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133. ANS: B The client is exhibiting characteristics of despair (B), consistent with Erikson's final developmental stage of Integrity vs. Despair, in which the older adult seeks to determine that one's life has had meaning and purpose. Negative resolution of this stage may result in withdrawal, crying, and demands for excessive attention. (A) is not defined as a stage by Erikson. According to Erikson's developmental stages, (C) occurs at infancy, and (D) occurs at young adulthood. 134. ANS: B A stoma that is purple in color has a compromised blood supply, and must be treated immediately by the surgeon (B). (A, C, and D) are normal findings for a client with a sigmoid colostomy. 135. ANS: D One kilogram of weight gain (2.2 pounds) is equivalent to one liter of fluid volume retention, so the client has retained three liters (D) of fluid. 136. ANS: C The charge nurse should assign the least critical client to the RN that just completed the internship and the client with chest tubes is the least critical (C) of these four. The more critically ill clients (A, B, and D) should be assigned to the more experienced nurses because they have life-threatening conditions and high mortality rates. 137. ANS: C It is a violation of a client's right to privacy to take their picture without consent, so (C) has the highest priority. The nurse should also implement (A and B), but these actions do not have the priority of (C). (D) is important, but it is most important to obtain written consent for the use of a personal picture. 138. ANS: D Enoxaparin sodium (Lovenox) should be administered in the abdominal area below or lateral to the periumbilical region with the client recumbent. The nurse should first observe these areas for any excessive bruising (D). (A, B, and C) are not recommended for administration of this medication. 139. ANS: B Because of the densely packed keratin composition of nails, the best way to eliminate onychomycosis, a fungal infection, is to take a prescribed systemic antifungal medication (B). (A, C, and D) will help to strengthen the nail plate, but systemic antifungal medication is the best measure to use to cure the infection. 140. ANS: A Regular aerobic exercise reduces menstrual cramping and pain by promoting relaxation and the release of endorphins (A). (B) is beneficial for older women to promote bone strength, but will not reduce menstrual discomfort. (C) promotes abdominal tone, and reduces back pain. (D) is useful for the woman with diminished bladder tone. 141. ANS: C Excessive warfarin is evaluated by an increase in the client's PT/INR (C). (A) is not essential, since the blood in the urine is visible. (B) may be useful, but is of less priority than (C). (D) will provide additional supportive data, but is of less importance than an increase in the PT/INR. 142. ANS: A Smoked meats are typically high in sodium, so the client should be instructed to replace the ham with a low sodium item such as toast and jelly (A). Eggs (B) are not high in sodium. Daily use of a salt substitute (C) is safe unless the client has hyperkalemia. Herbal tea (D) is not high in sodium 143. ANS: B Smoking is a risk factor for the development of pneumonia, so the client should be encouraged to stop, or at least decrease, smoking (B). (A) decreases the risk for deep vein thrombosis. (C) may decrease the risk for heart attack or stroke, and (D) is helpful in preventing hypertension. 144. ANS: A Clients with chronic pain often experience hopelessness (A), which the nurse recognizes by the client's withdrawal and refusal to make decisions. (B) may become a priority problem if the client also refuses to participate in self-care measures. There is no indication that the client is experiencing (C or D). 145. ANS: A The provision of care around the urethral opening for a client with an indwelling urinary catheter is not a sterile procedure, so the nurse should advise the UAP that exam gloves should be worn for the protection of the UAP, and sterile gloves are not necessary (A). This is a non-invasive task that can be performed by the UAP (B). The UAP has obtained unnecessary and expensive sterile gloves, so further instruction is needed (C). A sterile field (D) is not used to perform catheter care. 146. ANS: B Administration of IV antibiotics via a subclavian line (B) is a task the nurse is likely to have performed in an acute care setting, and this activity will assist in building the nurse's confidence. Admission assessment is a very complex and lengthy process (A), which may intimidate the new home health care nurse. To maintain continuity of care, the nurse who has been caring for the client being discharged should complete (C). (D) should be referred to a hospice nurse, a chaplain, or a social worker. 