1. An IV solution of 0.

9% sodium chloride is the most appropriate initial IV fluid for this client, because it is an isotonic solution that will act as a volume expander to quickly replace volume losses and promote physiological stabilization. 3% sodium chloride, is a high concentration (hypertonic) electrolyte solution; it would only be used in a client with hyponatremia and must be closely monitored during infusion. 5% dextrose and 0.9% sodium chloride and 5% dextrose and lactated Ringer's may be appropriate fluids to infuse after 0.9% sodium chloride. Test-Taking Tip: Become familiar with reading questions on a computer screen. Familiarity reduces anxiety and decreases errors. 2. Patient care assistants can make occupied and unoccupied beds. Taking routine vital signs is within the scope of practice of patient care assistants. Answering call lights and meeting clients' basic safety, hygiene, and comfort needs are within the scope of practice of patient care assistants. Watching a client take oral medications is part of procedure for administration of medications, which requires a professional license. Emptying a closed chest drainage system for intake and output is inappropriate; a closed chest drainage system is not emptied for intake and output. Documentation is indicated on the outside of the drainage collection chamber.

3. The nurse filling out an incident or variance report needs to state only the objective facts surrounding the incident, no opinion or speculation. In an incident report fault or blame is subjective and should not be implied. It is not necessary to include names except for those of witnesses. Speculations or opinions as to the reason why the ordered restraints were not on the client are subjective and not appropriate to include in an incident or variance report. 4. Primary prevention activities are directed toward promoting healthful lifestyles and increasing the level of well-being. Performing yearly physical examinations is a secondary prevention. Emphasis is on early detection of disease, prompt intervention, and health maintenance for those experiencing health problems. Providing hypertension screening programs is a secondary prevention. Emphasis is on early detection of disease, prompt intervention, and health maintenance for those experiencing health problems. Teaching a person with diabetes how to prevent complications is a tertiary prevention. Emphasis is on rehabilitating individuals and restoring them to an optimum level of functioning. 5. Clients who are mentally competent have the right to refuse treatment; the nurse must respect this right. Client's questions must always be answered truthfully. The health care provider should be notified when a client refuses an intervention so that an alternate treatment plan can be formulated. This is done after the

nurse explores the client's reasons for refusal. The client had a discussion with the nurse that indicated that the client had sufficient information to make the decision to refuse the medication. The client has a right to refuse treatment; this right takes precedence over the health care provider's prescription. 6. To facilitate visualization of the rectum and the sigmoid colon, the lower colon must be emptied immediately before the procedure. A fleet or tap water enema should be used. The client will be kept NPO for at least 8 hours before the procedure. Morphine is not typically used as a pre-op medication before a sigmoidoscopy. Restraints are not typically used during the procedure. 7. Because of fluid overload in the intravascular space, the neck veins become visibly distended. Rapid, thready pulse and elevated hematocrit level occur with a fluid deficit. If sodium causes fluid retention, its concentration is unchanged; if fluid is retained independently of sodium, its concentration is decreased. 8. The generativity versus stagnation stage precedes integrity versus despair; Erikson theorized that how well people adapt to a present stage depends on how well they adapted to the immediately preceding stage. Industry versus inferiority is the stage of school-age children; it precedes identity versus role confusion, not integrity versus despair. Identity versus role

confusion is the stage of adolescence; it precedes intimacy versus isolation, not integrity versus despair. Autonomy versus shame/doubt is the stage of early childhood; it precedes initiative versus guilt, not integrity versus despair. 9. The client is exhibiting the freedom to make a personal decision, and this reflects the concept of autonomy. Justice refers to fairness. Veracity refers to truthfulness. Beneficence refers to implementing actions that benefit others. 10. Some state boards of nursing identify specific activities that may be delegated to NAP, such as obtaining routine vital signs on stable clients, feeding or assisting clients at mealtimes, ambulating stable clients, and helping clients with bathing and hygiene. However, nursing interventions that require independent nursing knowledge, skill, or judgment, such as assessment, client teaching, and evaluation of care cannot be delegated. Although LPNs and LVNs may change dressings, evaluation of wounds must be done by the registered nurse (RN). Clients who have low oxygen saturation levels and telemetry readings must be evaluated by the RN. 11. An intravenous (IV) solution of 1000 mL 5% dextrose in water

is to be infused at 125 mL/hr to correct a client's fluid imbalance. The infusion set delivers 15 drops/mL. To ensure that the solution will infuse over an eight-hour period, at how many drops per minute should the nurse set the rate of flow? Record the answer using a whole number. _ gtts/min A:31

12. The nurse should remove and dispose of the patch in a manner that protects self and others from exposure to the fentanyl. Having the family remove and dispose of the patch or having the mortician remove the patch are not the responsibility of nonprofessionals because they do not know how to protect themselves and others from exposure to the fentanyl. It is unnecessary to return a used fentanyl patch. 13. Allowing the denial and being available to discuss the situation with the client does not remove the client's only way of coping, and it permits future movement through the grieving process when the client is ready. Reassuring the client that everything will be all right is false reassurance. The client must not be abandoned; the nurse's presence is a form of emotional support. The client's denial should be neither encouraged nor removed; encouraging denial is a form of false reassurance. 14. Conscious sedation is administered by direct intravenous (IV) injection (IV push) to dull or reduce the intensity of pain or awareness of pain during a procedure without loss of defensive reflexes. General anesthesia usually is administered via inhalation of the vapor of a volatile liquid or an anesthetic gas via a mask or endotracheal tube; as a result, the client is unconscious, unaware, and anesthetized. An epidural block, a type of regional anesthesia, involves the injection of a local anesthetic into the epidural

