1137 Reduction of Risk Potential
A neonate born at 38 weeks' gestation is admitted to the neonatal nursery for observation. The neonate's birth parent, who is positive for human immunodeficiency virus (HIV) infection, has received no prenatal care. The parent asks the nurse if the neonate is positive for HIV. The nurse can tell the parent which information? -"An enlarged liver at birth generally means the neonate is HIV positive." -"A complete blood count analysis is the primary method for determining whether the neonate is HIV positive." -"We will test your baby now, but testing will need to be repeated for an accurate diagnosis." -"More than 50% of neonates born to birth parents who are positive for HIV will be positive at 18 months of age."
"We will test your baby now, but testing will need to be repeated for an accurate diagnosis."
A nurse is providing discharge teaching for a client who had a laryngectomy. Which instruction should the nurse include in the teaching? -"Cover the stoma with your hand to prevent anything from entering it." -"Keep the humidity in your house low." -"Cover the stoma with a loose plastic cloth whenever you shower or bathe." -"Swimming is good exercise as long as you don't go under water."
"Cover the stoma with a loose plastic cloth whenever you shower or bathe."
The nurse teaches the parents of an infant with clubfoot requiring application of a plaster cast how to care for the cast. Which statement would indicate that the parents have understood the teaching? -"If the cast becomes soiled, we will clean it with soap and water." -"We will elevate the leg with the cast on pillows so the leg is above heart level." -"We will check the color and temperature of the toes of the casted leg frequently." -"The petals on the edge of the cast can be removed after the first 24 hours."
"We will check the color and temperature of the toes of the casted leg frequently."
Which client statement identifies a knowledge deficit about cast care? -"I will apply ice for 10 minutes to control edema for the first 24 hours." -"I will elevate the cast above my heart initially." -"I will exercise my joints above and below the cast." -"I can pull out cast padding to scratch inside the cast."
"I can pull out cast padding to scratch inside the cast."
A client received burns to the entire back and left arm. Using the Rule of Nines, the nurse can calculate that the client has sustained burns on what percentage of the body? -9% -27% -36% -18%
27%
What is the priority nursing intervention in the postictal phase of a seizure? -Reorient the client to time, person, and place. -Determine the client's level of sleepiness. -Assess the client's breathing pattern. -Position the client comfortably.
Assess the client's breathing pattern.
The nurse notes that a client with acute pancreatitis occasionally experiences muscle twitching and jerking. How should the nurse interpret the significance of these symptoms? -The client needs a muscle relaxant to promote rest. -The client has a nutritional imbalance. -The client may be developing hypocalcemia. -The client is experiencing a reaction to meperidine.
The client may be developing hypocalcemia.
What should the nurse do when suctioning a client who has a tracheostomy tube 3 days following insertion? -Use a clean catheter with each suctioning, and disinfect it in hydrogen peroxide between uses. -Clean the catheter in sterile water after each use, and reuse for no longer than 8 hours. -Protect the catheter in sterile packaging between suctioning episodes. -Use a sterile catheter each time the client is suctioned.
Use a sterile catheter each time the client is suctioned.
A nurse is preparing a discharge teaching plan for a client with atopic dermatitis. Which instruction should the nurse include in the teaching plan? -Bathe only three times per week. -Use a topical skin moisturizer daily. -Wear only synthetic fabrics. -Keep the thermostat above 75° F (23.9° C ).
Use a topical skin moisturizer daily.
The nurse is helping to prepare a client for nonemergency surgery. What should the nurse do? -Explain the surgical procedure. -Inform the client about the risks of the surgery to be performed. -Verify the client understands the informed consent form. -Obtain informed consent from the client.
Verify the client understands the informed consent form.
