetus may be at risk for:

A. spina bifida.
B. tetralogy of Fallot.
C. low birth weight.
D. hydronephrosis.

Correct Answer: C

Reason: The risk of intrauterine growth retardation may increase with the number of cigarettes a pregnant woman smokes. Neural tube defects (such as spina bifida), cardiac abnormalities (such as tetralogy of Fallot), and renal disorders (such as hydronephrosis) are associated with multifactorial genetic inheritance, not maternal cigarette smoking.

Wednesday, 19 August 2020

Q. Flumazenil (Romazicon) has been ordered for a client who has overdosed on oxazepam (Serax). Before administering the medication, the nurse should be prepared for which common adverse effect?

A. Seizures
B. Shivering
C. Anxiety
D. Chest pain

Correct Answer: A

Reason: Seizures are the most common serious adverse effect of using flumazenil to reverse benzodiazepine overdose. The effect is magnified if the client has a combined tricyclic antidepressant and benzodiazepine overdose. Less common adverse effects include shivering, anxiety, and chest pain.

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