(extradural) space; it works by binding to nerve roots as they enter and exit the spinal cord. Epidural blocks are not used for moderate sedation. The oral route of drug administration is commonly used for pediatric clients, not adults. 15. The reporting of possible child abuse is required by law, and the nurse's identity can remain confidential. The nurse is functioning in a professional capacity and therefore can be held accountable. Although the Good Samaritan Act protects health professionals, the nurse is still responsible for acting as any reasonably prudent nurse would in a similar situation. 16. In this situation being aware that a client is overmedicating and taking no action can be considered an act of euthanasia on the part of the home care nurse. Implementing a "do not resuscitate" order, abiding by the decision of a living will signed by the client's family, and encouraging the client to consult an attorney are all appropriate actions for a home care nurse. 17. Before suctioning, regardless of the means, oxygen should be administered, because the suctioning procedure depletes oxygen from the respiratory tract, causing a potential drop in oxygen saturation levels. In a client with an endotracheal tube, manually bagging with 100% oxygen will hyperoxygenate the lungs. The client who has an endotracheal tube may not be able to follow commands to take deep breaths, cough, or have the strength to

do either, which is why manual bagging is preferred. A new sterile suction catheter should be used each time the client is suctioned, but the suction tubing and equipment need not be changed. 18. The most important side effect to monitor in a client who has received epidural anesthesia is hypotension due to autonomic nervous system blockade. Therefore, in the immediate postoperative recovery period, the blood pressure should be assessed frequently. Other side effects include bradycardia, nausea, and vomiting. Increased oral temperature and unequal bilateral breath sounds are not effects associated with epidural anesthesia. Diminished peripheral pulses may result from hypotension, although they are not the most common side effects. 19. Acetazolamide is a carbonic anhydrase inhibitor that decreases inflow of aqueous humor and controls intraocular pressure in acute angle-closure glaucoma attack. Chlorothiazide and bendroflumethiazide have no effect on the eye. Demecarium bromide does not affect production of aqueous humor. 20. Skin elasticity will decrease because of a decrease in interstitial fluid. The pulse rate will increase to oxygenate the body's cells. Specific gravity will increase because of the greater concentration of waste particles in the decreased amount of urine. The temperature will increase, not decrease.

21. Papules are superficial and elevated up to 0.5 cm. Nodules and tumors are masses similar to papules but are elevated more than 0.5 cm and may infiltrate deeper into tissues. Erosions are characterized as loss of the epidermis layer; macules are nonpalpable, flat changes in skin color less than 1 cm in diameter; and vesicles are usually transparent, filled with serous fluid, and are a blisterlike elevation. 22. The Nurse Practice Act states that the nurse will do health teaching and administer nursing care supportive to life and wellbeing. The teaching was essential before discharge. The client is responsible for self-care. Health teaching is an independent nursing function. Test-Taking Tip: Avoid taking a wild guess at an answer. However, should you feel insecure about a question, eliminate the alternatives that you believe are definitely incorrect, and reread the information given to make sure you understand the intent of the question. This approach increases your chances of randomly selecting the correct answer or getting a clearer understanding of what is being asked. Although there is no penalty for guessing on the NCLEX examination, the subsequent question will be based, to an extent, on the response you give to the question at hand; that is, if you answer a question incorrectly, the computer will adapt the next question accordingly based on your knowledge and skill performance on the examination up to that point

23. Of the choices provided, the potential complication of highest risk for a client with an NG tube is aspiration pneumonia. Care should be taken to prevent dislodging of the tube or vomiting. Proper positioning of the client with an NG tube would include supine or side-lying, semi-Fowler's or higher. Skin breakdown in a client with an NG tube may result from pressure of the tube against nasal structures. The tube should be periodically repositioned and taped to prevent this complication. A retention ileus is not related to an NG tube. A client who develops profuse diarrhea with an NG tube requires further investigation. It may be totally unrelated or a result of an enteral feeding incompatibility. 24. The prayer cloth has religious significance for the client and should be preserved as is. Making a new prayer cloth disregards what the prayer cloth means to the client. The prayer cloth is the property of the client and should not be discarded. Washing the prayer cloth with a detergent disregards what the prayer cloth means to the client; this never should be done without the client's permission 25. Hyperventilation causes excessive loss of carbon dioxide, leading to carbonic acid deficit and respiratory alkalosis. Cardiac arrest is unlikely; the client may experience dysrhythmias but will lose consciousness and begin breathing regularly. Hyperventilation causes alkalosis; the pH is increased. Excess oxygen saturation

cannot occur; the usual oxygen saturation of hemoglobin is 95% to 98%. 26. Toxicity can result because the action of calcium ions is similar to that of digoxin. Calcium gluconate cannot be added to a solution containing carbonate or phosphate because a dangerous precipitation will occur. Calcium gluconate can be added to the IV solution the client is receiving. If calcium infiltrates, sloughing of tissue will result. 27. Shearing force is the pressure exerted on the skin when a debilitated client is pulled up in bed without a drawsheet, or when the client slides down in bed. With shearing, the skin adheres to the bed linens while the layers of subcutaneous tissue and bone slide in the direction of the body movements, causing a tearing of the skin. Using a drawsheet can reduce and minimize friction and shearing force. Maintaining the head of the bed at 35 degrees or less, repositioning the client at least every 2 hours and supporting with pillows and at least once every 8 hours, and performing passive range-of-motion exercises of all extremities are all appropriate interventions to prevent further pressure injury and to promote circulation, but they are not as effective as using a drawsheet in prevention of shearing force. 28. Prayer is an alternative therapy that may relax the client and provide strength, solace, or acceptance. The relief of pain through