A nurse is caring for a client who is receiving chemotherapy for lung cancer. During the hand-off report, the nurse from the previous shift states that the client has been placed on neutropenic precautions. Which laboratory value supports this nursing action? -a retculocyte count of 1% -a white blood cell count of 2200/mm3 -a platelet count of 90,000 per microliter -a red blood cell count of 3.5 million/mm3
a white blood cell count of 2200/mm3
When a client returns from a magnetic resonance imaging (MRI) exam with contrast, which action is appropriate? -placing the client on bed rest -administering fluids to the client -having the client take nothing by mouth until the gag reflex has returned -assessing the client for the presence of any metal implants
administering fluids to the client
A pregnant woman states that she frequently ingests laundry starch. The nurse should assess the client for which condition? -anemia -diabetes mellitus -muscle spasms -lactose intolerance
anemia
A primigravid client has just completed a difficult, forceps-assisted birth of a 9-lb (4.08-Kg) neonate. Her labor was unusually long and required oxytocin augmentation. The nurse who's caring for her should stay alert for uterine -atony. -involution. -discomfort. -inversion.
atony.
The nurse is caring for a client experiencing acute abdominal pain. What is the first action by the nurse? -review of the abdominal X-ray report -auscultation of all four quadrants using a stethoscope -administration of pain medications -palpation for rebound tenderness over the lower abdominal area
auscultation of all four quadrants using a stethoscope
The nurse cares for a child with severe gastroenteritis who has been receiving intravenous therapy for the past several hours. Which finding would alert the nurse to suspect that a child may be developing circulatory overload? -auscultation of moist crackles -change to slow, deep respirations -marked increase in urine output -a drop in blood pressure
auscultation of moist crackles
The nurse provides preprocedural teaching to the parents of a child with a ventricular septal defect who is scheduled for a cardiac catheterization. The nurse should explain that this procedure involves the use of which technique? -ultra-high-frequency sound waves -catheter placed in the right femoral vein -general anesthesia -cutdown procedure to place a catheter
catheter placed in the right femoral vein
The nurse is to check a client's gag reflex. The most effective technique for testing the gag reflex is to: -observe the client for evidence of spontaneous swallowing when the neck is stroked. -place a few milliliters of water on the client's tongue and note whether the client swallows. -observe the client's response to the introduction of a catheter for endotracheal suctioning. -touch the back of the client's throat with a tongue blade.
touch the back of the client's throat with a tongue blade.
A client undergoes an amniotomy. Shortly afterward, the nurse detects large variable decelerations in the fetal heart rate (FHR) on the external electronic fetal monitor (EFM). These findings may signify: -start of the second stage of labor. -umbilical cord prolapse. -need for labor induction. -infection.
umbilical cord prolapse.
A nurse assesses a client shortly after living donor kidney transplant surgery. Which postoperative finding must the nurse report to the health care provider (HCP) immediately? -serum potassium level of 4.9 mEq/L -temperature of 99.2°F (37.3°C) -urine output of 20 ml/hour -blood pressure of 145/95 mmHg
urine output of 20 ml/hour
A nurse is caring for a client admitted with an exacerbation of asthma. The nurse knows the client's condition is worsening when the client: uses the sternocleidomastoid muscles. asks for an additional pillow. wants the head of the bed raised to a 90-degree level. has a pulse oximetry reading of 91%.
uses the sternocleidomastoid muscles.
During the first hour after a precipitous birth, the nurse should monitor a multiparous client for signs and symptoms of which complication? -intrauterine infection -postpartum "blues" -urinary tract infection -uterine atony
uterine atony
The nurse is caring for a client with an I.V. line. During care of the I.V. line, the nurse would be required to wear protective gloves in which situations? Select all that apply. -when inserting the I.V. -When spiking a new I.V. bag -When priming the I.V. tubing -When changing the I.V. site -When discontinuing the I.V.
when inserting the I.V. When discontinuing the I.V. When changing the I.V. site
To prevent gastroesophageal reflux in a client with hiatal hernia, the nurse should provide which discharge instruction? -"Take antacids with meals." -"Limit fluid intake with meals." -"Lie down after meals to promote digestion." -"Avoid coffee and alcoholic beverages."
"Avoid coffee and alcoholic beverages."
A new nurse will be monitoring a client during a moderate sedation procedure for the first time, and is discussing this with the charge nurse. Which statement made by the newly graduated nurse will the charge nurse verify as accurate? -"Cardiac monitoring is not needed because moderate sedation medications are not high-risk medications." -"Complete vital signs should be charted at least every 5 minutes during the procedure." -"As long as I am monitoring the client continuously, I do not need to chart vital signs during the procedure." -"It is unnecessary to monitor both capnography and pulse oximetry; just one or the other is adequate."
