252-EXM4-Prioritization and Delegation NCLEX Style Qs (Passpoint PrepU)

Assess the physical problems. **Clients with schizophrenia generally have poor visceral recognition because they live so fully in their fantasy world. They need to have an in-depth assessment of physical complaints that may spill over into their delusional symptoms. Talking with the client won't provide an assessment of the itching, and itching isn't an adverse reaction of antipsychotic drugs. The client's provider should be called if the assessment warrants.

A 40-year-old client with schizophrenia lives in a rooming house. The client scratches vigorously and reports creatures eating at the skin. Which intervention should be done first? -Encourage the client to discuss the delusions. -Administer an anticholinergic medication. -Assess the physical problems. -Call the healthcare provider.

Provide oxygen and stimulate the baby to cry.

Immediately after birth, a nurse assesses the neonate's respiratory effort as slow. The neonate is actively moving but grimaces in response to stimulation. The neonate's fingers and toes are bluish and the heart rate is 130 bpm. Which step should the nurse take next? -Provide oxygen and stimulate the baby to cry. -Tell the provider that the neonate appears abnormal. -Wrap the infant in a warm blanket. -Assign an Apgar score of 8.

preventing hypoxia

The nurse is caring for a school-age client with sickle cell anemia who requires a tonsillectomy. What does the nurse prioritize as most important when planning care for the client with sickle cell anemia? -optimizing nutrition -controlling pain -preventing hypoxia -preventing injury

diluting the chemicals

The nurse is caring for an 8-year-old child who arrived at the emergency department with chemical burns to both legs. What is the priority intervention for this child? -diluting the chemicals -applying sterile dressings -applying topical antibiotics -debriding and grafting the burns

Projectile vomiting

The nurse is caring for an infant with pyloric stenosis. Which manifestation requires priority attention? -loss of appetite -explosive diarrhea -projectile vomiting -constipation

Place the client on her left side and apply oxygen.

A nurse is caring for a full-term pregnant client in active labor. The electronic fetal monitor reveals a fetal heart rate (FHR) of less than 70 beats for 1 minute. What is the nurse's priority intervention? -Position the client in the lithotomy position. -Place the client on her left side and apply oxygen. -Call the client's provider. -Slow down the client's I.V. rate.

Assess the nature of the commands by asking what the voices are saying.

A 49-year-old client is admitted to the emergency department frightened and reporting hearing voices telling the client to do bad things. Which intervention should be the nurse's priority? -Provide reassurance that the client is safe and the voices are not real. -Provide reassurance that the client is safe and promise the staff will protect the client. -Assess the nature of the commands by asking what the voices are saying. -Administer a neuroleptic medication before speaking with the client.

Be prepared for immediate intervention.

A 7-year-old child who ingested several leaves of a poisonous plant has arrived in the emergency department. What is the priority nursing intervention? -Provide emotional support to the parents. -Be prepared for immediate intervention. -Provide emotional support to the child. -Begin teaching accident prevention.

Managing pain **Adequate pain relief will enable this client to engage in initial mobility exercises and prevent potential complications. Ambulating 50 feet is a longer-term goal. Wound care and nutrition are important post-surgical priorities over the longer term to ensure wound healing, but they are not the priority with this type of procedure.

A 76-year-old woman, with a history of osteoporosis is 24-hours postoperative for a total right hip replacement. What is the priority nursing action for this client? -Promoting nutrition -Ambulating 50 feet -Caring for the surgical wound -Managing pain

Conduct a wound assessment.