hypnosis is based on suggestion; also, it focuses attention away from the pain. Some clients learn to hypnotize themselves. Aromatherapy can help relax and distract the individual and thus increase tolerance for pain, as well as relieve pain. Guided imagery can help relax and distract the individual and thus increase tolerance for pain, as well as relieve pain. Analgesics, both opioid and nonopioid, long have been part of the standard medical regimen for pain relief, so they are not considered an alternative therapy 29. Clients adapting to illness frequently feel afraid and helpless and strike out at health team members as a way of maintaining control or denying their fear. There is no evidence that the client denies the existence of the health problem. Although disorders such as brain attacks and atherosclerosis, which are associated with hypertension, may lead to cerebral anoxia, there is insufficient evidence to support this conclusion. Captopril (an antihypertensive) is a renin-angiotensin antagonist that reduces blood pressure and does not cause behavioral changes; alprazolam is prescribed to reduce anxiety. 30. The hospital is threatening to keep the infant; therefore false imprisonment is threatened. False imprisonment is restraining or confining a person without a clinical reason. False threat may be a term to describe false imprisonment; however it is inaccurate in this situation. Assault and battery legally means to threaten

violence and the physical act of violence. Breach of confidentiality is a disclosure to a third party, without client consent or court order of private information. 31. Dehydration is measured most readily and accurately by serial assessments of body weight; 1 L of fluid weighs 2.2 lb. Although dry skin may be associated with dehydration, it also is associated with aging and some disorders (e.g., hypothyroidism). Although hypovolemia eventually will result in a decrease in blood pressure, it is not an accurate, reliable measure because there are many other causes of hypotension. Altered appearance is too general and not an objective determination of fluid volume deficit. 32. HIV, which is the virus that causes AIDS, is transmitted through infected blood, semen, and bloody body fluids. HIV is not spread casually. Although HIV may be found in other body secretions, including feces, urine, sweat, tears, saliva, sputum, and emesis, the amount of virus is likely not sufficient enough to be transmitted. 33. Additional fluid from surrounding tissues will be drawn into the lung because of the high osmotic pressure exerted by the salt content of the aspirated ocean water; this results in pulmonary edema. Hypoxia and acidosis may occur after a near-drowning. Renal failure is not a sequela of near-drowning. Hypovolemia occurs because fluid is drawn into the lungs by the hypertonic saltwater.

34. Assessing the client's knowledge to delineate baseline information should be done before planning appropriate health teaching. Providing written material without knowing the client's ability to read is inappropriate; also, it limits the nurse's personal involvement in the teaching process. Having the client talk with the health care provider avoids carrying out the nurse's responsibility to provide teaching about a prescribed medication regimen. Health teaching about medication is the responsibility of the registered professional nurse. 35. Beneficence commonly is referred to as "doing of good"; it is related to the nurse's duty to help clients further their legitimate interest within the boundaries of safety. Unfortunately in this situation the client's priority is relief from pain and the nurse should be working with other health team members to achieve this objective. Veracity is defined as telling the truth. Autonomy, as an ethical principle, means that the nurse respects the client and the choices that are made. Paternalism occurs if the nurse interferes with the individual's autonomy by disregarding the client's choices. 36. Denial includes feelings that the health care provider has made a mistake, so the client seeks additional opinions. Anger follows denial; behavior will be hostile and critical. Bargaining occurs after anger; the client verbally or secretly may promise something in return for wellness or a prolonged life. Depression occurs after

bargaining; the client feels sadness and despair and may be withdrawn. 37. This behavior is a sign of hypersomnia and the client needs a medical assessment; it frequently is caused by central nervous system damage or certain kidney, liver, or metabolic disorders. Exercise is appropriate for a client experiencing insomnia, not hypersomnia. This behavior is a sign of hypersomnia and medical causes should be ruled out before attributing it to a psychogenic cause. Narcolepsy consists of recurrent sudden waves of overwhelming sleepiness that occur during the day, even during activities such as eating or conversing. Study Tip: Determine whether you are a lark or an owl. Larks, day people, do best getting up early and studying during daylight hours. Owls, night people, are more alert after dark and can remain up late at night studying, catching up on needed sleep during daylight hours. It is better to work with natural biorhythms than to try to conform to an arbitrary schedule. You will absorb material more quickly and retain it better if you use your most alert periods of each day for study. Of course, it is necessary to work around class and clinical schedules. Owls should attempt to register in afternoon or evening lectures and clinical sections; larks do better with morning lectures and day clinical sections.

38. The Z-track method seals the puncture at the intramuscular level, preventing seepage of injected medication up the needle track and thereby avoiding injury to subcutaneous tissue and skin. The Z-track technique is unrelated to the volume of medication to be administered. When the volume of medication is large, it should be administered into a large muscle or divided into two syringes. Massage is avoided with the Z-track technique to help prevent the injected medication from flowing back up the needle track. Administration of a small air bubble at the completion of injection of medication into a muscle (air-lock technique) is no longer recommended because it does not increase the likelihood that medication will remain in the muscle without flowing back up the needle track. 39. Contact precautions should be used for direct client or environmental contact with blood or body fluids from an infected client. This includes colonization of infection with multidrugresistant organisms (MDRO) such as MRSA, stool infected with Clostridium difficle, draining wounds where secretions are not contained, or scabies. Airborne precautions are used for infected droplets smaller then 5 mcg, such as measles, chickenpox (varicella), or pulmonary TB. Droplet precautions are used for droplets larger than 5 mcg and being within 3 feet of the client, such as streptococcal pharyngitis, mumps, and influenza. Protective environment focuses on clients with a compromised immune system to protect them from incoming pathogens.