"Complete vital signs should be charted at least every 5 minutes during the procedure."
A client with diabetes is explaining to the nurse how to care for the feet at home. Which statement indicates that the client understands proper foot care? -"I should inspect my feet at least once a week." -"When I injure my toe, I'll plan to put iodine on it." -"It's important to dry my feet carefully after my bath." -"It's okay to go barefoot in the house."
"It's important to dry my feet carefully after my bath."
A nurse is instructing a client with bipolar disorder on proper use of lithium carbonate, the drug's adverse effects, and symptoms of lithium toxicity. Which client statement indicates that additional teaching is required? -"When my moods fluctuate, I'll increase my dose of lithium." -"Eating too much watermelon will affect my lithium level." -"A good blood level of the drug means the drug concentration has stabilized." -"I can still eat my favorite salty foods."
"When my moods fluctuate, I'll increase my dose of lithium."
An athletic teenager who is diagnosed with infectious mononucleosis is told to avoid contact sports for 3 to 4 weeks. The teenager protests to the nurse and demands to know why sports must be avoided for so long. What is the best response by the nurse? -"Your illness causes fatigue and it's best for you to rest while recovering." -"Your spleen is enlarged from your illness and could easily rupture with an injury." -"Vigorous activity can further weaken your immune system." -"This helps prevent transmission of the infection to your teammates."
"Your spleen is enlarged from your illness and could easily rupture with an injury."
Which assessment(s) made by a nurse during a morning assessment of a client require immediate intervention? Select all that apply. -client with slight shortness of breath after returning from the bathroom -client coughing and expectorating large amounts of thick mucus -client vomiting of a large amount of bright red blood -sleeping client with respiratory rate of 10 breaths/minute -unconscious client with rattling sound in the pharynx
-unconscious client with rattling sound in the pharynx -client vomiting of a large amount of bright red blood
When administering a tube feeding to a client through a percutaneous feeding tube, how should the nurse position the client? -Head of bed elevated 90 degrees -Head of bed elevated 30 to 45 degrees -Left lateral decubitus position -Supine
Head of bed elevated 30 to 45 degrees
The nurse is caring for a client with an injury to the thalamus. What information should the nurse include in the care plan? -Monitor the temperature of the bathwater. -Avoid turning the client. -Keep patches on the client's eyes to prevent corneal abrasion. -Give higher doses of pain medication.
Monitor the temperature of the bathwater.
The mother of a toddler diagnosed with iron deficiency anemia asks what foods she should give her child. The nurse should evaluate the teaching as successful when the mother later reports that she feeds the toddler which foods? -milk, carrots, and beef -eggs, cheese, and milk -raisins, chicken, and spinach -beef, lettuce, and juice
raisins, chicken, and spinach
Which food should the nurse eliminate from the diet of a client in alcohol withdrawal? -regular coffee -eggs -orange juice -milk
regular coffee
Which assessment would be the priority for a 2-year-old child after a bronchoscopy? -respiratory quality -pulse pressure changes -heart rate -sputum color
respiratory quality
A client with ascites and peripheral edema is at risk for impaired skin integrity. To prevent skin breakdown, what should the nurse do? -Institute range-of-motion (ROM) exercise every 4 hours. -Elevate the lower extremities. -Massage the abdomen once a shift. -Use an alternating air pressure mattress.
the nurse will have to apply restraints to prevent the client from dislodging the endotracheal (ET) tube.
