1) The nurse cares for a client with a cuffed tracheostomy tube. Before performing oral care, the nurse notes that the client's tracheostomy c

1. Leave the cuff inflated and suction through the tracheostomy.

2. Deflate the cuff and suction through the tracheostomy tube.

3. Inflate the cuff pressure to 40 mm Hg before suctioning.

4. Adjust the wall suction pressure to 160 to 180 mm Hg before suctioning.

1) CORRECT - Implementation: outcome desired; cuff inflation decreases the risk of aspiration; cuff position and pressure should be assessed f

2) Implementation: outcome not desired; accumulated oral secretions above the cuff will drain into the bronchi; increased risk of infection

3) Implementation: outcome not desired; cuff pressure should be lessthan 20 mm Hg (25 cm H2O); risk of trauma to trachea with higher pressure

4) Implementation: outcome not desired; increases the risk of trauma to lower airways

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2) A young adult brings a friend to the emergency department and states that the friend has been using heroin. Which action by the nurse isth

1. Assess pupil size and reactivity.

2. Assess oxygen saturation levels.

3. Palpate dorsalis pedis pulses.

4. Ask the client if he knows today's date.

1) Assessment: outcome not priority but may be appropriate; pinpoint pupils are a sign of heroin overdose

2) CORRECT - Assessment: outcome priority; shallow respirations seen; impaired alveolar gas exchange and possible respiratory arrest

3) Assessment: outcome not priority; most important to assess airway and breathing

4) Assessment: outcome not priority but may be appropriate; drowsiness and euphoria may be seen; not priority

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3) The client tells the clinic nurse that the client isthinking about using nicotine polacrilex (Nicorette). Which question is MOST important

1. "Have you tried other methods to stop smoking?"

2. "How long have you been smoking?"

3. "Have you ever had chest pain?"

4. "Do you have a partial dental bridge?"

1) Assessment: outcome not priority but may be appropriate; can be asked as part of assessment

2) Assessment: outcome not priority but may be appropriate; should be assessed for further teaching

3) CORRECT - Assessment: outcome priority; action of nicotine is vasoconstriction; increases heart rate and myocardial oxygen consumption; inc

4) Assessment: outcome may be appropriate but not priority; gum is place between cheek and gums; may stain dental work

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4) The nurse cares for the client with a client controlled analgesia (PCA) pump. The nurse determines that the client has pressed the button 1

1. Assess the patency of the PCA IV tubing.

2. Determine the client's understanding of the PCA pump function.

3. Obtain an order to begin a PCA infusion of fentanyl.

4. Ask the client to describe the pain.

1) Assessment: outcome not priority but may be appropriate; if tubing is obstructed, alarm is activated

2) Assessment: outcome may be appropriate but not priority; more important to determine pain level, description of the pain, region and radiat

3) Implementation: outcome not desired; more important to assess severity of pain and pain relief first

4) CORRECT - Assessment: outcome priority; must validate that client isin pain before implementation

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5) A pregnant woman receives an epidural anesthetic. After administration of the epidural anesthetic, the client's blood pressure changes from

1. Place the client flat on her back.

2. Elevate the head of the bed 30 degrees.

3. Place the client on her left side with her legs flexed.

4. Place the client supine with the foot of the bed elevated.

1) Implementation: outcome not desired; no increase in venous return

2) Implementation: outcome not desired; will decrease venousreturn

3) CORRECT - Implementation: outcome desired; will increase venous return and cardiac output; fetal pressure on inferior vena cava reduced

4) Implementation: outcome not desired; elevation of legs will increase venousreturn, but fetal pressure on vena cava will prevent blood retu

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6) A nursing order, "Increase fluid intake" is written for a client diagnosed with dehydration. Which finding BEST indicates improving fluid s

