NCLEX Select All That Apply Questions

ANSWER: Firm skin turgor ; Moist mucous membranes ; Urine output of at least 30 ml/hour ; RATIONALE: Because of the criteria in the question, FLUID RESUSCITATION, the diagnosis for diarrhea in this case is narrowed to Deficient Fluid Volume related to excessive fluid loss in stool. Thus, fluid resuscitation is needed and expected outcomes of successful intervention include:  Firm skin turgor  Moist mucous membranes  Urine output of at least 30 ml/hr The client also has a nursing diagnosis of diarrhea with the following expected outcomes:  Passage of formed stools at regular intervals  Decrease in stool frequency and liquidity

ANSWER: Tea and coffee are restricted on the day of the test. ; The test will take between 45 minutes and 2 hours. ; The hair should be washed the evening before the test. ; RATIONALE: Pre-procedure instructions include informing the client that the procedure is painless. The procedure requires no dietary restrictions other than avoidance of cola, tea, and coffee on the morning of the test. These products have a stimulating effect and should be avoided. The hair should be washed the evening before the test, and gels, hairsprays, and lotion should be avoided. The client is informed that the test will take 45 minutes to 2 hours and that medications are usually not withheld before the test.

ANSWER: Psychosocial ; RATIONALE: The psychosocial data is the least priority during the initial admission data collection. In the African-American culture, it is considered intrusive to ask personal questions during the initial contact or meeting. Additionally, respiratory, neurological, and cardiovascular data include physiological assessments that would be the priority.

ANSWER: Disconnecting the IV tubing from the catheter in the vein ; RATIONALE: The tubing should not be removed from the IV catheter. With each break in the system, there is an increased chance of introducing bacteria into the system, which can lead to infection. Options 1 and 4 are appropriate. The flow rate should be checked immediately after changing the hospital gown, because the position of the roller clamp may have been affected during the change.

ANSWER: Increased clotting time. ; Hypertension. ; Headaches ; RATIONALE: Polycythemia vera is a condition in which the bone marrow produces too many red blood cells. This causes an increase in hematocrit and viscosity of the blood. Patients can experience headaches, dizziness, and visual disturbances. Cardiovascular effects include increased blood pressure and delayed clotting time. Weight loss is not a manifestation of polycythemia vera.

ANSWER: federal nurse practice acts. ; RATIONALE: c. Nurse practice acts are based in state law, not federal law, as mandated for the advocacy of nurses; JCAHO, ANA, and institutional review boards all support nurse advocacy.

ANSWER: Inserting an IV ; Applying a sterile dressing ; Inserting a urinary catheter ; Suctioning the oropharynx and trachea ; RATIONALE: a. c, d. The cavities are considered sterile; sterile technique is required to not introduce microorganisms into the client’s body. b. The application of a sterile dressing requires a sterile field to not introduce microorganisms.

ANSWER: "I will give my child cough syrup if a cough develops." ; RATIONALE: Cough syrups and cold medicines are not to be given, because they may dry and thicken secretions. During a croup attack, the child can be taken to a cool basement or garage. Acetaminophen is used if a fever develops. Adequate hydration of 500 to 1000 mL of fluids daily is important for thinning secretions.

ANSWER: Specific gravity of 1.03 ; Absence of protein ; Absence of glucose ; RATIONALE: Normal urine pH is 4.5 to 8; therefore, a urine pH of 3.0 is abnormal. Urine specific gravity normally ranges from 1.002 to 1.035, making this client’s value normal. Normally, urine contains no protein, glucose, ketones, bilirubin, bacteria, casts, or crystals. Red blood cells should measure 0 to 3 per high-power field; white blood cells, 0 to 4 per high-power field. Urine should be clear, its color ranging from pale yellow to deep amber.

ANSWER: The client with a colostomy ; RATIONALE: Causes of a fluid volume deficit include vomiting, diarrhea, conditions that cause increased respirations or increased urinary output, insufficient intravenous fluid replacement, draining fistulas, ileostomy, and colostomy. A client with cirrhosis, CHF, or decreased kidney function is at risk for fluid volume excess.

ANSWER: Side-lying ; Fowler’s ; RATIONALE: Research demonstrate that the occurrence of SIDS is reduced with these two positions.

ANSWER: Ineffective tissue perfusion related to decreased peripheral blood flow secondary to decreased cardiac output. ; Decreased cardiac output related to structural and functional changes. ; RATIONALE: HF is a result of structural and functional abnormalities of the heart tissue muscle. The heart muscle becomes weak and does not adequately pump the blood out of the chambers. As a result, blood pools in the left ventricle and backs up into the left atrium, and eventually into the lungs. Therefore, greater amounts of blood remain in the ventricle after contraction thereby decreasing cardiac output. In addition, this pooling leads to thrombus formation and ineffective tissue perfusion because of the decrease in blood flow to the other organs and tissues of the body. Typically, these clients have an ejection fraction of less than 50% and poorly tolerate activity. Activity intolerance is related to a decrease, not increase, in cardiac output. Gas exchange is impaired. However, the decrease in cardiac output triggers compensatory mechanisms, such as an increase in sympathetic nervous system activity.

ANSWER: Reflects electrical impulse beginning at the SA node ; Reflects atrial muscle depolarization ; Has duration of normally 0.11 seconds or less ; RATIONALE: In a client who has had an ECG, the P wave represents the activation of the electrical impulse in the SA node, which is then transmitted to the AV node. In addition, the P wave represents atrial muscle depolarization, not ventricular depolarization. The normal duration of the P wave is 0.11 seconds or less in duration and 2.5 mm or more in height.