A 7-year-old child is admitted with epiglottitis. When reviewing the lateral neck X-ray, what finding will the nurse anticipate? -subglottic narrowing -thickened mass -steeple sign -supraglottic narrowing
thickened mass
Which nursing action is most appropriate for a client hospitalized with acute pancreatitis? -withholding all oral intake, as ordered, to decrease pancreatic secretions -limiting I.V. fluids, as ordered, to decrease cardiac workload -keeping the client supine to increase comfort -administering oral pain medications, as ordered, to relieve severe pain
withholding all oral intake, as ordered, to decrease pancreatic secretions
The nurse is caring for a client experiencing acute abdominal pain. What is the first action by the nurse? -palpation for rebound tenderness over the lower abdominal area -review of the abdominal X-ray report -administration of pain medications -auscultation of all four quadrants using a stethoscope
auscultation of all four quadrants using a stethoscope
The nurse is teaching a client with type I diabetes self-administration of insulin. Which statement by the client would be an expected outcome of the teaching session? Select all that apply. -"I need to make sure that I eat my meals and snacks on time after I take my insulin." -"If I exercise more than is normal, there is a risk that I might become hypoglycemic." -"If I lose weight and control my carbohydrate intake, I can progress to diabetic pills." -"If I monitor and control my blood glucose levels carefully, there is less likelihood of suffering long-term complications." -"It is ok for me to skip my insulin dose if I feel that my blood sugar is not elevated."
"I need to make sure that I eat my meals and snacks on time after I take my insulin." "If I monitor and control my blood glucose levels carefully, there is less likelihood of suffering long-term complications." "If I exercise more than is normal, there is a risk that I might become hypoglycemic."
The nurse is caring for a client who underwent an episiotomy. What statement by the client indicates teaching was successful? -"I should avoid sitting in chairs for the next 4 weeks and sit with my legs elevated." -"I should refrain from using tampons until advised by my healthcare provider" -"I should immediately report any itching at the site to the healthcare provider." -"I should return to the healthcare provider in 2 weeks for suture removal."
"I should refrain from using tampons until advised by my healthcare provider"
A client weighs 300 lb (136 kg) and has a history of deep vein thrombosis and thrombophlebitis. When coaching a client about behaviors to maintain health, the nurse determines that the client has understood the nurse's instructions when the client makes which statement? -"I'll perform leg lifts every 4 hours to strengthen hamstring muscles." -"I'll wear knee-high stockings, rolled at the top to hold the stockings up." -"I'll limit exercise that involves walking." -"I'll try to lose weight by following a reduced-calorie, balanced diet."
"I'll try to lose weight by following a reduced-calorie, balanced diet."
External monitoring of contractions and fetal heart rate of a multigravida in labor reveals a variable deceleration pattern on the fetal heart rate. What should the nurse do first? -Prepare the client for a cesarean birth. -Administer oxygen at 2 L by mask. -Change the client's position. -Notify the anesthesiologist.
Change the client's position.
The nurse is obtaining blood from a central venous access device (CVAD) using aseptic technique and during the procedure soils the CVAD dressing with blood. After the sample is obtained and sent to the laboratory, what should the nurse do next? -Reinforce the CVAD dressing. -Call the health care provider regarding contamination of the CVAD dressing. -Redraw the specimen from the CVAD using sterile technique. -Change the soiled dressing per facility policy.
Change the soiled dressing per facility policy.
The night nurse has completed the change of shift report. As the day nurse makes rounds on a postpartum client receiving magnesium sulfate for preeclampsia, the magnesium sulfate rate is found to be infusing well below the prescribed rate. After the nurse adjusts the infusion rate and notifies the health care provider (HCP), what is the most important action by the day nurse? -Ask the charge nurse if an incident report is necessary. -Evaluate the client's vital signs for 4 hours before making a decision. -Discuss the matter with the night nurse the next time they work. -Complete an incident report.
Complete an incident report.
What is an expected assessment finding when caring for a client with a percutaneous feeding tube? -Raised red papules around the stoma -Dark pink stoma without drainage -Copious fluid leakage from the stoma -Moist bright red stoma with a scabbed area on one side
Dark pink stoma without drainage
A client receiving a continuous infusion of lidocaine for ventricular dysrhythmias states "I am so tired. Even my vision is blurry." What is the nurse's best action? -Administer zolpidem. -Ask the client the date of the most recent eye exam. -Cluster activities to allow the client uninterrupted rest time. -Decrease the lidocaine infusion rate.
Decrease the lidocaine infusion rate.