40. Prostaglandins accumulate at the site of an injury, causing pain; NSAIDs inhibit COX-1 and COX-2 (both are isoforms of the enzyme cyclooxygenase), which inhibit the production of prostaglandins, thereby contributing to analgesia. NSAIDs inhibit COX-2, which is associated with fever, thereby causing antipyresis. NSAIDs inhibit COX-2, which is associated with inflammation, thereby reducing inflammation. NSAIDs do not cause diuresis; reversible renal ischemia and renal insufficiency in clients with heart failure, cirrhosis, or hypovolemia can be potential adverse effects of NSAIDs. NSAIDs do not cause bronchodilation. Anticoagulation is an adverse effect, not a desired outcome; NSAIDs can impair platelet function by inhibiting thromboxane, an aggregating agent, resulting in bleeding. 41. Noisy, increased respirations and increased pulse are signs that the client needs immediate suctioning to clear the airway of secretions. After suctioning, a complete respiratory assessment should be performed. After suctioning, then performing a respiratory assessment, further problem solving may require readjustment of the tracheostomy tube and ties or a physician changing the tracheostomy tube. 42. The gamma-globulin fraction in the plasma is the fraction that includes the antibodies. Albumin helps regulate fluid shifts by

maintaining plasma oncotic pressure. Thrombin is involved with clotting. Hemoglobin carries oxygen. 43. The impaired skin integrity is physiologically a result of unrelieved pressure and shearing force. This is supported by the data provided that the client is non-ambulatory and has a reddened sacrum. Risk for pressure ulcer is not an approved NANDA-I nursing diagnosis. The client's problem is not being "at risk" because the client already has an actual problem. Not enough information is provided to make the assumption that the impaired skin integrity is related to infrequent turning and repositioning. 44. Increased respirations blow off carbon dioxide (CO2), which decreases the hydrogen ion concentration and the pH increases (less acidity). Decreased respirations result in CO2 buildup, which increases hydrogen ion concentration and the pH falls (more acidity). The kidneys either conserve or excrete bicarbonate and hydrogen ions, which helps to adjust the body's pH. The buffering capacity of the renal system is greater than that of the pulmonary system, but the pulmonary system is quicker to respond. Skeletal and nervous systems do not maintain the pH, nor do muscular and endocrine systems. Although the circulatory system carries fluids and electrolytes to the kidneys, it does not interact with the urinary system to regulate plasma pH.

45. The client has the right to make this decision, and the staff should accept the client's wishes. The client is a doctor, and the nurse's statement attacks the client's self-concept. The informality of using first names is not encouraged unless it is the client's choice. The nurse can and should honor the client's request. 46. Socialization, values, and role definition are learned within the family and help develop a sense of self. Once established in the family, the child can move more easily into society. Although important, providing rewards and punishments, supporting the child's development, and reflecting the mores of society are just one aspect of the family's influence and are not as important as identity and roles in relation to emotional development. 47. Dependent edema around the area of feet and ankles often indicates right sided heart failure or venous insufficiency. The nurse should assess for pitting edema by pressing firmly for several seconds then release to assess for any depression left on the skin. The grading of 1+ to 4+ characterizes the severity of the edema. A grade of grade of 4+ indicates an 8 mm depression. A grade of 1+ indicates a 2 mm depression. A grade of 2 + indicates a 4 mm depression. A grade of 3+ indicates a 6 mm depression. 48. An intravenous piggyback (IVPB) of cefazolin (Kefzol)

500 mg in 50 mL of 5% dextrose in water is to be administered over a 20-minute period. The tubing has a

drop factor of 15 drops/mL. At what rate per minute should the nurse regulate the infusion to run? Record the answer using a whole number. ______ gtts/min A: 38
49. Because of the profound effect of paralysis on body image, the nurse should foster an environment that permits exploration of feelings without judgment, punishment, or rejection. Attempts to distract the client may be interpreted as denial of the client's feelings and will not resolve the underlying problem. Including the client in decision making and helping the client to problem-solve personal issues are an important part of nursing care, but they are not related to the client's feelings. 50. Ibuprofen irritates the gastrointestinal (GI) mucosa and can cause mucosal erosion, resulting in bleeding; blood in the stool (melena) occurs as the digestive process acts on the blood in the upper GI tract. Hemoglobin, which carries oxygen to body cells, is decreased with anemia; the heart rate increases as a compensatory response to increase oxygen to body cells. Constipation usually is related to immobility, a low-fiber diet, and inadequate fluid intake, not the data listed in this situation. Clay-colored stools are related to biliary problems, not GI bleeding. Painful bowel movements are related to hemorrhoids, not GI bleeding. 51. The liver manufactures albumin, the major plasma protein. A deficit of this protein lowers the osmotic (oncotic) pressure in the

intravascular space, leading to a fluid shift. An enlarged liver compresses the portal system, causing increased, rather than decreased, pressure. The kidneys are not the primary source of the pathologic condition. It is the liver's ability to manufacture albumin that maintains the colloid oncotic pressure. Potassium is not produced by the body, nor is its major function the maintenance of fluid balance. 52. Best practice guidelines indicate that non-coring needles be changed at least every seven days to decrease risk of infection. Changing a non-coring needle every 3 to 5 days is too frequent and increases the risk for infection as well as patient discomfort. Changing a non-coring needle every 9 days increases the risk of infection due to the prolonged length of time the needle is in place. 53. Meta-analysis is a synthesis of evidence from associated randomized controlled trials. Meta-analysis is more reliable than a randomized controlled trial. Randomized controlled trials are studies where subjects randomly are assigned to a treatment or control group. A randomized control trial is more reliable than a controlled trial without randomization. Controlled trials without randomization are studies in which subjects are assigned nonrandomly to a treatment or control group. A controlled trial without randomization is more reliable than a cohort study. Cohort studies observe a group to determine the development of an