ANSWER: A client on a ventilator ; RATIONALE: The airway is always a high priority, and the nurse first checks the client on a ventilator. The clients described in options 2, 3, and 4 have needs that would be identified as intermediate priorities.

ANSWER: patient’s medical and health information ; RATIONALE: a. The Act is a federal privacy standard that protects the patient’s medical records and other identifiable health information. The Act requires confidentiality and ensures the privacy of patients.

ANSWER: living will and durable power of attorney ; RATIONALE: a. A living will provides for an individual’s preferences around end-of-life care; durable power of attorney designates a substitute decision maker for health care and medical decisions should the individual not be able to decide.

ANSWER: Diabetic mellitus client ; Malnourished client ; Renal failure client ; RATIONALE: Diabetes mellitus, malnutrition, and renal failure lead to metabolic acidosis because of the increasing acids in the body. Options 1, 2, and 5 are respiratory problems, not metabolic, and result in either respiratory acidosis or respiratory alkalosis.

ANSWER: Place the client in good body alignment ; Check the level of the drainage bag ; Check the peritoneal dialysis system for kinks ; Reposition the client to his or her side. ; RATIONALE: If outflow drainage is inadequate, the nurse attempts to stimulate outflow by changing the client’s position. Turning the client to the other side or making sure that the client is in good body alignment may assist with outflow drainage. The drainage bag needs to be lower than the client’s abdomen to enhance gravity drainage. The connecting tubing and the peritoneal dialysis system is also checked for kinks or twisting and the clamps on the system are checked to ensure that they are open. There is no reason to contact the physician.

ANSWER: Gloves, a gown, and goggles ; RATIONALE: Goggles are worn to protect the mucous membranes of the eye during interventions that may produce splashes of blood, body fluids, secretions, and excretions. In addition, contact precautions require the use of gloves, and a gown should be worn if direct client contact is anticipated. Shoe protectors are not necessary.

ANSWER: In a semi-Fowler's position ; With the head in a midline position ; RATIONALE: Clients who have undergone supratentorial surgery should have the head of the bed elevated 30 degrees to promote venous drainage from the head. The client is positioned to avoid extreme hip or neck flexion, and the head is maintained in a midline, neutral position. If a large tumor has been removed, the client should be placed on the nonoperative side to prevent the displacement of the cranial contents.

ANSWER: Low PCO2 ; Acetone breath ; RATIONALE: Metabolic acidosis initiates respiratory compensation in the form of Kussmaul respirations to counteract the effects of ketone buildup, resulting in a lowered PCO2. A fruity odor to the breath (acetone breath) occurs when the ketone level is elevated in ketoacidosis.

ANSWER: Wearing gloves when emptying the client's bedpan ; Keeping all linens in the room until the implant is removed ; Wearing a film (dosimeter) badge when in the client's room ; Wearing a lead apron when providing direct care to the client ; RATIONALE: A private room with a private bath is essential if a client has an internal radiation implant. This is necessary to prevent the accidental exposure of other clients to radiation. The remaining options identify interventions that are necessary for a client with a radiation device.

ANSWER: To avoid activities that require bending over ; To place an eye shield on the surgical eye at bedtime ; To contact the surgeon if a decrease in visual acuity occurs ; To take acetaminophen (Tylenol) for minor eye discomfort ; RATIONALE: After eye surgery, some scratchiness and mild eye discomfort may occur in the operative eye and is usually relieved by mild analgesics. If the eye pain becomes severe, the client should notify the surgeon because this may indicate hemorrhage, infection, or increased intraocular pressure. The nurse would also instruct the client to notify the surgeon of purulent drainage, increased redness, or any decrease in visual acuity. The client is instructed to place an eye shield over the operative eye at bedtime to protect the eye from injury during sleep and to avoid activities that increase intraocular pressure such as bending over.

ANSWER: Extended time to fall asleep ; Difficulty staying asleep ; Feeling tired after a night’s sleep ; RATIONALE: These symptoms are often reported by clients with insomnia. Clients report nonrestorative sleep. Arising once at night to urinate (nocturia) is not in and of itself insomnia.

ANSWER: Postural blood pressure changes ; RATIONALE: Postural blood pressure changes occur in the client with hyponatremia. Dry mucous membranes and intense thirst are seen in clients with hypernatremia. A slow, bounding pulse is not indicative of hyponatremia. In a client with hyponatremia, a rapid thready pulse is noted.

ANSWER: encourage medical treatment decision making prior to need. ; RATIONALE: b.The purpose of the PSDA is to promote decision making prior to need. The focus of the PSDA is healthcare decision making. A federal standard for advance directives does not exist. Each state has jurisdiction regarding these policies and protocols. The PSDA emphasizes the need for patient education in order to support an individual's treatment decisions.

ANSWER: emergency surgery may be completed if deemed necessary by two attending physicians when a patient is unable to give consent and the next of kin cannot be reached. ; RATIONALE: a. Standards of practice and many state laws support the initiation of emergency surgery if deemed necessary by two attending physicians when a patient is unable to give consent and the next of kin is unavailable to give consent.

ANSWER: Keep small toys and sharp objects away from the cast. ; Contact the health care provider if the child complains of numbness or tingling in the extremity. ; Elevate the extremity on pillows for the first 24 to 48 hours after casting to prevent swelling. ; RATIONALE: While the cast is drying, the palms of the hands are used to lift the cast. If the fingertips are used, indentations in the cast could occur and cause constant pressure on the underlying skin. Small toys and sharp objects are kept away from the cast, and no objects (including padded objects) are placed inside of the cast because of the risk of altered skin integrity. A heating pad is not applied to the cast or fingers. Cold fingers could indicate neurovascular impairment, and the HCP should be notified. The extremity is elevated to prevent swelling, and the HCP is notified immediately if any signs of neurovascular impairment develop.