A client is being discharged following an open reduction and internal fixation of the left ankle, and is to wear a non-weight-bearing cast for 2 weeks. What should the nurse teach the client to do when using crutches? -Keep leg dependent when sitting. -Maintain two to three finger widths between the axillary fold and underarm piece grip. -Use a four-point gait. -Maintain balance by supporting body's weight on the axillae.
Maintain two to three finger widths between the axillary fold and underarm piece grip.
The nurse is reviewing the electrocardiogram of a client who has elevated ST segments visible in leads II, III, and aVf. Which choice is the nurse's best action? -Document the finding in the medical record. -Teach the client about risks for coronary artery disease. -Notify the healthcare provider. -Determine whether the rhythm is irregular, coinciding with inspiration and expiration.
Notify the healthcare provider.
A 4-year-old child is scheduled for a nephrectomy to remove a Wilms' tumor. Which intervention listed in the care plan should the nurse question? -Palpate the child's abdomen to monitor tumor growth. -Provide preoperative teaching to the child and parents. -Monitor urine for hematuria. -Assess vital signs and report hypertension.
Palpate the child's abdomen to monitor tumor growth.
A client who had a splenectomy is being discharged. What should the nurse teach the client to do? -Make an appointment for the staples to be removed. -Refrain from driving a car for 6 weeks. -Alternate rest and activity. -Report early signs of infection.
Report early signs of infection.
A nurse is teaching an older adult who has had a left modified radical mastectomy with axillary node dissection about lymphedema. What should the nurse tell the client about when lymphedema occurs? -in older women -if all cancer cells are not removed -only with radical mastectomy -at any time after surgery
at any time after surgery
A client, 38 weeks pregnant, arrives in the emergency department complaining of contractions. To help confirm that she's in true labor, the nurse should assess for: -changes in cervical effacement and dilation after 1 to 2 hours. -irregular contractions. -increased fetal movement. -contractions that feel like pressure in the abdomen and groin.
changes in cervical effacement and dilation after 1 to 2 hours.
A nurse is caring for a client who's had surgery to repair a hip fracture. The client says their left hand and arm are numb and they can't move the extremity. The nurse contacts the physician, who suspects brachial plexus nerve damage. What additional priority assessment does the nurse need? -copies of the operating room notes on client positioning -function of the client's left hand before the operation -x-ray of the affected arm -function of the client's right hand before the operation
function of the client's left hand before the operation
The nurse develops the plan of care for a toddler with an acetaminophen overdose. Which intervention should the nurse expect to include as part of the initial treatment? -gastric lavage -tracheostomy -frequent serum drug levels -electrocardiogram
gastric lavage
A positive tuberculin skin test indicates that a client -has produced an immune response. -is actively immune to tuberculosis. -will develop full-blown tuberculosis. -has an active case of tuberculosis.
has produced an immune response.
A nurse is caring for a client who is experiencing alcohol withdrawal. Which assessment finding indicates the need for an as-needed dose of chlordiazepoxide? -blood pressure of 140/80 mm Hg -heart rate of 120 to 140 beats/minute -heart rate of 50 to 60 beats/minute -blood pressure of 100/70 mm Hg
heart rate of 120 to 140 beats/minute
The nurse is administering an oral medication to a 4-month-old infant. How should the nurse position the infant? -seated in a high chair -seated upright on mother's lap -held in the bottle-feeding position -held on the nurse's lap
held in the bottle-feeding position
A nurse evaluates discharge teaching as successful when the parents of a school-age child with a ventriculoperitoneal shunt insertion identify which sign as signaling a blocked shunt? -irritability and increasing difficulty with eating -tense fontanelle and increased head -circumference -decreased urine output with stable intake -elevated temperature and reddened incisional site
irritability and increasing difficulty with eating
The nurse is caring for a client who reports right lower quadrant pain. Which assessment is most important for this client? -auscultation -inspection -percussion -palpation
palpation
A toddler is admitted to the facility for treatment of a severe respiratory infection. The child's recent history includes fatty stools and failure to gain weight steadily. The physician diagnoses cystic fibrosis. By the time of the child's discharge, the child's parents must be able to perform which task independently? -maintaining the child in an oxygen tent -maintaining the child on a fat-free diet -allergy-proofing the home -performing postural drainage
performing postural drainage
A nurse is obtaining the history of an infant with suspected acute otitis media. What should the nurse ask the parent about? -covering of the infant's ears when out in the cold -position of the infant when taking a bottle -immunization status of the infant -thorough drying of the infant's ears after a bath
position of the infant when taking a bottle
Immediately following endoscopy of the upper gastrointestinal tract, it is most important for the nurse to assess for: -bowel sounds. -return of the gag reflex. -intake and output. -peripheral pulses.
return of the gag reflex.