1. Urinary output of 1,500 mL in 24 hours.

2. Serum hematocrit 52%.

3. Oral fluid intake of 900 mL in 24 hours.

4. Blood pressure of 100/82.

1) CORRECT - Assessment: outcome priority; increased amounts of antidiuretic hormone secreted; urine output decreased and concentrated

2) Assessment: outcome not priority; indicatesthat blood is hemoconcentrated

3) Assessment: outcome not priority; normal intake is 1,500 mL in 24 hours

4) Assessment: outcome not priority; normal BP is 120/80

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7) The nurse prepares to administer the initial dose of oral enalapril (Vasotec) 20 mg in the morning. Which medication should the nurse quest

1. 20 mg oral escitalopram (Celexa) in the morning.

2. 40 mg oral furosemide (Lasix) in the morning.

3. 300 mg of oral gabapentin (Neurontin) twice daily.

4. 10 mg zolpidem (Ambien) at bedtime.

1) Implementation: outcome not a problem; no interaction with ACE inhibitors; is an SSRI antidepressant

2) CORRECT - Implementation: outcome potential problem; may promote significant diuresis; first dose of ACE inhibitors increases risk of "firs

3) Implementation: outcome not a problem; no interaction; gabapentin classified as antiseizure medication; off-label use for neuropathic pain

4) Implementation: outcome not a problem; is a hypnotic; no interaction with ACE inhibitors

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8) The home care nurse visits a client with a halo fixator traction device. Which client statement MOST concerns the nurse?

1. "My wife looks at the pin sites every day."

2. "I like to bathe in the tub."

3. "I drove to the library yesterday."

4. "I drink with a straw."

1) Assessment: outcome desired; risk of infection at pin sites; client should be taught signs of inflammation and infection

2) Implementation: outcome desired; showers increase risk of infection at pin sites

3) CORRECT - Implementation: outcome not desired and may be a problem; client is not able to turn with halo device; increases the risk of inju

4) Implementation: outcome desired; difficulty manipulating cup or glass due to immobilized neck

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9) The nurse cares for a client diagnosed with depression. Which statement by the client indicates improvement?

1. "I have been sleeping 6 hours at night."

2. "I have lost 2 lbs in the past week."

3. "Lately, I have trouble watching television."

4. "I have much less muscle tension now."

1) CORRECT - Assessment: outcome desired; clients with depression may have increased or decreased sleep time

2) Assessment: outcome not desired; lack of appetite is a frequent sign of depression

3) Assessment: outcome not desired; lack of concentration is sign of depression

4) Assessment: outcome not desired; is a sign of anxiety

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10) The nurse on the maternity unit must accept a transfer client from a medical/surgical unit. The nurse considers which transfer client appr

1. A 38-year-old client with a diagnosis of systemic lupus erythematosus.

2. A 45-year-old client receiving daily external radiation therapy treatments for breast cancer.

3. A 58-year-old client receiving antibiotic treatment for cellulitis of the left leg.

4. A 74-year-old client who hasreceived intravenous antibiotics for 7 days.

1) CORRECT - Implementation: outcome desired; autoimmune disease; not infectious

2) Implementation: outcome not desired; possible skin damage and suppression of bone marrow with decreased white-blood-cell levels; increased

3) Implementation: outcome not desired; generalized skin infection of deeper connective tissue; usually caused by Streptococcus or Staphylococ

4) Implementation: outcome not desired; elderly clientsreceiving long-term antibiotic therapy are at risk for Clostridium difficile infection

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11) The nurse in the outclient surgery unit prepares a 4-year-old child for surgery. It is MOST important for the nurse to make which of these

1. "Your parents are going to leave a half hour before the surgery."

2. "You're going to talk with some other children who had this surgery."

3. "If you have this surgery, your parents will buy you a new toy."

4. "Take this doll and show me where the operation will be done."

1) Implementation: outcome not desired; parents are encouraged to remain with child

2) Implementation: outcome not desired; appropriate only forschool-aged and adolescent children

3) Implementation: outcome not desired; not appropriate