ANSWER: Elevate the HOB to 90 degrees ; Loosen constrictive clothing ; Assess for bladder distention and bowel impaction ; RATIONALE: The client has signs and symptoms of autonomic dysreflexia. The potentially life-threatening condition is caused by an uninhibited response from the sympathetic nervous system resulting from a lack of control over the autonomic nervous system. The nurse should immediately elevate the HOB to 90 degrees and place extremities dependently to decrease venous return to the heart and increase venous return from the brain. Because tactile stimuli can trigger autonomic dysreflexia, any constrictive clothing should be loosened. The nurse should also assess for distended bladder and bowel impaction, which may trigger autonomic dysreflexia, and correct any problems. Elevated blood pressure is the most life-threatening complication of autonomic dysreflexia because it can cause stroke, MI, or seizures. If removing the triggering event doesn’t reduce the client’s blood pressure, IV antihypertensives should be administered. A fan shouldn’t be used because cold drafts may trigger autonomic dysreflexia.

ANSWER: Disconnecting the IV tubing from the catheter in the vein ; RATIONALE: The tubing should not be removed from the IV catheter. With each break in the system, there is an increased chance of introducing bacteria into the system, which can lead to infection. Options 1 and 4 are appropriate. The flow rate should be checked immediately after changing the hospital gown, because the position of the roller clamp may have been affected during the change.

ANSWER: Monitor for hemorrhage. ; Administer eye medications. ; Maintain the eye patch or shield. ; RATIONALE: An eye patch or shield is applied to protect the eye and prevent any further detachment. Educating the client regarding symptoms is necessary because the client is at risk for subsequent retinal detachment. Positioning, activity restrictions, and eye patches hinder the client in the performance of activities of daily living, and the client needs the nurse's assistance with these activities. Eye medications are prescribed postoperatively, and hemorrhage is also a risk post surgery. Coughing is not encouraged because this can increase intraocular pressure and harm the client.

ANSWER: COPD ; Guillain-Barre syndrome ; Barbiturate or sedative overdose ; Weakness of respiratory muscles ; RATIONALE: Respiratory Acidosis, a primary excess of carbonic acid in the extracellular fluid leading to decreased in pH, elevated pCO2 and bicarbonate (if renal compensation is present), may be caused by: • COPD • Barbiturate or sedative overdose • Acute airway obstruction • Weakness of respiratory muscles • Guillain-Barre syndrome

ANSWER: Cardiac glycosides ; Phosphodiesterase (PDE) inhibitors ; Angiotensin-converting enzyme (ACE) inhibitors ; RATIONALE: Medications recommended for treatment of heart failure include diuretics, cardiac glycosides such as digoxin (Lanoxin), PDE inhibitors, and ACE inhibitors. Clients in heart failure do not need anticoagulants or anticholinergics.

ANSWER: Decline in visual acuity ; Increased susceptibility to urinary tract infections ; Increased incidence of awakening after sleep onset ; RATIONALE: Anatomical changes to the eye affect the individual's visual ability, which leads to potential problems with activities of daily living. Light adaptation and visual fields are reduced. Respiratory rates are usually unchanged. The heart rate decreases, and the heart valves thicken. Age-related changes that affect the urinary tract increase an older client's susceptibility to urinary tract infections. Short-term memory may decline with age, but long-term memory is usually maintained. Changes in sleep patterns are consistent, age-related changes. Older persons experience an increased incidence of awakening after sleep onset.

ANSWER: Place the child on a low-bacteria diet. ; Change dressings using sterile technique. ; Perform meticulous hand washing before caring for the child ; RATIONALE: For the hospitalized neutropenic child, flowers or plants should not be kept in the room because standing water and damp soil harbor Aspergillus and Pseudomonas, to which these children are very susceptible. Fruits and vegetables not peeled before being eaten harbor molds and should be avoided until the white blood cell count rises. The child is placed on a low-bacteria diet. Dressings are always changed with sterile technique. Not all visitors need to be restricted, but anyone who is ill should not be allowed in the child’s room. Meticulous hand washing is required before caring for the child. In addition, gloves, a mask, and a gown are worn (per agency policy).

ANSWER: Consuming a small glass of warm milk at bedtime ; RATIONALE: A small glass of milk relaxes the body and promotes sleep.

ANSWER: Palpitations ; Diaphoresis ; Slurred speech ; RATIONALE: Palpitations, an adrenergic symptom, occur as the glucose levels fall; the sympathetic nervous system is activated and epinephrine and norepinephrine are secreted causing this response. Diaphoresis is a sympathetic nervous system response that occurs as epinephrine and norepinephrine are released. Slurred speech is a neuroglycopenic symptom; as the brain receives insufficient glucose, the activity of the CNS becomes depressed.

ANSWER: Shock ; dismay ; RATIONALE: Shock and dismay are early signs of denial-the first stage of grief. The other options are associated with depression—a later stage of grief.

ANSWER: To avoid activities that require bending over ; To place an eye shield on the surgical eye at bedtime ; To contact the surgeon if a decrease in visual acuity occurs ; To take acetaminophen (Tylenol) for minor eye discomfort ; RATIONALE: After eye surgery, some scratchiness and mild eye discomfort may occur in the operative eye and is usually relieved by mild analgesics. If the eye pain becomes severe, the client should notify the surgeon because this may indicate hemorrhage, infection, or increased intraocular pressure. The nurse would also instruct the client to notify the surgeon of purulent drainage, increased redness, or any decrease in visual acuity. The client is instructed to place an eye shield over the operative eye at bedtime to protect the eye from injury during sleep and to avoid activities that increase intraocular pressure such as bending over.