A client is recovering from coronary artery bypass graft (CABG) surgery and begins to experience chest pain, shortness of breath, and tachycardia. Further assessment reveals a widened QRS complex and an elevated ST segment. Which nursing diagnosis takes highest priority at this time? -Anxiety related to an actual threat to health status and pain -Decreased cardiac output related to depressed myocardial function -Acute pain related to impaired electrical conduction -Activity intolerance related to imbalance between oxygen supply and demand
Decreased cardiac output related to depressed myocardial function
After teaching the mother of a 7-month-old diagnosed with bronchiolitis, the nurse determines that the teaching has been effective when the mother states she will immediately report which sign or symptom? -seven wet diapers a day -longer periods of sleep than usual -clear nasal discharge for longer than 2 days -temperature of 100° F (37.8° C) for 2 days
longer periods of sleep than usual
The nurse is teaching the family of a client with dysphagia about decreasing the risk of aspiration while eating. Which strategies should the nurse include in the teaching plan. Check all that apply. -maintaining an upright position while eating -introducing foods on the unaffected side of the mouth -restricting the diet to liquids until swallowing improves -cutting food into large pieces of finger food -keeping distractions to a minimum
side-lying
A home care nurse is making the initial home visit to a client with lung cancer who had a peripherally inserted central catheter placed during hospitalization for an upper respiratory infection. During the visit, the nurse must administer an antibiotic, teach the client how to care for the catheter, and provide information about when to notify the home care agency and physician. When the nurse arrives at the client's home, the client's face is flushed and he complains of feeling tired. Which actions should the nurse take first? -Call the physician to update him on the client's condition and administer the antibiotic. -Obtain the client's vital signs and assess breath sounds. -Administer the antibiotic, obtain vital signs, assess breath sounds, and then begin the teaching session. -Obtain the client's vital signs and then administer the antibiotic.
Obtain the client's vital signs and assess breath sounds.
A 4-year-old child is admitted for an appendectomy. What is the most appropriate way for the nurse to prepare the child for surgery? -Show the child a visual analog scale (VAS) based on a scale from 0 to 10. -Show the child a video about the surgery. -Explain how to use a patient-controlled analgesia (PCA) pump for pain control. -Permit the child to play with the blood pressure cuff, electrocardiogram (ECG) pads, and a face mask.
Permit the child to play with the blood pressure cuff, electrocardiogram (ECG) pads, and a face mask.
The surgeon prescribes cefazolin 1 g to be given IV at 0730 when the client's surgery is scheduled at 0800. What is the primary reason to start the antibiotic exactly at 0730? -The antibiotic is most effective in preventing infection if it is given 30 to 60 minutes before the operative incision is made. -The postoperative dose of cefazolin needs to be started exactly 8 hours after the preoperative dose of cefazolin. -The peak and titer levels are needed for antibiotic therapy. -Legally the medication has to be given at the prescribed time.
The antibiotic is most effective in preventing infection if it is given 30 to 60 minutes before the operative incision is made.
A nurse visits the employee health department because of mild itching and a rash on both hands. During the assessment interview, the employee health nurse should focus on -medication allergies. -life stressors the nurse may be experiencing. -laundry detergent or bath soap changes. -chemical and latex glove use.
chemical and latex glove use.