A 9-year-old is brought to the emergency department with extensive burns sustained in a restaurant fire. What is the nurse's most important intervention? -Administer prescribed antibiotics to prevent superimposed infections. -Conduct a wound assessment. -Administer liquids orally to replace lost fluid. -Administer frequent, small meals to support nutritional requirements.

contacting the Poison Control Center by phone

A child has ingested a bottle of over-the-counter medication and is brought into the emergency department by the parents. The nurse expedites rapid first aid for poisoning by immediately accessing what resource? -consulting the current Compendium of Pharmaceuticals and Specialties (CPS) -contacting the Poison Control Center by phone -reviewing the treatment for overdose on the medication bottle -reviewing the emergency department poison control guidelines

Place a "do not palpate abdomen" sign over the child's bed

A child is admitted to the pediatric unit with an unknown mass in her lower left abdomen. Which is the nurse's priority action? -Obtain the history of the illness -Place a "do not palpate abdomen" sign over the child's bed -Obtain a complete set of vital signs -Schedule a hemoglobin and hematocrit test for early morning

Prepare the client for surgical intervention

A client displays signs associated with a possible ruptured aortic aneurysm. What is the priority nursing intervention? -Administer prescribed antihypertensive medication -Prepare the client for an aortogram -Administer prescribed beta-adrenergic blocker medication -Prepare the client for surgical intervention

Administer acetylcysteine. **acetylcysteine is the specific antidote for acetaminophen poisoning, thus this is the priority.

A client ingested a large amount of acetaminophen at 1:00 am. Two hours later, the client comes to the emergency department, and is diagnosed with acetaminophen poisoning. What is the priority intervention for this client? -Perform gastric lavage. -Obtain blood work. -Administer I.V. fluid. -Administer acetylcysteine.

-"I feel dizzy and light-headed when I get up." **The priority intervention, by the nurse, would be to assess the client's vital signs to note any alterations. A client stating "My life is over if I gain weight" is an example of catastrophizing.

A client is admitted with an eating disorder. Which client response should the nurse address first? -"My life is over if I gain weight." -"I feel dizzy and light-headed when I get up." -"I cannot eat because my teeth hurt." -"I do not have the same energy that I used to have."

Have the client void.

A client is scheduled for amniocentesis. What priority intervention should the nurse implement? -Tell the client to drink 34 oz (1 L) of water. -Have the client void. -Instruct the client to fast for 12 hours. -Place the client on her left side.

Ask the client about her most recent blood glucose levels. **Asking about the client's most recent blood glucose levels will indicate how well her diabetes has been controlled. Oral hypoglycemic drugs are never used during pregnancy because they cross the placental barrier, stimulate fetal insulin production, and are potentially teratogenic. Plans to admit the infant to the neonatal intensive care unit are premature. Cesarean is not the preferred birth method for clients with diabetes. Vaginal birth is preferred and presents a lower risk to the mother and fetus.

A client who developed gestational diabetes mellitus during the pregnancy has just been admitted in the labor and delivery unit. What is the priority nursing action for this client? -Ask the client about her most recent blood glucose levels. -Prepare oral hypoglycemic medications for administration during labor. -Notify the neonatal intensive care unit that a client with diabetes has been admitted. -Prepare the client for cesarean birth.

Implementing suicide precautions.

A client who is experiencing thoughts of self-harm is brought to the crisis response center by family members. Which action is most important for the nurse to implement? -Teaching relaxation techniques. -Establishing trust with client. -Assessing for auditory hallucinations. -Implementing suicide precautions.

-Provide 15 to 20 grams of a fast-acting oral carbohydrate.

A client with type 1 diabetes mellitus is conscious but confused, weak, diaphoretic, and having heart palpitations. What is the nurse's priority action? -Inject 10 units of fast-acting insulin subcutaneously. -Administer glucagon intramuscularly (IM) or subcutaneously. -Provide 15 to 20 grams of a fast-acting oral carbohydrate. -Give an intravenous (IV) bolus of dextrose 50%.

prednisone

A client's laboratory results indicate hypokalemia, hyperglycemia, and increased white blood cell (WBC) count. Which newly prescribed medication should the nurse associate as most likely to contribute to these changes? -albuterol (salbutamol) -prednisone -furosemide -ciprofloxacin

Registered nurse with one year of experience

A client, who underwent femoral-popliteal (fem-pop) bypass surgery, is scheduled to return from the post-anesthesia care unit. Which staff member should receive this client? -Registered nurse with one year of experience -Licensed practical nurse (LPN) with five years of experience -Nursing assistant with 15 years of experience -Charge nurse with 10 years of experience

Maintain the client on respiratory isolation

A hospitalized client, with a productive cough, chills, and night sweats is suspected of having active tuberculosis (TB). What is the nurse's most important intervention? -Maintain the client on respiratory isolation -Prepare the client to be discharged on bed rest -Administer the tuberculin test ordered by the health care provider -Administer the isoniazid ordered by the health care provider immediately before discharge

Apply petroleum jelly to the site for 24 to 48 hours.