ANSWER: Cyanosis ; Tachycardia; Unconsciousness ; Rise in venous pressure ; RATIONALE: In air embolism the expected clinical manifestations are cyanosis, hypotension, tachycardia, rise in venous pressure and unconsciousness.

ANSWER: Metabolic alkalosis ; RATIONALE: The loss of gastric fluid via nasogastric suction or vomiting causes metabolic alkalosis as a result of the loss of hydrochloric acid; this results in an alkalotic condition. Options 3 and 4 deal with respiratory problems. Option 1 relates to acidosis

ANSWER: your patient's family will be there to care for him 24 hours/day. ; RATIONALE: c. 24-hour family availability to provide care and assistance is not an indicator for home care. In fact, the nurse might see some opportunity for family education in meeting the patient's needs so that less community support may be needed. This would need to be negotiated with the family. Frequent hospital readmissions imply that the patient has not been able to manage either due to condition instability or lack of care needs being met. This would be a red flag for home care services to be able to meet those needs and appropriately monitor the patient. A Foley catheter is an indication for home healthcare due to infection potential and care requirements. IV antibiotics involve home care due to maintaining line patency and assessment of the site.

ANSWER: Gloves, a gown, and goggles ; RATIONALE: Goggles are worn to protect the mucous membranes of the eye during interventions that may produce splashes of blood, body fluids, secretions, and excretions. In addition, contact precautions require the use of gloves, and a gown should be worn if direct client contact is anticipated. Shoe protectors are not necessary.

ANSWER: Does Mrs. T like to read? ; RATIONALE: b. Mrs. T's reason for admission is weakness and a fall. Priority concerns in assessment would be to identify any intrinsic or extrinsic factors that lead to her fall. Her interest in reading, although it be important in determining possible activities to incorporate into her care plan while in the hospital, is a lesser priority.

ANSWER: Taking photographs of the client without consent ; RATIONALE: Invasion of privacy takes place when an individual's private affairs are intruded on unreasonably. Threatening to place a client in restraints constitutes assault. Performing a surgical procedure without consent is an example of battery. Not allowing a client to leave the hospital constitutes false imprisonment.

ANSWER: A wagon ; RATIONALE: Toys for the toddler must be strong, safe, and too large to swallow or place in the ear or nose. Toddlers need supervision at all times. Push-pull toys, large balls, large crayons, trucks, and dolls are some appropriate toys. A puzzle with large pieces only may be appropriate. A farm set and a golf set may contain items that the child could swallow.

ANSWER: Constantly neglects personal grooming ; RATIONALE: Coping mechanisms are behaviors that are used to decreased stress and anxiety. In response to a death, ineffective coping is manifested by an extreme behavior that in some instances may be harmful to the individual, physically, psychologically, or both. Option 1 is indicative of a behavior that identifies an ineffective coping behavior as part of the grieving process. The remaining options identify effective coping behaviors.

ANSWER: Diabetic mellitus client ; Malnourished client ; Renal failure client ; RATIONALE: Diabetes mellitus, malnutrition, and renal failure lead to metabolic acidosis because of the increasing acids in the body. Options 1, 2, and 5 are respiratory problems, not metabolic, and result in either respiratory acidosis or respiratory alkalosis.

ANSWER: Trauma ; Ultraviolet rays ; X-rays ; RATIONALE: Majority (over 80%) of human cancers related to environmental carcinogens. The types of environmental carcinogens are: Physical • Radiation: x-rays, radium, nuclear explosion or waste, UV • Trauma or chronic irritation Chemical • Nitrites and food additives, alkylating agents • Drugs: arsenicals, stilbesterol • Cigarrete smoke • Hormones

ANSWER: Protect the stoma from water. ; Soaps should be avoided near the stoma. ; Wash the stoma daily using a washcloth. ; RATIONALE: The client with a stoma should be instructed to wash the stoma daily with a washcloth. Soaps, cotton swabs, or tissues should be avoided because their particles may enter and obstruct the airway. The client should be instructed to avoid applying alcohol to a stoma because it is both drying and irritating. A thin layer of petroleum jelly applied to the skin around the stoma helps prevent cracking. The client is instructed to protect the stoma from water.

ANSWER: Fever ; Sweating ; Agitation ; RATIONALE: Thyrotoxic crisis (thyroid storm) is an acute, potentially life-threatening state of extreme thyroid activity that represents a breakdown in the body's tolerance to a chronic excess of thyroid hormones. The clinical manifestations include fever greater than 100° F, severe tachycardia, flushing and sweating, and marked agitation and restlessness. Delirium and coma can occur.

ANSWER: Oliguria ; Proteinuria 3+ ; Blood pressure 168/116 mm Hg ; RATIONALE: Severe preeclampsia is characterized by blood pressure higher than 160/110 mm Hg, proteinuria 3+ or higher, and oliguria. Seizures (convulsions) are present in eclampsia and are not a characteristic of severe preeclampsia. Muscle cramps and contractions are not findings noted in severe preeclampsia, although the client is monitored for these occurrences.

ANSWER: Change in wart or mole ; Nagging cough or hoarseness ; Lump in breast or elsewhere ; RATIONALE: Warning signs of cancer: • Change in bowel or bladder habits • Sore that doesn’t heal • Lump in breast or elsewhere • Unusual bleeding or discharge • Indigestion or dysphagia • Change in wart or mole • Nagging cough or hoarseness

ANSWER: promotes multidisciplinary team collaboration ; is cost effective ; increases quality of care ; RATIONALE: a. An advantage of the case management model is that it promotes a collaborative process for quality cost-effective outcomes; it is a process of interactions within health care network, which enables a client to receive needed services. b. An advantage of the case management model is that outcomes result in more effective use of services and lessen costs. c. A principal advantage of the case management model is the client receives more services and has fewer unmet needs.

