1) The nurse caresfor a client with a cuffed tracheostomy tube.Before performing oral care, the nurse notesthat the client's tracheostomy c

1. Leave the cuffinflated 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; cuffinflation decreasesthe 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 oftrauma to lower airways

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2) A young adult brings a friend to the emergency department and statesthat 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 butmay be appropriate; drowsiness and euphoria may be seen; not priority

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

1. "Have you tried other methodsto 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 butmay 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 forthe client with a client controlled analgesia (PCA) pump. The nurse determinesthat the client has pressed the button 1

1. Assessthe patency of the PCA IV tubing.

2. Determine the client's understanding ofthe 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 butmay 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 ofthe pain, region and radiat

3) Implementation: outcome not desired; more important to assessseverity 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 ofthe 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 herleft side with her legs flexed.

4. Place the client supine with the foot ofthe 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 venousreturn and cardiac output; fetal pressure on inferior vena cava reduced

4) Implementation: outcome not desired; elevation oflegs 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 preparesto 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. "Ilike to bathe in the tub."

3. "I drove to the library yesterday."

4. "I drink with a straw."

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

2) Implementation: outcome desired; showersincrease risk ofinfection 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 indicatesimprovement?

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

2. "I have lost 2 lbsin 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 issign 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 ofthe left leg.

4. A 74-year-old client who hasreceived intravenous antibioticsfor 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 ofdeeper connective tissue; usually caused by Streptococcus or Staphylococ

4) Implementation: outcome not desired; elderly clientsreceiving long-termantibiotic therapy are at risk forClostridium 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 ofthese

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 thissurgery."

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

4) CORRECT -Implementation: outcome desired; encourage expression of feelings(e.g., anger); fear mutilation; allow child to play with models

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12) The nurse cares for a client diagnosed with Alzheimers disease. The client is confused and incontinent of urine. What is the MOST importan

1. Insert an indwelling urinary drainage catheter.

2. Perform intermittent catheterization every 4 hours.

3. Offer the bedpan to the client every 2 hours.

4. Assist the client to a bedside commode every 2 hours.

1) Implementation: outcome not desired; increases risk ofinfection; catheter-related infections are most common hospital-acquired infection

2) Implementation: outcome not desired; increases chance of infection

3) Implementation: outcome appropriate but not priority; does not keep client independent and active

4) CORRECT -Implementation: outcome desired; keeps client active and independent

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13) The nurse caresfor a client with a history oftype 1 diabetes mellitus who hasjust returned to the surgical acute-care unit after a righ

1. Check the client records to see if insulin was given prior to surgery.

2. Administerthe 6 units of regularinsulin subcutaneously.

3. Administerthe insulin when oral fluids are tolerated.

4. Contact the healthcare provider.

1) Assessment: outcome desired but not priority; client needsinsulin coverage now

2) CORRECT -Implementation: outcome desired; sliding scale-receives predetermined amount ofinsulin according to glucose level; surgery and i

3) Implementation: outcome not desired; needsinsulin regardless of oral intake due to elevated blood glucose

4) Implementation: outcome not desired; no reason to contact healthcare provider; orderis valid and appropriate forsituation

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14) During the admission interview, the client reports a red, itchy raised rash on the chest and lip swelling after use of aspirin and penicil

1. Administerthe Ceclor as ordered; do not administer the naproxen.

2. Administerthe naproxen as ordered; do not administerthe Ceclor.

3. Administer both the Ceclor and naproxen as ordered; document the client'sresponse.

4. Do not administerthe Ceclor or naproxen; notify the healthcare provider.

1) Implementation: outcome not desired; cephalosporins have cross-allergies with penicillins

2) Implementation: outcome not desired; NSAIDs should be used cautiously with aspirin allergies

3) Implementation: outcome not desired; both medications should be withheld due to allergies

4) CORRECT - Implementation:outcome desired; both medicationsshould be withheld; risk of hypersensitivity reaction

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15) The nurse teaches a client about how to care for an ileostomy. Which comment, if made by the client to the nurse, indicates further teachi

1. "The skin around the stoma should be cleaned with warm water and thoroughly dried."

2. "The appliance should fit snugly around the ileostomy opening."

3. "Ishould take polyethylene glycol (MiraLax) with a large glass of water."

4. "I will continue to take a daily multi-vitamin."

1) Implementation: outcome desired; standard of care for ileostomy

2) Implementation: outcome desired; ileostomy drainage isliquid and very alkaline; great risk ofskin irritation

3) CORRECT - Implementation: outcome not desired; osmotic laxative and is contraindicated; avoid enteric-coated or capsule medication, which m

4) Implementation: outcome desired; inform healthcare provider and pharmacist about ileostomy

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16) The nurse caresfor a client diagnosed with chronic bronchitis and peripheral vascular disease. The nurse expects to assess which of these

1. Continuous,high-pitched musical sounds heard on expiration.

2. Soft, high-pitched interrupted sounds heard on inspiration.

3. Deep, low-pitched rumbling sounds are heard mainly on expiration.

4. Harsh, grating sounds heard best during inspiration.

1) Assessment: outcome not expected; sibilant wheezes, heard with asthma, caused by narrow bronchioles

2) Assessment: outcome not expected; crackles, heard with pneumonia and CHF, caused by fluid in the alveoli

3) CORRECT - Assessment: outcome expected; sonorous wheezes or rhonchi, caused by mucusin the airways; excessive mucous production is primary

4) Assessment: outcome not expected; pericardial friction rub, caused by inflamed pleura or pericarditis

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17) The nurse preparesto administer gentamicin (Garamycin)to the 65-year-old client. Which isthe MOST important action for the nurse to tak

1. Request a daily hemoglobin and hematocrit test.

2. Monitorthe serumBUN and creatinine.

3. Request a highly-sensitiveC-reactive protein (hs-CRP)test.