A male neonate has just been circumcised. Which nursing intervention is part of the initial care of a circumcised neonate? Wash the circumcised penis with warm water. Change the diaper as needed. Keep a bandage on the site for 24 to 48 hours. Apply petroleum jelly to the site for 24 to 48 hours.

Report the incident to risk management.

A nurse administers incorrect medication to a client. After assessing the client, and completing an incident report, which is the priority action by the nurse? -Report the incident to the nursing regulatory agency. -Complete an adverse drug reaction (ADR) report. -Anticipate suspension from the facility due to the error. -Report the incident to risk management.

"What drugs have you used to manage your weight and appetite?"

A nurse is assessing a client with bulimia nervosa for possible substance abuse. What is the most important question for the nurse to ask this client? -"How would you describe your alcohol use?" -"Do you participate in "pharm" parties?" -"What drugs have you used to help control anxiety?" -"What drugs have you used to manage your weight and appetite?"

-client who is being prepared for a major surgery receiving clopidogrel **Clopidogrel is an anti-platelet drug that should be stopped seven days prior to surgery because it can increase the risk of bleeding. All the other options are correct. Fondaparinux can be given to a client who had ORIF to prevent blood clot formation. Pegfilgrastim is given to a client with low white blood cell (WBC). Emtricitabine is a nucleoside-nucleotide reverse transcriptase inhibitor (NNRTI) drug used for clients with HIV/AIDS.

A nurse is assigned to four clients. Which client should the nurse see first? -A client who is being prepared for a major surgery receiving clopidogrel -A client who had open reduction internal fixation (ORIF) receiving fondaparinux -A client with a low white blood cell count receiving pegfilgrastim -A client with acquired immunodeficiency syndrome receiving emtricitabine

A client who reports genital pruritus and paresthesia **Pruritus and paresthesia as well as redness of the genital area are prodromal symptoms of recurrent herpes infection. These symptoms occur 30 minutes to 48 hours before the lesions appear. Headache and fever are symptoms of viremia associated with the primary infection. Vaginal and urethral discharge are also a local sign of primary infection. Dysuria and lymphadenopathy are localized symptoms of a primary infection that may also occur with recurrent infection.

A nurse is caring for clients who have a history of genital herpes infection. Which client is most at risk for an outbreak of genital herpes? -A client who reports headache and fever -A client who reports vaginal and urethral discharge -A client who reports dysuria and lymphadenopathy -A client who reports genital pruritus and paresthesia

Expose the client to fresh air

A nurse is making a home visit and finds an older adult client who requires immediate treatment for exposure to carbon monoxide. What priority action would the nurse take prior to the arrival of the paramedics? -Provide warm clothing or a blanket -Expose the client to fresh air -Loosen all tight fitting clothing -Monitor for breathing difficulties

massaging the fundus firmly

A nurse is performing an assessment of a postpartum client 2 hours after birth, and notes heavy bleeding with large clots. What should be the nurse's initial action? -notifying the health care provider -massaging the fundus firmly -performing bi-manual uterine compressions -administering ergonovine

A 43-year-old homeless man with a history of alcoholism

A nurse, working in a rural county's public health department, has been alerted that there is an outbreak of tuberculosis (TB) in the area. Which client is at highest risk for developing TB? -A 16-year-old female high school student -A 35-year-old female day-care worker -A 43-year-old homeless man with a history of alcoholism -A 54-year-old businessman who travels worldwide

Decrease supplemental feedings with formula.

A postpartum mother is concerned about a noted decrease in her breast milk production. Which response by the nurse best addresses this mother's concern? -Decrease supplemental feedings with formula. -Suggest the mother consume a diet high in vitamin C. -Have several alcoholic beverages for relaxation. -Feed the infant less frequently.