147. ANS: B Autonomic dysreflexia is an acute emergency that occurs because of an exaggerated autonomic response such as a full bladder. The client may have a severe, pounding headache with paroxysmal hypertension, profuse diaphoresis (mostly forehead), nausea, nasal congestion and bradycardia (B). (A) are signs/symptoms of spinal shock that occur immediately after spinal cord injury. (C) are signs/symptoms of pulmonary embolus. (D) are signs/symptoms of possible urinary tract infection. 148. ANS: A The highest priority for this client, is risk for injury related to uterine atony (A). A client who is treated with magnesium sulfate has an increased risk for hemorrhage because magnesium sulfate is a CNS depressant and muscle relaxant. (B, C, and D) do not have the priority of (A). 149. ANS: A It is most important for the nurse to determine medication compliance (A) because the client's lithium level is below the therapeutic range of 0.8 to 1.4 mEq/L. Questioning the client about (B and C) can occur after determining medication compliance. (D) does not need to be completed at this time. 150. ANS: A Spilled solution (A) will allow capillary action to contaminate the sterile field. Sterile gloves should be applied after pouring the solution (B). The solution cap (C) is not sterile, and placing in on the sterile field would contaminate the field. (D) does not impact asepsis once the solution is poured. 151. ANS: C A prone position (C) will stretch the flexor muscles and help prevent flexion contracture of the hip. (A) is incorrect because a flexion contracture of the hip may result. (B) will toughen the stump but will not prevent contractures. The client should be turned from side to side to prevent flexion contracture, not just to the unaffected side (D). 152. ANS: D Breaking client confidentiality is a breach of fidelity (D), the ethical principle which relates to keeping one's word. When a client is admitted to a hospital, an expectation of privacy and confidentiality is incurred by the client, and assured by the hospital. (A) relates to truthfulness. (B), while not an ethical principle, relates to ensuring a degree of sameness. (C) relates to self-determination. 153. ANS: B The nurse should initiate the normal saline infusion (B) first to replace intravascular fluid volume because the client is hypotensive and hyponatremic (normal 135 to 145 mEq/L) due to heat exposure and diaphoresis. Oliguria should be assessed because it is a compensatory mechanism used to conserve body fluids that also contributes to hyponatremia, so the nurse should insert the indwelling catheter (A), but first saline replacement should be initiated. (C and D) can assist in the definitive evaluation of the tachycardia and syncope, but first fluid and electrolyte replacement should be initiated. 154. ANS: B Hypoparathyroidism occurs when the parathyroid glands are accidentally removed during the thyroidectomy, decreasing calcium levels and resulting in tetany (B). (A) would be indicative of hyperparathyroidism. (C) is a desired outcome and would indicate that hypoparathyroidism had not developed. The symptoms described in (D) are not signs of hypoparathyroidism, but of a tumor of the adrenal medulla (pheochromocytoma). 155. ANS: C (C) provides the client with correct information (her risk is low), offers praise for her health maintenance behavior, and does not give false reassurance. (A) gives false reassurance--although malignant masses typically are not painful, some are. (B) is technically correct information but does not take into consideration the client's emotional state. (D) is shaming, does not offer emotional support, and could alarm the client. 156. ANS: D Clients who experience high levels of anxiety should be instructed to limit intake of caffeine and sugar (D) because both are central nervous system (CNS) stimulants. (A) is a symptom of anxiety and should not be encouraged. (B) is essentially arguing with the client. Alcohol (C) should not be used for treating anxiety. COMPLETION 157. ANS: 100 158. ANS: 20 ml/hr 176 lb divided by 2.2 lb/ kg = 80 kg. Begin the infusion at 1,000 units/hour. Calculate using the formula: D/H x Q= 1000 units/hr / 25,000 units x 500 ml = 20 ml/hr 159. ANS: 1.75 Demerol: 100:1 = 75:X X = 75/100 = 3/4 ml or 0.75 ml Phenergan: 1 ml = 25 mg Amount to administer: 0.75 ml of Demerol +1 ml of Phenergan =1.75 ml