In a client with a urine specific gravity of 1.040, a subnormal serum osmolality, and a serum sodium level of 128 mEq/L, the nurse should question an order for which I.V. fluid? -dextrose 5% in water (D5W) -dextrose 5% in half-normal saline solution. -lactated Ringer's solution. -normal saline solution.
dextrose 5% in water (D5W)
A nurse is caring for a 16-year-old adolescent with a head injury resulting from a fight after a high school football game. A physician has intubated the client and written orders to wean them from sedation therapy. A nurse needs further assessment data to determine whether -nutritional protocol will be effective after the client sedation therapy is tapered. -the nurse will have to apply restraints to prevent the client from dislodging the endotracheal (ET) tube. -payment status will change if the client isn't sedated. -to continue I.V. administration of other scheduled medications.
maintaining an upright position while eating introducing foods on the unaffected side of the mouth keeping distractions to a minimum
After a right total knee replacement, the client's right leg is placed in a continuous passive motion (CPM) machine. Nursing responsibilities when caring for a client with this apparatus should include: -maintaining proper positioning of the leg on the CPM machine. -adjusting the settings as needed to prevent client discomfort. -increasing the range-of-motion settings at least every 8 hours. -discontinuing the CPM therapy when the client's range of motion increases.
maintaining proper positioning of the leg on the CPM machine.
Which nursing intervention is essential in caring for a client with compartment syndrome? -starting an I.V. line in the affected extremity in anticipation of venogram studies -keeping the affected extremity below the level of the heart -removing all external sources of pressure, such as clothing and jewelry -wrapping the affected extremity with a compression dressing to help decrease the swelling
removing all external sources of pressure, such as clothing and jewelry
Following a tonsillectomy, a client returns to the medical-surgical unit. The client is lethargic and reports having a sore throat. In which position should the nurse place the client? -supine -high-Fowler's -semi-Fowler's -side-lying
side-lying
Which is appropriate for the nurse to include in a plan for the prevention of pressure ulcers? -daily skin cleaning with soap and hot water -systematic skin assessment at least once per shift -encouraging the client to sit up as much as possible -gentle massage of bony prominences every shift
systematic skin assessment at least once per shift
A client has been prescribed a new antihypertensive medication and is reporting dizziness. Which is the best way for the nurse to assess blood pressure? -Assess the blood pressure at the beginning and the end of the examination. -Ask the client to ambulate first, then assess the blood pressure. -Assess the blood pressure in the supine, sitting, then standing positions. -Take the blood pressure on both arms, and compare the values.
Assess the blood pressure in the supine, sitting, then standing positions.
A nurse assesses a client who has manifestations of peripheral intravenous extravasation. List the actions to take in order of priority. All options must be used. Photograph the site with the client's written permission. Elevate the affected arm on pillows. Notify the healthcare provider. Discontinue the intravenous tubing as close to the hub as possible. Apply ice in short intervals to the affected site.
Discontinue the intravenous tubing as close to the hub as possible. Notify the healthcare provider. Elevate the affected arm on pillows. Apply ice in short intervals to the affected site. Photograph the site with the client's written permission.
The nurse prepares to draw blood from a child with hemophilia. What is the most appropriate method to use? -Prepare to administer platelets. -Apply heat to the extremity before venipunctures. -Schedule all labs to be drawn at one time. -Use finger punctures for lab draws.
Schedule all labs to be drawn at one time.
A client is transferred to the acute stroke unit, and the nurse initiates a neurologic flow sheet to provide ongoing data about the recovery phase of care. The nurse is aware this information indicates what regarding a client's clinical status? -changes in level of consciousness or responsiveness as evidenced by movement and orientation to time, place, and person -alterations in speech and aphasic status -quality and rate of pulses, respirations, and blood gas values -whether blood pressure is maintained within the lower end of desired parameters
changes in level of consciousness or responsiveness as evidenced by movement and orientation to time, place, and person
The nurse is preparing a client for an MRI after trauma to the spinal column. Which item(s) must be removed prior to the client undergoing this procedure? Select all that apply. -non-colored contact lenses -EKG electrodes -epidural catheter -oximetry probe -metal jewelry
epidural catheter EKG electrodes metal jewelry oximetry probe
After a plane crash, a client is brought to the emergency department with severe burns and respiratory difficulty. The nurse helps to secure a patent airway and attends to the client's immediate needs, then prepares to perform an initial neurologic assessment. The nurse should perform an -evaluation of bowel and bladder functions. -examination of the fundus of the eye. -assessment of the client's gait. -evaluation of the corneal reflex response.
evaluation of the corneal reflex response.