Reassure the client that all her questions will be answered during the visit.

A primiparous client arrives for her first prenatal visit at 10 weeks' gestation. The client seems nervous and has many questions. What is the most important intervention by the nurse? -Provide the client with reading material for newly expectant mothers. -Reassure the client that all her questions will be answered during the visit. -Tell the client not to worry, because the health care provider will take good care of her. -Ask the client to undress to prepare for the physical examination.

Loosen any restrictive clothing.

A school-age client with a diagnosis of epilepsy is admitted to the pediatric unit of a local hospital for evaluation of anticonvulsant medications. As the nurse enters the client's room, the client begins to have a seizure. What is the priority nursing action? -Push the call light and ask for help. -Hold the child down to prevent injury. -Loosen any restrictive clothing. -Force the jaw open to maintain an open airway.

placement of a bag of ice over the child's face **Vagal maneuvers, such as placing a bag of ice over the face for 15 to 30 seconds, or immersing the hands in cold water are commonly the first mechanism used to decrease the heart rate. Other vagal maneuvers include breath-holding, carotid massage, gagging, and placing the head lower than the rest of the body. Synchronized cardioversion may be required if vagal maneuvers and drugs are ineffective. If a child has low cardiac output, cardioversion may be used instead of drugs. Adenosine is the drug of choice for medical conversion of SVT.

An 18-month-old child is experiencing supraventricular tachycardia (SVT). What should be the nurse's first intervention? -administration of adenosine -administration of digoxin -placement of a bag of ice over the child's face -synchronized cardioversion

Educate the client about the accompanying risk of cervical cancer. **This client's external lesions should be treated, and she should receive education regarding the relationship between HPV and cervical cancer. Antibiotics would be ineffective because of the viral etiology of HPV. Hormonal contraceptives are of no benefit, and HPV is not normally the cause of systemic infection.

An adolescent girl is being treated for anogenital warts caused by the human papillomavirus (HPV). What is the nurse's priority intervention for this client? -Educate the client about the need to adhere to antibiotic therapy. -Educate the client about the accompanying risk of cervical cancer. -Assess the client's knowledge of hormonal contraceptives. -Assess the client for signs and symptoms of systemic infection.

Immobilize the client's head and neck

An alert and oriented client comes to the emergency department after hitting his head in a motor vehicle accident. What should the nurse do first? -Assess range of motion (ROM) to determine the extent of injuries -Immobilize the client's head and neck -Open the airway with the head-tilt, chin-lift maneuver -Call for an immediate chest X-ray

Assess fetal heart tones.

An amniotomy is performed on a client in labor. What is the priority nursing intervention following this procedure? -Assist the client to ambulate to promote labor. -Encourage the client to use breathing exercises as contractions increase. -Assess fetal heart tones. -Position the client on her left side.

Ask the nurse assigned to this client about the medications.

At the beginning of a shift, the team leader notices that all of the I.V. antibiotics for a client are still in the medication room. What is the team leader's first action? -Ask the client if medication was received during the previous shift. -Notify the unit's nurse manager. -Ask the nurse assigned to this client about the medications. -Return the medications to the pharmacy to reduce hospital expenses.

Turn the client on her left side. **As the uterus gets larger, it increases pressure on the inferior vena cava. This inhibits venous return causing dizziness, lightheadedness, and pallor when the client is supine. Turning the client on her left side relieves the pressure on the vena cava and restores venous return.

During a routine prenatal examination, a client who is at 32 weeks' gestation becomes dizzy, lightheaded, and pale. After placing the client in a supine position, what is the priority nursing action? -Take the client's blood pressure. -Listen to fetal heart tones. -Ask the client to breathe deeply. -Turn the client on her left side.