outcome. Expert opinion based on principles is not based on actual evidence; it is relied on when there is no evidence from research. 54. Assigning one staff member to approach the client regularly and interact with the client provides continuity and demonstrates to the client that the nursing staff is concerned; frequent contact should reduce the client's need to call the staff for reassurance. Closing the door to the room so that the client cannot see the staff members as they pass by may increase the client's anxiety and the need for contact with staff. Telling the client is not the same as doing it; the client may not believe that staff will come in frequently. Arranging for a variety of staff members to take turns going into the room to see whether the client has any requests will not facilitate the development of a therapeutic relationship with a staff member. 55. Refocusing the conversation on the client's fears, frustrations, and anger about the condition provides an opportunity for the client to verbalize the feelings underlying the behavior. Describing the purpose of different hospital therapies will have no effect on decreasing the client's anxiety or on allowing ventilation of feelings. Explaining that becoming so upset dangerously blocks the need for rest will not decrease anxiety so that the client can rest. Although allowing release of feelings is therapeutic, leaving denies the client the opportunity for verbalization and discussion.

56. The first step in the problem-solving process is data collection so that client needs can be identified. During the initial interview a direct approach obtains specific information, such as allergies, current medications, and health history. The exploratory approach is too broad because in a nondirective interview the client controls the subject matter. Problem solving and information giving are premature at the initial visit. 57. Tetanus antitoxin provides antibodies, which confer immediate passive immunity. Antitoxin does not stimulate production of antibodies. It provides passive, not active, immunity. Passive immunity, by definition, is not long-lasting. 58. Rehabilitation refers to a process that assists clients to obtain optimal functioning. Care should be initiated immediately when a health problem exists to avoid complications and facilitate recuperation. All resources that can be beneficial to client rehabilitation, including the private health care provider and acute care facilities, should be used. Rehabilitation is a commonality in all areas of nursing practice. Rehabilitation is necessary to help clients return to a previous or optimal level of functioning. 59. At the beginning of the shift at 7 AM, a client has 650

mL of normal saline solution left in the intravenous bag, which is infusing at 125 mL/hr. At 9:30 AM the health care

provider changes the IV solution to Ringer's lactate, which is to infuse at 100 mL/hr. What total amount of intravenous solution should the client have received by the end of the eight-hour shift? Record your answer using a whole number. ___ mL A: 863
The client will have absorbed 313 mL of solution before the health care provider changes the prescription (2 hours 125 mL/hour = 312.5, rounded up to 313); for the remaining 5 hours of the shift, the client will have received 550 mL (5 hours 100 mL/hour), for a total of 863 mL. 60. Tachypnea occurs with Addisonian crisis because of inadequate circulating glucocorticoids and mineralocorticoids. Inadequate circulating glucocorticoids and mineralocorticoids cause hypotension, pallor, weakness, tachycardia, and tachypnea. Double vision does not occur with Addisonian crisis. Difficulty swallowing does not occur with Addisonian crisis. Tachycardia, not bradycardia, occurs with Addisonian crisis. Study Tip: The old standbys of enough sleep and adequate nutritional intake also help keep excessive stress at bay. Although nursing students learn about the body's energy needs in anatomy and physiology classes, somehow they tend to forget that glucose

is necessary for brain cells to work. Skipping breakfast or lunch or surviving on junk food puts the brain at a disadvantage. 61. Clients receiving TPN require monitoring of blood glucose because the TPN solution contains a high concentration of dextrose. In response to the high-dextrose TPN solution, the pancreas increases production of insulin to meet the glucose demands. In this situation, the current TPN infusion is completed, and the nurse should infuse 10% dextrose to compensate for the loss while the next TPN bag is being prepared. If this action is not taken, the client could experience a profound hypoglycemic reaction. After beginning an infusion of 10% dextrose, the nurse may perform a fingerstick glucose test and notify the physician if the results are abnormal. Discontinuing the infusion and flushing the line until the next TPN bag is ready is not recommended. Starting an infusion of 5% dextrose at KVO until the next TPN is ready may not prevent hypoglycemia; the nurse manager does not need to be involved unless there is a negative patient outcome that results. 62. False imprisonment is a wrong committed by one person against another in a willful, intentional way without just cause or excuse. Negligence is an unintentional tort. Malpractice, which is professional negligence, is classified as an unintentional tort. Breach of duty is an unintentional tort.

63. PTU can cause depression of leukocytes and platelets. Propylthiouracil and potassium iodide should be given with milk, juice, or food to prevent gastric irritation. Drug therapy decreases the risk of postoperative hemorrhage because this drug regimen decreases the size and vascularity of the thyroid gland. Drug therapy is continued for at least six to eight weeks, even if the client's temperature and pulse return to the expected range. 64. A neurovascular assessment involves evaluation of nerve and blood supply to an extremity involved in an injury. The area involved may include an orthopedic and/or soft tissue injury. A correct neurovascular assessment should include evaluation of capillary refill, pulses, warmth and paresthesias, and movement and sensation. Orientation, pupillary response, and respiratory rate are components of a neurological assessment. 65. The voltage or current is adjusted on the basis of the degree of pain relief experienced by the client. Maintaining the settings programmed by the health care provider may provide too little or too much stimulation to achieve the desired response. Pain suppressor TENS units must be turned on several times a day for 10 to 20 minutes, not the conventional unit. The electrodes should be applied either on the painful area or immediately below or above the area.