ANSWER: Notify the registered nurse. ; Prepare to administer morphine sulfate. ; Prepare to administer intravenous fluids. ; Prepare to administer 100% oxygen by face mask ; RATIONALE: The child who is cyanotic with oxygen saturations dropping to 60% is having a hypercyanotic episode. Hypercyanotic episodes often occur among infants with tetralogy of Fallot, and they may occur among infants whose heart defect includes the obstruction of pulmonary blood flow and communication between the ventricles. If a hypercyanotic episode occurs, the infant is placed in a knee-chest position immediately. The registered nurse is notified, who will then contact the health care provider. The knee-chest position improves systemic arterial oxygen saturation by decreasing venous return so that smaller amounts of highly saturated blood reach the heart. Toddlers and children squat to get into this position and relieve chronic hypoxia. There is no reason to call a code blue unless respirations cease. Additional interventions include administering 100% oxygen by face mask, morphine sulfate, and intravenous fluids, as prescribed.

ANSWER: Respirations that are abnormally deep, regular, and increased in rate ; RATIONALE: Kussmaul’s respirations are abnormally deep, regular, and increased in rate. In apnea, respirations cease for several seconds. In bradypnea, respirations are regular but abnormally slow. In hyperpnea, respirations are labored and increased in depth and rate.

ANSWER: Treat hypocalcemic tetany.

ANSWER: Monitor for hemorrhage. ; Administer eye medications. ; Maintain the eye patch or shield. ; Assist with activities of daily living. ; Educate regarding symptoms of retinal detachment. ; RATIONALE: An eye patch or shield is applied to protect the eye and prevent any further detachment. Educating the client regarding symptoms is necessary because the client is at risk for subsequent retinal detachment. Positioning, activity restrictions, and eye patches hinder the client in the performance of activities of daily living, and the client needs the nurse’s assistance with these activities. Eye medications are prescribed postoperatively, and hemorrhage is also a risk post surgery. Coughing is not encouraged because this can increase intraocular pressure and harm the client.

ANSWER: A client on a ventilator ; RATIONALE: The airway is always a high priority, and the nurse first checks the client on a ventilator. The clients described in options 2, 3, and 4 have needs that would be identified as intermediate priorities.

ANSWER: Phosphate binders ; Insulin ; Antibiotics ; RATIONALE: Phosphate binders and insulin can be administered because they aren’t removed from the blood by dialysis. Some antibiotics are removed by dialysis and should be administered after the procedure to ensure their therapeutic effects. The nurse should check a formulary to determine whether a particular antibiotic should be administered before or after dialysis.Cardiac glycosides such as digoxin should be withheld before hemodialysis. Hypokalemia is one of the electrolyte shifts that occur during dialysis, and a hypokalemic client is at risk for arrhythmias secondary to digitalis toxicity.

ANSWER: personal value system of the decision maker ; kind of data used in making the decision ; defensibility of the decision ; selling the decision ; RATIONALE: a. Many factors enter into the ability for problem identification; one factor that can influence problem identification is the decision maker’s personal value system. b. The generation of alternatives; if good alternatives are not generated, a good decision cannot be made. c. Can the decision maker support the outcome(s) and explain why the particular alternative was chosen if she/he had to support the decision to colleagues and nursing administration. d. Acceptance of the decision by those who will be affected by it is a key component to not having the decision fail.

ANSWER: The client functions well in other areas of his life. ; The degree of aggressiveness is out of proportion to the stressor. ; The client has a history of parental alcoholism and chaotic, abusive family life ; RATIONALE: A client with an impulse control disorder who displays violent, aggressive, and assaultive behavior generally functions well in other areas of his life. The degree of aggressiveness is typically out of proportion with the stressor. Such a client commonly has a history of parental alcoholism and a chaotic family life, and often verbalizes sincere remorse and guilt for the aggressive behavior.

ANSWER: Fever ; Sweating ; Agitation ; RATIONALE: Thyrotoxic crisis (thyroid storm) is an acute, potentially life-threatening state of extreme thyroid activity that represents a breakdown in the body’s tolerance to a chronic excess of thyroid hormones. The clinical manifestations include fever greater than 100° F, severe tachycardia, flushing and sweating, and marked agitation and restlessness. Delirium and coma can occur.

ANSWER: Presence of chest pain. ; Color of nail beds ; Auscultation of breath sounds ; RATIONALE: A respiratory assessment, which includes auscultation of breath sounds and assessing the color of the nail beds, is a priority for clients with pneumonia. Assessing for the presence of chest pain is also an important respiratory assessment as chest pain can interfere with the client’s ability to breathe deeply. Auscultate bowel sounds and assessing for peripheral edema may be appropriate assessments, but these are not priority assessments for the patient with pneumonia.

ANSWER: Head tilt ; Vomiting ; Lethargy ; RATIONALE: Head tilt, vomiting, and lethargy are classic signs assessed in a child with a brain tumor. Clinical manifestations are the result of location and size of the tumor.

ANSWER: Excess Fluid Volume ; Imbalanced Nutrition; Less than Body Requirements ; Activity Intolerance ; RATIONALE: Appropriate nursing diagnoses for clients with chronic renal failure include excess fluid volume related to fluid and sodium retention; imbalanced nutrition, less than body requirements related to anorexia, nausea, and vomiting; and activity intolerance related to fatigue. The nursing diagnoses of impaired gas exchange and pain are not commonly related to chronic renal failure.