-gravida 2 Para 2002, cesarean birth, incisional site intact, hemoglobin level 9.8 g/dl

Four clients each gave birth 12 hours ago. Based upon report and assessment, which client should the nurse see first? -gravida 1 Para 1001, vaginal birth, ruptured membranes 10 hours before birth -gravida 2 Para 1011, cesarean birth, incisional site intact, pulse 84 beats/minute -gravida 2 Para 2002, cesarean birth, incisional site intact, hemoglobin level 9.8 g/dl -gravida 1 Para 1001, vaginal birth, midline episiotomy, temperature 99.8° F (37.7° C)

gravida 2 Para 2002, cesarean birth, incisional site intact, hemoglobin level 9.8 g/dl **Women who are anemic in pregnancy (defined as a hemoglobin <10 g/dl) may experience additional complications, such as poor wound healing and the inability to tolerate activity. The vital signs of pulse 84 beats/min and temperature 99.8° F (37.7° C) are within normal limits. Dehydration can cause a slightly elevated temperature. The client with ruptured membrane is not displaying any symptoms. Women whose membranes are ruptured more than 24 hours before birth are more prone to developing chorioamnionitis; complications of chorioamnionitis may include high temperature, rapid heartbeat, sweating, a uterus that is tender to the touch, and discharge from the vagina that has an unusual smell.

Four clients each gave birth 12 hours ago. Based upon report and assessment, which client should the nurse see first? -gravida 2 Para 2002, cesarean birth, incisional site intact, hemoglobin level 9.8 g/dl -gravida 2 Para 1011, cesarean birth, incisional site intact, pulse 84 beats/minute -gravida 1 Para 1001, vaginal birth, midline episiotomy, temperature 99.8° F (37.7° C) -gravida 1 Para 1001, vaginal birth, ruptured membranes 10 hours before birth

Assess the child's vital signs and neurological status. **The nurse must assess the child to determine if life-saving intervention such as cardiopulmonary resuscitation is needed. This assessment will direct all the subsequent actions, such as the application of oxygen and intravenous fluids. The parents have indicated the source of suspected poisoning is unknown, so although interviewing them to try to determine the possible source and the initial symptoms should be done, the nurse must first assess and stabilize the child.

Parents bring a preschool-age client to the emergency department with suspected ingestion of an unknown toxic substance. What intervention should the nurse perform first? -Assess the child's vital signs and neurological status. -Establish intravenous access, and provide supplemental oxygen. -Ask the parents what they think the child ingested. -Interview the parents about the initial onset of symptoms.

client with Guillain-Barré syndrome **Guillain-Barré syndrome is a progressive neuromuscular disorder that can affect the respiratory muscles and cause respiratory failure. The other conditions don't typically affect the respiratory system.

Which client would be considered to be at the highest risk for respiratory failure? -A client with breast cancer -A client with Guillain-Barré syndrome -A client with a fractured hip -A client with cervical sprains

had a newly created urinary diversion 3 days ago.

The nurse can assign an unlicensed assistive personnel (UAP) to which client? A client who: -is 1 day postoperative following cranial surgery. -has prostate cancer undergoing radiation implant seeding. -had a newly created urinary diversion 3 days ago. -was admitted to the hospital showing signs of progressive confusion.

suction the nares

The nurse in pediatric intensive care is caring for an infant whose respiratory rate is 50 with nasal flaring, grunting and experiencing thick yellow nasal discharge. Vital signs are stable with oxygen saturation of 96% on 0.25 L of oxygen via face mask. Chest physiotherapy has been completed, and the infant is sleeping in the supine position. What should be the nurse's next intervention? -call the health care provider -suction the nares -give ordered medications -change the infant's position

Prepare to administer intravenous fluids and insulin per order.

The nurse is assessing a child with type 1 diabetes mellitus who recently came to the emergency department with signs and symptoms consistent with diabetic ketoacidosis. What is the nurse's priority when planning care for this child? -Monitor the child closely in the emergency department before transfer to the medical unit. -Prepare to administer intravenous fluids and insulin per order. -Teach the family about the prevention of this complication of diabetes. -Make a referral to the pediatric diabetes nurse.