While the nurse is performing a complete assessment of a term neonate, which finding would alert the nurse to notify the health care provider (HCP)? -prominent xiphoid process -respiratory rate of 45 breaths/min -expiratory grunt -red reflex in the eyes
expiratory grunt
An infant, age 3 months, undergoes surgical repair of a cleft lip. After surgery, the nurse should use which equipment to feed the infant? -rubber dropper -single-hole nipple -plastic spoon -paper straw
rubber dropper
A client is scheduled for electroconvulsive therapy (ECT). Before ECT begins, the nurse expects to administer which neuromuscular blocking agent? -pancuronium -succinylcholine -atracurium -vecuronium
succinylcholine
A newborn is diagnosed with meconium ileus. Which diagnostic test should be performed on the client? -chest X-ray -sweat chloride test -rectal biopsy -heel stick for glucose
sweat chloride test
A child admitted to the hospital with a serum sodium level of 160 mEq/L (160mmol/L) is receiving 5% dextrose with 0.45 normal saline solution. The mother asks the child's nurse why the child is receiving sodium. What is the nurse's best reply? -"Your child's sodium is low; we need to give some more sodium IV." -"Your child's sodium is high; I'll stop the infusion and check with the primary care provider." -"Your child's sodium is high; but if the serum sodium level is decreased too rapidly, it may cause seizures." -"Your child's sodium is normal; the solution will maintain the level."
"Your child's sodium is high; but if the serum sodium level is decreased too rapidly, it may cause seizures."
A client with schizophrenia started risperidone 2 weeks ago. Today, the client reports feeling flu-like symptoms. The nurse's assessment reveals the following: temperature 104.4° F (40.2° C), respirations 24 breaths/minute, blood pressure 130/102 mm Hg, pulse rate 120 beats/minute. The nurse also notes muscle stiffness and pain, excessive sweating and salivation, and changes in mental status. The nurse suspects the client is experiencing: -malignant hyperthermia. -the flu. -neuroleptic malignant syndrome. -septicemia.
neuroleptic malignant syndrome.
A nurse is obtaining the history of an infant with suspected acute otitis media. What should the nurse ask the parent about? -position of the infant when taking a bottle -thorough drying of the infant's ears after a bath -covering of the infant's ears when out in the cold -immunization status of the infant
position of the infant when taking a bottle
A client gave birth to a healthy full-term girl 2 hours ago by cesarean birth. When assessing this client which finding requires immediate nursing action? -tachycardia and hypotension -complaints of abdominal pain -blood stain 2″ (5.1 cm) in diameter on the abdominal dressing -gush of vaginal blood when she stands up
tachycardia and hypotension
The nurse is assessing a client with a darker-skin tone in need of emergency care for acute respiratory distress. Which area would the nurse inspect when assessing for cyanosis in this client? -mucous membranes -nail beds -earlobes -lips
mucous membranes
A client is transferred to the acute stroke unit, and the nurse initiates a neurologic flow sheet to provide ongoing data about the recovery phase of care. The nurse is aware this information indicates what regarding a client's clinical status? -whether blood pressure is maintained within the lower end of desired parameters -alterations in speech and aphasic status -quality and rate of pulses, respirations, and blood gas values -changes in level of consciousness or responsiveness as evidenced by movement and orientation to time, place, and person
changes in level of consciousness or responsiveness as evidenced by movement and orientation to time, place, and person
Which nursing assessment is recommended to confirm placement of the nasogastric (NG) tube into the stomach of a client? -Measure NG tube length to confirm it is equal to the distance from the client's ear lobe to the nose plus the distance from the nose to the tip of the xiphoid process. -Obtain a chest X-ray and measure the pH of stomach contents. -Measure to the second or third black marking on the NG tube. -Apply the stethoscope to the xiphoid process and instill 50 mL of air into the tube and listen for a gurgling or popping sound.
Obtain a chest X-ray and measure the pH of stomach contents.