ANSWER: To place an eye shield on the surgical eye at bedtime ; To contact the surgeon if a decrease in visual acuity occurs ; To take acetaminophen (Tylenol) for minor eye discomfort ; RATIONALE: After eye surgery, some scratchiness and mild eye discomfort may occur in the operative eye and is usually relieved by mild analgesics. If the eye pain becomes severe, the client should notify the surgeon because this may indicate hemorrhage, infection, or increased intraocular pressure. The nurse would also instruct the client to notify the surgeon of purulent drainage, increased redness, or any decrease in visual acuity. The client is instructed to place an eye shield over the operative eye at bedtime to protect the eye from injury during sleep and to avoid activities that increase intraocular pressure such as bending over.

ANSWER: Monitoring intake and output ; Monitoring extremities for edema ; Maintaining a low-sodium diet ; RATIONALE: The client with Cushing's syndrome experiencing fluid overload should be maintained on a high-potassium and low-sodium diet. Decreased sodium intake decreases renal retention of sodium and water. Monitoring weight, intake, output, and extremities for edema are all appropriate interventions for such a nursing diagnosis.

ANSWER: assumes responsibility ; is accountable ; RATIONALE: a. The nursing assistant accepts the responsibility to carry out the necessary care on the assigned patients. b. By reporting back to the staff nurse the nursing assistant demonstrates accountability for her/his actions; the nursing assistant by accepting the assignment has an obligation to periodically report back to the delegator.

ANSWER: Inquiring about the client’s feelings that may affect coping ; RATIONALE: The client must first deal with feelings and negative responses before the client is able to work through the meaning of the crisis. Option 3 pertains directly to the client’s feelings. Options 1, 2, and 4 do not directly address the client’s feelings.

ANSWER: Wearing gloves when emptying the client’s bedpan ; Keeping all linens in the room until the implant is removed ; Wearing a film (dosimeter) badge when in the client’s room ; Wearing a lead apron when providing direct care to the client ; RATIONALE: A private room with a private bath is essential if a client has an internal radiation implant. This is necessary to prevent the accidental exposure of other clients to radiation. The remaining options identify interventions that are necessary for a client with a radiation device.

ANSWER: A premature infant ; A 101-year-old man ; A client on renal dialysis ; RATIONALE: Clients with cardiac, respiratory, renal, or liver diseases and older and very young clients cannot tolerate an excessive fluid volume. The risk of fluid (circulatory) overload exists with these clients

ANSWER: A 10-year-old female client with a urinary tract infection ; RATIONALE: Children should not be given herbal therapies, especially in the home and without professional supervision. There are no general contraindications for the clients described in options 1, 2, and 4.

ANSWER: Notify the registered nurse. ; Prepare to administer morphine sulfate. ; Prepare to administer intravenous fluids. ; Prepare to administer 100% oxygen by face mask. ; RATIONALE: The child who is cyanotic with oxygen saturations dropping to 60% is having a hypercyanotic episode. Hypercyanotic episodes often occur among infants with tetralogy of Fallot, and they may occur among infants whose heart defect includes the obstruction of pulmonary blood flow and communication between the ventricles. If a hypercyanotic episode occurs, the infant is placed in a knee-chest position immediately. The registered nurse is notified, who will then contact the health care provider. The knee-chest position improves systemic arterial oxygen saturation by decreasing venous return so that smaller amounts of highly saturated blood reach the heart. Toddlers and children squat to get into this position and relieve chronic hypoxia. There is no reason to call a code blue unless respirations cease. Additional interventions include administering 100% oxygen by face mask, morphine sulfate, and intravenous fluids, as prescribed.

ANSWER: Inquiring about the client's feelings that may affect coping ; RATIONALE; The client must first deal with feelings and negative responses before the client is able to work through the meaning of the crisis. Option 3 pertains directly to the client's feelings. Options 1, 2, and 4 do not directly address the client's feelings.

ANSWER: Partial thromboplastin time. ; Platelet count ; Prothrombin time ; RATIONALE: Prothrombin time, partial thromboplastin time, and platelet count are all included in coagulation studies. The hemoglobin level, though important information prior to an invasive procedure like liver biopsy, does not assess coagulation.

ANSWER: Metabolic alkalosis ; RATIONALE: The loss of gastric fluid via nasogastric suction or vomiting causes metabolic alkalosis as a result of the loss of hydrochloric acid; this results in an alkalotic condition. Options 3 and 4 deal with respiratory problems. Option 1 relates to acidosis.

ANSWER: “I can usually keep my ostomy pouch on for 3 to 7 days before changing it.” ; “I must use a skin barrier to protect my skin from urine.” ; RATIONALE: The client with an ileal conduit must learn self-care activities related to care of the stoma and ostomy appliances. The client should be taught to increase fluid intake to about 3,000 ml per day and should not limit intake. Adequate fluid intake helps to flush mucus from the ileal conduit. The ostomy appliance should be changed approximately every 3 to 7 days and whenever a leak develops. A skin barrier is essential to protecting the skin from the irritation of the urine. An aspirin should not be used as a method of odor control because it can be an irritant to the stoma and lead to ulceration. The ostomy pouch should be emptied when it is one-third to one-half full to prevent the weight from pulling the appliance away from the skin.