Assess the client's vital signs

The nurse is assessing a client who has been experiencing black stools for the past month. The client suddenly reports chest and stomach pain. What is the most important action by the nurse? -Draw blood for laboratory analysis -Administer oxygen via nasal cannula -Assess the client's vital signs -Initiate cardiac monitoring

Preventing irreversible shock

The nurse is caring for a client admitted with Addisonian crisis. Which outcome is the priority? -Relieving anxiety -Preventing irreversible shock -Preventing infection -Lowering blood pressure

deep breathing, coughing, and incentive spirometry exercises.

The nurse is caring for a client diagnosed with postoperative atelectasis. What intervention performed by the nurse best addresses the underlying pathophysiology that leads to atelectasis? -Mobilize the client in the hallway a minimum of three times per day as tolerated. -Encourage adequate fluid intake to thin respiratory secretions. -Provide supplemental oxygen as prescribed, and check oxygen saturation every hour. -Teach deep breathing, coughing, and incentive spirometry exercises.

Assess vital signs.

The nurse is caring for a client who has just undergone electroconvulsive therapy (ECT) for the treatment of severe depression that is unresponsive to medication. What is the nurse's most important intervention immediately postprocedure? -Administer analgesics. -Assess vital signs. -Provide oral fluids. -Reorient the client to the environment.

Maintaining adequate hydration **Maintaining fluid intake is essential in a client with DI. The client is at risk for developing hypovolemic shock because of increased urine output. Weight should be measured daily to monitor fluid balance. Urine specific gravity should be monitored for low osmolality, generally <1.005, due to the body's inability to concentrate urine.

The nurse is caring for a client with diabetes insipidus (DI). What is the nurse's priority intervention? -Maintaining adequate hydration -Monitoring urine for specific gravity >1.030 -Checking weight every three days -Watching for signs and symptoms of septic shock

Ask a direct question such as, "Do you ever think about killing yourself?"

The nurse is concerned that a client admitted with major depressive disorder may be suicidal. What is the most important action by the nurse? -Speak to family members to ascertain whether the client is suicidal -Ask a direct question such as, "Do you ever think about killing yourself?" -Arrange for the client to be placed on immediate suicidal precautions -Talk to the client to determine whether the client is an attention seeker

Use a caring approach to maintain close observation of the client

The nurse is developing a plan of care for a hospitalized client who is at risk for suicide. What is the most important intervention for the nurse to include? -Develop a strong and healthy relationship with the client -Obtain an order for an antianxiety medication to keep the client calm -Encourage the client to avoid over-stimulating group activities -Use a caring approach to maintain close observation of the client

-A client who needs assistance with colostomy irrigation -A client who is receiving glargine subcutaneously

The nurse is making assignments for the next shift. Which client can be assigned to a licensed practical nurse/licensed vocational nurse (LPN/LVN)? Select all that apply. -A client who just had coronary artery bypass graft (CABG) -A client who needs initial admission assessment -A client who needs assistance with colostomy irrigation -A client who is receiving glargine subcutaneously -A client who has C3 to C5 spine injury

daily weight **The most accurate clinical assessment for total body water is weight. Weight helps assess all the water in all spaces while other assessments are dependent on renal function or movement of fluid between spaces, making them less accurate. While sodium levels are relevant, they cannot inform about total body water volume; an infant can be in fluid volume deficit and hyponatremic concurrently depending on how much sodium is lost in relation to water. Weighing diapers is a way of measuring output, but depending on the renal function of the infant, there can be very little urine output. The infant may be retaining fluids and actually be experiencing fluid volume excess or have very little urine output because of fluid volume deficit. Similarly, urine specific gravity can be altered by the kidney's ability to concentrate the urine, so it may not accurately reflect the total water volume.

The nurse is planning care for an infant with bronchiolitis who requires monitoring for fluid balance. What is the most accurate assessment the nurse can perform to determine the total body water volume of the infant? -daily weight -serum sodium levels -urine specific gravity -weighing each diaper

Assess respiratory status frequently.

The nurse is planning care for an infant with bronchiolitis. What is the nurse's priority intervention for this child? -Incorporate parents into the child's care. -Assess respiratory status frequently. -Monitor intake and output. -Position the infant with the head elevated.