66. Early notification provides an opportunity to prepare for change. The ability to decrease the client's anxiety, families being more relaxed and less likely to cause problems with nursing staff may be a secondary gain but are not the primary purpose. 67. An infant having a seizure should receive care first because the infant is in acute distress. A person having a seizure should never be left alone. The primary responsibilities include maintaining client safety and observing the characteristics of the seizure. A woman having acute chest pain should receive care second because chest pain can indicate a myocardial infarction or other potential fatal cardiac event. Acute pancreatitis is extremely painful and therefore this client should be medicated as soon as possible after clients with life-threatening problems are stabilized. A child with a non-life-threatening cut and needing stitches can wait until the more acute clients are attended to and stabilized. Although a blood glucose level of 190 is elevated it is not life threatening; therefore, meeting the needs of clients with more acute problems first is appropriate. 68. Blood plasma and interstitial fluid are both part of the extracellular fluid and are of the same ionic composition. The osmotic pressure is the same. The composition is the same. The main cation of both extracellular fluids is sodium.

69. Self-help groups are successful because they support a basic human need for acceptance. A feeling of comfort and safety and a sense of belonging may be achieved in a nonjudgmental, supportive, sharing experience with others. AA meets dependency needs rather than focusing on independence, trust, and growth. 70. Because the client's condition is terminal, the nursing priority should be directed toward providing basic care and comfort. Although intake and output, diet and nutrition, and body mechanics and posture are important aspects of nursing care, provision of comfort is the priority when caring for a dying client. 71. Eye contact indicates to the client that the nurse is listening and interested. Paraphrasing is an effective interviewing technique; it indicates to the client that the message was heard and invites the client to elaborate further. Open-ended statements provide a milieu in which people can verbalize their problems rather than be placed in a situation of providing a forced response. Asking "why" and "how" questions can be threatening to the client, who may not have the answer to these questions. False reassurance is detrimental to the nurse-client relationship and does not promote communication. Direct questions do not open or promote communication. 72. Moving the client who is singing away from the other clients diminishes the disturbance. A client with dementia will not

remember instructions. It is unsafe to close the doors of clients' rooms because they need to be monitored. The use of a sedative should not be the initial intervention. 73. The intake and output of a client over an eight-hour

period (from 0800-1600) is as follows: 150 mL urine voided at 0800; 220 mL urine voided at 1200; 235 mL urine voided at 1600; 200 mL gastric tube formula + 50 mL water administered initially and then repeated x 2; IV had 900 mL in the bag at 0800, and 550 mL remains in the bag at 1600. What is the difference between the clients intake and output? Record the answer using a whole number ___ mL A:495
Intake: Gastric tube: 250 x 3 = 750 mL; IV: 900 - 550 = 350 mL; Intake total: 1100 mL. Output: Urinary output: 150 + 220 + 235 = 605 mL I & O difference: 1100 605 = 495 mL 74. Medication reconciliation involves the creation of a list of all medications the client is taking and comparing it to the health care provider's prescriptions on admission or when there is a transfer to a different setting or service, or discharge. A change in status does not require medication reconciliation. A medication reconciliation should be completed long before entering the

operating room. Total hip replacement is elective surgery, and scheduling takes place before admission; medication reconciliation takes place when the client is admitted. 75. Using long-handled forceps keeps the sealed implant away from the nurse as the implant is retrieved and placed in a lead container kept in the client's room. Wearing a dosimeter film badge offers no protection from exposure to radiation; it only measures the nurse's exposure to the radiation. Exposure should be limited to no more than 30 minutes daily. Visitors should maintain a minimum distance of 6 feet from the radiation source and visit for only 30 minutes daily. 76. When a sterile surface becomes wet, microorganisms from the unsterile surface below the sterile field will be drawn up, contaminating the sterile field. The absorption of fluids by gauze results from the adhesion of water to the gauze threads; the surface tension of water causes contraction of the fiber, pulling fluid up the threads. Dialysis is separation of substances in solution using their differing rates of diffusion through a membrane. Osmosis refers to movement of water through a semipermeable membrane. Diffusion is movement of molecules from a high to a low concentration. 77. When emotional stress overwhelms an individual's ability to cope, the unconscious seeks to reduce stress. A conversion

reaction removes the client from the stressful situation, and the conversion reaction's physical/sensory manifestation causes little or no anxiety in the individual. This lack of concern is called la belle indifference. No physiologic changes are involved with this unconscious resolution of a conflict. The conversion of anxiety to physical symptoms operates on an unconscious level. 78. The client is unconscious. Although the spouse can give consent, there is no legal power to refuse a treatment for the client unless previously authorized to do so by a power of attorney or a health care proxy; the court can make a decision for the client. Explanations will not be effective at this time and will not meet the client's needs. Instituting the prescribed blood transfusion and phoning the health care provider for an administrative prescription are without legal basis, and the nurse may be held liable. 79. Use the Desire over Have formula of ratio and proportion to solve this problem. Desire 125 mg = x mL Have 225 mg 1 mL 225x = 125 X = 125 225 X = 0.55 mL. Round the answer up to 0.6 mL (pic of a syringe) 80. Perspiration is an involuntary physiologic response. It is mediated by the autonomic nervous system under a variety of circumstances, such as rising ambient temperature, high humidity, stress, and pain. Crying is an emotional response that may or may