ANSWER: To avoid activities that require bending over ; To place an eye shield on the surgical eye at bedtime ; To contact the surgeon if a decrease in visual acuity occurs ; To take acetaminophen (Tylenol) for minor eye discomfort ; RATIONALE: After eye surgery, some scratchiness and mild eye discomfort may occur in the operative eye and is usually relieved by mild analgesics. If the eye pain becomes severe, the client should notify the surgeon because this may indicate hemorrhage, infection, or increased intraocular pressure. The nurse would also instruct the client to notify the surgeon of purulent drainage, increased redness, or any decrease in visual acuity. The client is instructed to place an eye shield over the operative eye at bedtime to protect the eye from injury during sleep and to avoid activities that increase intraocular pressure such as bending over.

ANSWER: Early onset cough ; Purulent mucus production ; Mild episodes of dyspnea ; RATIONALE: Key features of pulmonary emphysema include dyspnea that is often marked, late cough (after onset of dyspnea), scant mucus production, and marked weight loss. By contrast, chronic bronchitis is characterized by an early onset of cough (before dyspnea), copious purulent mucus production, minimal weight loss, and milder severity of dyspnea.

ANSWER: Gastric lavage ; Activated charcoal and a saline cathartic ; Administration of Flumazenil ; RATIONALE: If ingestion is recent, decontamination of the GI system is indicated. The administration of syrup of ipecac is contraindicated because of aspiration risks related to sedation. Gastric lavage is generally the best and most effective means of gastric decontamination. Activated charcoal and a saline cathartic may be administered to remove any remaining drug. Hemodialysis is not useful in the treatment of benzodiazepine overdose. Flumazenil can be used to acutely reverse the sedative effects of benzodiazepines, though this is normally done only in cases of extreme overdose or sedation.

ANSWER: Early onset cough ; Purulent mucus production ; Mild episodes of dyspnea ; RATIONALE: Key features of pulmonary emphysema include dyspnea that is often marked, late cough (after onset of dyspnea), scant mucus production, and marked weight loss. By contrast, chronic bronchitis is characterized by an early onset of cough (before dyspnea), copious purulent mucus production, minimal weight loss, and milder severity of dyspnea.

ANSWER: Verify patency of the line by the presence of a blood return at regular intervals. ; Inspect the insertion site for swelling, erythema, or drainage ; If unable to aspirate blood, reposition the client and encourage the client to cough. ; Contact the health care provider about verifying placement if the status is questionable. ; RATIONALE: A major concern with intravenous administration of cytotoxic agents is vessel irritation or extravasation. The Oncology Nursing Society and hospital guidelines require frequent evaluation of blood return when administering vesicant or non vesicant chemotherapy due to the risk of extravasation. These guidelines apply to peripheral and central venous lines. In addition, central venous lines may be long-term venous access devices. Thus, difficulty drawing or aspirating blood may indicate the line is against the vessel wall or may indicate the line has occlusion. Having the client cough or move position may change the status of the line if it is temporarily against a vessel wall. Occlusion warrants more thorough evaluation via x-ray study to verify placement if the status is questionable and may require a declotting regimen.

ANSWER: Elevate head of bed 30 degrees before meals. ; RATIONALE: It is specific in what to do and when.

ANSWER: Gender. ; Health ; Temperament ; Intelligence ; RATIONALE: On average girls are born lighter and shorter than boys. A child who inherits a genetically transmitted disease may not grow as rapidly or develop fully as a healthy child, depending on the type of illness and the therapy or care available for the disease. Children with high intelligence do not generally grow faster than other children, but they do tend to advance faster in skills. Temperament is an inborn characteristic set at birth.

ANSWER: Elevated blood pressure ; Facial edema ; RATIONALE: The three classic signs of preeclampsia are hypertension, generalized edema, and proteinuria. Increased respirations are not a sign of preeclampsia.

ANSWER: Psychosocial ; RATIONALE: The psychosocial data is the least priority during the initial admission data collection. In the African-American culture, it is considered intrusive to ask personal questions during the initial contact or meeting. Additionally, respiratory, neurological, and cardiovascular data include physiological assessments that would be the priority.

ANSWER: Chronic stress ; Excessive caffeine ; Environmental noise ; RATIONALE: Acute or primary insomnia is caused by emotional or physical discomfort not caused by the direct physiologic effects of a substance or a medical condition. Excessive caffeine intake is an example of disruptive sleep hygiene; caffeine is a stimulant that inhibits sleep. Environmental noise causes physical and/or emotional and therefore is related to primary insomnia.

ANSWER: Oliguria ; Proteinuria 3+ ; Muscle cramps ; RATIONALE: Severe preeclampsia is characterized by blood pressure higher than 160/110 mm Hg, proteinuria 3+ or higher, and oliguria. Seizures (convulsions) are present in eclampsia and are not a characteristic of severe preeclampsia. Muscle cramps and contractions are not findings noted in severe preeclampsia, although the client is monitored for these occurrences.

ANSWER: Barbiturates deprive people of REM sleep ; When the barbiturates are discontinued, the REM sleep increases ; Nightmares are often an adverse effect when discontinuing barbiturates ; RATIONALE: Barbiturates deprive people of REM sleep. When the barbiturate is stopped and REM sleep once again occurs, a rebound phenomenon occurs. During this phenomenon, the persons dream time constitutes a larger percentage of the total sleep pattern, and the dreams are often nightmares.

ANSWER: “Take the medication with each meal." ; "Side effects include abdominal bloating and flatus." ; "Take some form of glucose if hypoglycemia occurs." ; "Report symptoms such as shortness of breath or tiredness." RATIONALE: The mechanism of action of acarbose is a delay in absorption of dietary carbohydrates, thereby reducing the rise in blood glucose after a meal. To accomplish this, the medication must be taken with each meal. Because of its bacterial fermentation of unabsorbed carbohydrates in the colon, side effects such as borborygmus, cramps, abdominal distention, and flatulence can occur. The medication also can affect absorption of iron, leading to symptoms (shortness of breath, tiredness) of anemia.