Administer prescribed analgesics **Administering prescribed analgesics to relieve pain would be the priority. The other actions are appropriate measures, but aren't the priority

The nurse is planning interventions for a client who is having an acute gout attack. What is the priority nursing intervention for this client? -Instruct the client to change their dietary intake -Instruct the client about relaxation techniques -Administer prescribed analgesics -Encourage increased fluid intake

Give a fluid bolus of 500 ml. **One of the major adverse effects of epidural administration is hypotension. Therefore, a 500-ml fluid bolus is usually administered to help prevent hypotension in the client who wishes to receive an epidural for pain relief. Eliciting maternal reflexes, inserting a Foley catheter, and administering I.V. pain medications are not necessary for the insertion of an epidural.

The nurse is preparing a client in labor for the administration of an epidural. What is the most important intervention by the nurse? -Give a fluid bolus of 500 ml. -Administer I.V. pain medication prescribed by the provider. -Elicit maternal reflexes. -Insert a Foley catheter.

Burp the infant frequently. **These infants usually swallow a lot of air from sucking on their hands and fingers because of their intense hunger. Burping frequently will reduce gastric distention, and increase the likelihood that the infant will retain the feeding. Feedings should be given slowly with the infant lying in a semi-upright position. Parental participation should be encouraged to the extent possible, but this will not increase the likelihood that the feeding will be retained.

The nurse is preparing to feed an infant diagnosed with pyloric stenosis prior to surgical repair. What is the nurse's most important intervention? -Encourage parental participation. -Burp the infant frequently. -Don't give more feedings if the infant vomits. -Give feedings quickly.

interventions to enhance the child's self-esteem ***Hypopituitarism and reduced stature can have a negative effect on self-esteem and development. Interventions to address these risks are appropriate. There is no need for a high-nutrient diet, and the child is not at high risk for injury. Weight-bearing exercise has no direct effect on the course of the illness.

The nurse is providing care for a school-age child with hypopituitarism. What is the nurse's priority intervention? -high-protein, high-calorie diet -vigilant fall precautions and fracture prevention -interventions to enhance the child's self-esteem -education for the child and parents about the importance of weight-bearing exercise

Immediately assess the client's level of consciousness. **Before taking any action, the nurse needs to confirm the accuracy of the telemetry reading. The nurse first assesses the client. If in ventricular fibrillation, the cardiac output drops rapidly and the client will lose consciousness. If the client is conscious and asymptomatic, the nurse needs to assess for reasons for artifact and adjust the client's telemetry leads. The other actions may be taken once the nurse confirms accuracy of the reading, beginning with calling the emergency response team (i.e., calling a code blue). The nurse will initiate cardiopulmonary resuscitation after calling the code. Once the team arrives, interventions such as defibrillation and medications will be administered.

The nurse notes what appears to be a ventricular fibrillation rhythm on a client's telemetry monitor. What should the nurse do first? -Call for the emergency response team. -Prepare an intravenous dose of epinephrine. -Immediately assess the client's level of consciousness. -Prepare for immediate cardiac defibrillation.

A client infected with the human papillomavirus (HPV)

Which client would benefit most from information explaining the importance of receiving an annual Papanicolaou (PAP) test? -A client with a history of recurrent candidiasis -A client who had her first pregnancy before the age of 20 -A client infected with the human papillomavirus (HPV) -A client who has used oral contraceptives for 27 years

29-year-old multipara who is 4 hours postpartum after delivery of a 39-week infant weighing 10 pounds 2 ounces **The 29-year-old multiparous mother who recently delivered a large infant is at risk for postpartum hemorrhage. The other multiparous mother has less of a risk for postpartum hemorrhage since her infant was small. The two primiparous mothers are not at risk for postpartum hemorrhage.