not be related to pain. Splinting is a voluntary action that may limit tension on the abdomen, thus reducing pain. Grimacing is a result of contraction of the facial muscles; it may or may not be a response to pain. 81. Vitamin C (ascorbic acid) plays a major role in wound healing. It is necessary for the maintenance and formation of collagen, the major protein of most connective tissues. Vitamin A is important for the healing process; however, vitamin C is the priority because it cements the ground substance of supportive tissue. Cyanocobalamin is a vitamin B12 preparation needed for red blood cell synthesis and a healthy nervous system. Phytonadione is vitamin K, which plays a major role in blood coagulation. 82. The high pH and low carbon dioxide level are consistent with respiratory alkalosis, which can be caused by mechanical ventilation that is too aggressive. Airway obstruction causes carbon dioxide buildup, which leads to respiratory acidosis. Inadequate nutrition causes excess ketones, which can lead to metabolic acidosis. Prolonged gastric suction causes loss of hydrochloric acid, which can lead to metabolic alkalosis. 83. Advance directives allow clients to designate another person to consent to procedures if they are unable to do so. Advance directives are not related to insurance. No information suggests the client cannot consent to treatment. Directions for distribution

of belongings should be stipulated in a will, not in an advance directive. 84. The 2-year-old child will be at higher risk for fluid and electrolyte imbalance due to higher fluid content of the body and decreased ability to regulate fluid balance that put this client in a life-threatening situation. Care of the 35-year-old client with nausea is not a priority because the client's body has higher ability to regulate fluid and electrolyte balance compared to the child. Care of the 83-year-old female having difficulty moving her bowels is not a nursing priority because it is not a life-threatening situation. Care of the 40-year-old female with vomiting is not a nursing priority because this client has a higher ability to regulate fluid and electrolyte balance comparing to the child. 85. The pulse oximeter measures the oxygen saturation of blood by determining the percentage of hemoglobin-carrying oxygen. A pulse oximeter does not interpret the amount of oxygen or carbon dioxide carried in the blood, nor does it measure respiratory rate. 86. A person is legally unable to sign a consent until the age of 18 years unless the client is an emancipated minor or married. The nurse must determine the legal status of the adolescent. Although the adolescent may be capable of intelligent choices, 18 is the legal age of consent unless the client is emancipated or married. Parents or guardians are legally responsible under all

circumstances unless the adolescent is an emancipated minor or married. Adolescents have the capacity to choose, but not the legal right in this situation unless they are legally emancipated or married. 87. A common side effect of vincristine is a paralytic ileus that results in constipation. Preventative measures include high-fiber foods and fluids that exceed minimum requirements. These will keep the stool bulky and soft, thereby promoting evacuation. Low in fat, high in iron, and low in residue dietary plans will not provide the roughage and fluids needed to minimize the constipation associated with vincristine. 88. Clean gloves should be worn to check the IV site because there is a risk of coming into contact with the client's blood. Ensuring that the medication is mixed is important. Rotating the bag is one way, although there are others. Because IV solutions enter the body's internal environment, all solutions and medications using this route must be sterile to prevent the introduction of microbes. The amount and type of solution depend on the medication. The insertion site does not have to be flushed with an infusing IV. The IVPB should be hung higher, not lower, than the existing bag. 89. The etiology, or cause, of the problem provides direction for selection of nursing interventions. It is important to remember that gathering the "S" comes first in the diagnostic process, even

though the format is described as PES. Collaborative problems are potential or actual complications, diseases, or treatment that nurses treat most frequently with other health care providers. A wellness diagnosis may be identified when an individual is in transition from a specific level of wellness to a higher level of wellness. This diagnosis begins with "Readiness for enhanced," followed by the higher level of wellness desired. 90. The TURP procedure is performed by insertion of a scope device into the urethra to reach the prostate from within the urinary tract. No incision is made to reach the prostate, therefore the client statement about an incision being painful after surgery warrants further evaluation and teaching by the nurse. The client is demonstrating correct knowledge about the TURP procedure by stating that after surgery his urine will be red, he will have a catheter, and he will need to increase fluid intake. 91. Evidenced-based nursing care uses information gleaned from theory, research, expert opinion, client history and physical examination, client preferences and values, and the clinical expertise of the nurse. Time/motion studies are not used as a basis of evidenced-based practice. Accepted nursing rituals are not used as a basis of evidenced-based practice. 92. In the stage of acceptance, the client frequently detaches from the environment and may become indifferent to family members.

In addition, the family may take longer to accept the inevitable death than does the client. Although the family may not understand the anger, dealing with the resultant behavior may serve as a diversion. Denial often is exhibited by the client and family members at the same time. During depression, the family often is able to offer emotional support, which meets their needs. 93. Gamma globulin, which is an immune globulin, contains most of the antibodies circulating in the blood. When injected into an individual, it prevents a specific antigen from entering a host cell. Gamma globulin does not stimulate antibody production. It does not affect antigen-antibody function. 94. Turning the client to the side promotes drainage of secretions and prevents aspiration, especially when the gag reflex is not intact. This position also brings the tongue forward, preventing it from occluding the airway when it is in the relaxed state. The risk for aspiration is increased when the supine position is assumed by a semi-alert client. High Fowler position may cause the neck to flex in a client who is not alert, interfering with respirations. Trendelenburg position is not used for a postoperative client because it interferes with breathing. 95. Because the plasma COP is the major force drawing fluid from the interstitial spaces back into the capillaries, a drop in COP caused by albuminuria results in edema. Hydrostatic tissue