ANSWER: Tuck pant legs into socks. ; Wear closed shoes when hiking. ; Apply insect repellent containing DEET. ; Cover the ground with a blanket when sitting. ; RATIONALE: Measures to prevent tick bites focus on covering the body as completely as possible and spraying insect repellent containing DEET on the skin and clothing. Long sleeves and pants tucked into the socks along with closed shoes will offer some protection. Light-colored clothing should be worn so that ticks would be easily visible. Hikers should not sit directly on the ground and should cover the ground with an item such as a blanket. Ticks should be removed with tweezers.

ANSWER: confusion, , and. ; headache. ; seizures ; RATIONALE ; Dialysis equilibrium syndrome causes confusion, a decreasing level of consciousness, headache, and seizures. These findings, which may last several days, probably result from a relative excess of interstitial or intracellular solutes caused by rapid solute removal from the blood. The resultant organ swelling interferes with normal physiologic functions. To prevent this syndrome, many dialysis centers keep first-time sessions short and use a reduced blood flow rate. Acute bone pain and confusion are associated with aluminum intoxication, another potential complication of dialysis. Weakness, tingling, and cardiac arrhythmias suggest hyperkalemia, which is associated with renal failure. Hypotension, tachycardia, and tachypnea signal hemorrhage, another dialysis complication

ANSWER: In a semi-Fowler’s position ; With the head in a midline position ; RATIONALE: Clients who have undergone supratentorial surgery should have the head of the bed elevated 30 degrees to promote venous drainage from the head. The client is positioned to avoid extreme hip or neck flexion, and the head is maintained in a midline, neutral position. If a large tumor has been removed, the client should be placed on the nonoperative side to prevent the displacement of the cranial contents.

ANSWER: Monitor renal function and cardiac function closely ; Keep calcium gluconate on hand in case of a magnesium sulfate overdose ; Monitor deep tendon reflexes hourly ; Notify the physician if urinary output is less than 30 ml per hour. ; RATIONALE: When caring for a client receiving magnesium sulfate therapy, the nurse would monitor maternal vital signs, especially respirations, every 30-60 minutes and notify the physician if respirations are less than 12, because this would indicate respiratory depression. Calcium gluconate is kept on hand in case of magnesium sulfate overdose, because calcium gluconate is the antidote for magnesium sulfate toxicity. Deep tendon reflexes are assessed hourly. Cardiac and renal function is monitored closely. The urine output should be maintained at 30 ml per hour because the medication is eliminated through the kidneys.

ANSWER: Visual disturbance ; Headache ; Orthopnea ; Gout ; RATIONALE: Polycythemia vera, a condition in which too many RBCs are produced in the blood serum, can lead to an increase in the hematocrit and hypervolemia, hyperviscosity, and hypertension. Subsequently, the client can experience dizziness, tinnitus, visual disturbances, headaches, or a feeling of fullness in the head. The client may also experience cardiovascular symptoms such as heart failure (shortness of breath and orthopnea) and increased clotting time or symptoms of an increased uric acid level such as painful swollen joints (usually the big toe). Hearing loss and weight loss are not manifestations associated with polycythemia vera.

ANSWER: "Take pulse rate each day." ; "Weigh at the same time each day." ; "Palpitations may occur early in therapy." ; "Be careful when rising from sitting to standing." ; RATIONALE: Nifedipine is a calcium-channel blocker. Its therapeutic outcome is to decrease blood pressure. Its method of action is blockade of the calcium channels in vascular smooth muscle, promoting vasodilation. Side effects that can occur early in therapy include reflex tachycardia (palpitations) and first-dose hypotension, leading to orthostatic hypotension. Weight should be checked regularly to monitor for early signs of heart failure. Also the client is taught to take his or her own pulse. Nifedipine does not affect serum calcium levels. Increased water intake is not indicated in the client with cardiovascular disease.

ANSWER: Diarrhea ; Possible seizure activity ; Positive Trousseau's sign ; RATIONALE: A positive Chvostek's sign is indicative of hypocalcemia. Other signs and symptoms include tachycardia, hypotension, paresthesias, twitching, cramps, tetany, seizures, positive Trousseau's sign, diarrhea, hyperactive bowel sounds, and a prolonged QT interval.

ANSWER: Verify patency of the line by the presence of a blood return at regular intervals. ; Inspect the insertion site for swelling, erythema, or drainage. ; If unable to aspirate blood, reposition the client and encourage the client to cough. ; RATIONALE: A major concern with intravenous administration of cytotoxic agents is vessel irritation or extravasation. The Oncology Nursing Society and hospital guidelines require frequent evaluation of blood return when administering vesicant or non vesicant chemotherapy due to the risk of extravasation. These guidelines apply to peripheral and central venous lines. In addition, central venous lines may be long-term venous access devices. Thus, difficulty drawing or aspirating blood may indicate the line is against the vessel wall or may indicate the line has occlusion. Having the client cough or move position may change the status of the line if it is temporarily against a vessel wall. Occlusion warrants more thorough evaluation via x-ray study to verify placement if the status is questionable and may require a declotting regimen.

ANSWER: Providing skin care following bowel movements ; Maintaining intake and output records ; Obtaining the client’s weight. ; RATIONALE: The nurse can delegate the following basic care activities to the unlicensed assistant: providing skin care following bowel movements, maintaining intake and output records, and obtaining the client’s weight. Assessing the client’s bowel sounds and evaluating the client’s response to medication are registered nurse activities that cannot be delegated.