The postpartum nurse is about to perform the initial assessment of four clients. Which client should the nurse see first? -35-year-old multipara who is 3 hours postpartum after delivery of a 36-week infant weighing 5 pounds 6 ounces -20-year-old primipara who is 6 hours postpartum after delivery of a 40-week infant weighing 7 pounds 5 ounces -29-year-old multipara who is 4 hours postpartum after delivery of a 39-week infant weighing 10 pounds 2 ounces -15-year-old primipara who is 3 hours postpartum after delivery of a 38-week infant weighing 6 pounds 2 ounces

signs of increased intracranial pressure (ICP)

Which nursing assessment data would be given priority for a child with clinical findings related to tubercular meningitis? -onset and character of fever -degree and extent of nuchal rigidity -signs of increased intracranial pressure (ICP) -occurrence of urinary and fecal incontinence

Monitor vital signs.

What is the nurse's priority action in caring for a client who has just had a liver biopsy? -Assess the level of pain. -Monitor vital signs. -Instruct the client to avoid alcohol in the future. -Assess for feelings about body image.

Block radiant, convective, conductive, and evaporative losses. **Prevention of heat loss is always the first goal in thermoregulation to avoid hypothermia. The second goal is to minimize the energy necessary for neonates to produce heat. Adding extra heat sources is a means of correcting hypothermia. The ambient room temperature should be kept at approximately 100° F (37.8° C).

What is the nurse's priority to regulate the temperature of a neonate? -Supply extra heat sources to the neonate. -Keep the ambient room temperature less than 100° F (37.8° C). -Minimize the energy needed for the neonate to produce heat. -Block radiant, convective, conductive, and evaporative losses.

maintaining an adequate airway

What is the nurse's priority when caring for a 10-month-old infant with meningitis? -maintaining an adequate airway -maintaining fluid and electrolyte balance -controlling seizures controlling -hyperthermia

Assist the client to identify coping mechanisms used in the past **To help a client develop effective coping skills, the nurse must know the client's baseline functioning.

What is the priority nursing action for a client with generalized anxiety disorder who is working to develop coping skills? -Determine whether the client has fears or obsessive thinking -Monitor the client for overt and covert signs of anxiety -Teach the client how to use effective communications skills -Assist the client to identify coping mechanisms used in the past

-Refer the client to a dietitian for nutritional counseling.

Which nursing intervention is a priority for a pregnant adolescent during her first trimester? -Refer the client to a dietitian for nutritional counseling. -Schedule the client for a screening glucose tolerance test. -Assess the client for signs and symptoms of placenta previa. -Tell the client that she will most likely need a cesarean birth due to the head size of the fetus.

Involve the parents in feeding as soon as possible. ***The sooner the parents become involved, the quicker they're able to determine the method of feeding best suited for them and their infant. Breastfeeding, like bottle feeding, may be difficult but can be facilitated if the mother is supported in this decision. If the cleft isn't severe, breastfeeding may be easier than other feeding techniques because the human nipple conforms to the shape of the infant's mouth. Feedings are usually given in the upright position to prevent formula from coming through the nose. Various special nipples have been developed for infants with cleft lip or palate. A regular nursery nipple is not effective.

Which nursing intervention is essential while caring for an infant with cleft lip or palate? -Involve the parents in feeding as soon as possible. -Cradle the infant horizontally while feeding. -Avoid encouraging breastfeeding. -Choose a regular nursery nipple for feedings.

Leave the fingers in place and press the nurse call light. **When the umbilical cord precedes the fetal presenting part, it's known as a prolapsed cord. Leaving the fingers in place and calling for assistance is the safest intervention for the fetus. The nurse will need to keep the fetus off the cord to reduce cord compression. The nursing staff will contact the provider, and the client will probably require a cesarean birth to decrease the risk of fetal demise during birth. Placing the client in the semi-Fowler's position would increase the pressure of the fetus on the umbilical cord. Asking the client to push with the next contraction would force the presenting part against the cord, causing severe bradycardia and possible fetal demise.

While performing a cervical examination on a client in labor, a nurse's fingertips feel pulsating tissue. What is the most appropriate nursing intervention? -Leave the client and call the provider. -Ask the client to push with the next contraction. -Leave the fingers in place and press the nurse call light. -Put the client in a semi-Fowler's position.