pressure is unaffected by alteration of protein levels; colloidal pressure is affected. Hydrostatic pressure is influenced by the volume of fluid and the diameter of the blood vessel, not directly by the presence of albumin. The osmotic pressure of tissues is unchanged. 96. Restraint of a client, whether physical or chemical, is considered a high-risk procedure requiring a valid health care provider's prescription and intensive monitoring for safety and meeting the client's needs. A nurse who does not follow correct procedures regarding restraints can legally be charged with assault and battery. Laws regarding restraint orders may differ from state to state and in different settings. A felony is a severe offense or crime such as murder, rape, or burglary and is commonly punished by imprisonment. Nurses have a professional obligation to report institutional misuse of restraints since this may constitute false imprisonment and abuse. 97. Paralytic ileus occurs when neurologic impulses are diminished as a result of anesthesia, infection, or surgery. Interference in blood supply will result in necrosis of the bowel. Perforation of the bowel will result in pain and peritonitis. Obstruction of the bowel initially will cause increased peristalsis and bowel sounds. 98. Abduction means to move the limb away from the median plane, or axis, of the body. In care of the client with a fractured

hip, the legs and hip must be aligned in an abducted position to prevent internal rotation, reduce the risk of dislocation, and decrease pain. In a client with a fractured hip, adduction of the limb, traction, and elevation are not appropriate procedures. Adduction means to move the limbs toward the medial plane, or axis, of the body, and traction involves the process of applying a pulling force in opposite directions using weights. 99. Immunization programs prevent the occurrence of disease and are considered primary interventions. Stopping smoking prevents the occurrence of disease and is considered a primary intervention. Preventing disabilities is a tertiary intervention. Correcting dietary deficiencies is a secondary intervention. Establishing goals for rehabilitation is a tertiary intervention. 100. Weakened muscles supporting the bladder in women and enlargement of the prostate gland in men commonly cause urinary urgency and frequency in older adults. Skin elasticity decreases in older adults because of a decline in subcutaneous fat and collagen fibers, as well as thinning of the epidermis. Swallowing difficulties result from a decrease in salivary gland secretions. With aging, an increase in systolic blood pressure and a slight increase in diastolic blood pressure occur. A decrease in subcutaneous fat results in a decreased body warmth.

101. Regional perfusion therapy permits relative isolation of the tumor area and saturation with the drug(s) selected. This method of drug administration requires medical and nursing supervision. Although toxic effects are confined mainly to the treated area, some migration may still occur. Combinations of chemotherapeutic drugs are administered via intravenous or oral routes, not via regional perfusion. 102. Albuterol's sympathomimetic effect causes central nervous stimulation, precipitating tremors, restlessness, and anxiety. Albuterol's sympathomimetic effect causes cardiac stimulation that may result in tachycardia and palpitations. Albuterol may cause restlessness, irritability, and tremors, not lethargy. Albuterol may cause dizziness, not visual disturbances. Albuterol will cause tachycardia, not bradycardia. 103. Certain diagnostic tests (e.g., CBC, urinalysis, chest x-ray examination) are done preoperatively to rule out the existence of health problems that may increase the risks involved with surgery. Feelings will not be dispelled by telling the client not to worry; it also blocks further communication. Surgery poses a risk despite test results. Lack of knowledge without a statement of plans to obtain the information suggests incompetence on the part of the nurse.

Study Tip: The old standbys of enough sleep and adequate nutritional intake also help keep excessive stress at bay. Although nursing students learn about the body's energy needs in anatomy and physiology classes, somehow they tend to forget that glucose is necessary for brain cells to work. Skipping breakfast or lunch or surviving on junk food puts the brain at a disadvantage. 104. These are signs of digitalis toxicity, which is more likely to occur in the presence of hypokalemia. Although furosemide most likely contributed to the hypokalemia, the client's symptoms are consistent with digitalis toxicity. Although propranolol can cause nausea, vomiting, and blurred vision, the presence of hypokalemia and yellow vision are more suggestive of digitalis toxicity. A side effect of spironolactone is hyperkalemia, not hypokalemia. 105. Maintaining functional alignment of the head prevents flexion and hyperextension of the neck, both of which place tension on the suture line; tension on the suture line can precipitate wound dehiscence. The cervical vertebrae are designed to flex and hyperextend; there should be no ill effects. Flexion and hyperextension of the neck do not cause laryngeal spasms. Flexion and hyperextension of the neck do not cause laryngeal edema. 106. Human tetanus antitoxin (tetanus immune globulin [TIG]) provides antibodies against tetanus; it is used for the individual

who may be infected and never has received tetanus toxoid or has not received it for more than 10 years. It confers passive immunity. Administration of the Td will produce active, not passive, immunity. Although equine tetanus antitoxin provides passive immunity, the risk for a hypersensitivity reaction is high and therefore TIG is preferred. DTaP vaccine produces active, not passive, immunity; in addition, DTaP usually is not given to adults. 107. Tetany is caused by hypocalcemia. Seizures caused by electrolyte imbalances are associated with low calcium or sodium levels. Because of potassium's role in the sodium/potassium pump, hyperkalemia will cause diarrhea, weakness, and cardiac dysrhythmias. 108. Cooling blankets and antipyretic medications can induce hypothermia thus decreasing brain metabolism. This in turn makes the brain less vulnerable by decreasing the need for oxygen. The integrity of intracerebral neurons and osmotic pressure equalization depend on an adequate supply of oxygen, carbon dioxide, and glucose, and may occur as a result of decreased cerebral metabolism and hypoxia. Diaphoresis does not cause hypoxia. Antipyretic medications may cause diaphoresis as vasodilation occurs.