ADH
A nurse is caring for a 2 year old child. The parents request a toy for their child. The nurse understands that the most appropriate toy from the playroom for this child is which of the following? Doll with clothes Cartoon DVD Video game 10-piece wood puzzle
10-piece wood puzzle Age-appropriate toys for a 2-year-old child include puzzles, large crayons, blocks, picture books, push-pull toys, finger paints, modeling clay, and musical toys. These toys all allow for manipulation and exploration and meet the child's developmental and diversional activity needs.
A nurse is caring for a group of clients in a long-term care setting. One of the clients is found walking in the hallway, bumping into walls, and unresponsive to his name. Which of the following actions should the nurse take first? Obtain a baseline assessment of the client. Accompany the client back to his room. Notify the client's primary care provider. Administer a PRN antianxiety medication
Accompany the client back to his room. The highest priority is safety. The nurse ensures safety by accompanying the client back to his room. Assessment is also essential because the client's incoordination may indicate impairment of the client's balance and level of consciousness, which may be a manifestation of an emerging complication.
A nurse is performing an assessment on a client. Which of the following in the client's history is a contraindication to use of sildenafil (Viagra)? Diabetes mellitus Current use of isosorbide (Isordil) for heart failure Eyeglasses required for presbyopia Osteoarthritis
Current use of isosorbide (Isordil) for heart failure Sildenafil (Viagra), a medication used in the treatment of erectile dysfunction, is contraindicated in clients taking any nitrates, such as isosorbide (Isordil). These medications taken concurrently may cause life-threatening hypotension.
A nurse is assisting with breastfeeding immediately following the birth of a newborn. Which of the following is the most important benefit of breastfeeding during the fourth stage of labor? The nurse is available to assist the mother with breastfeeding techniques. Maternal-newborn bonding is promoted while the neonate is in an alert phase. Warmth is provided for the newborn being held against the mother's skin. Oxytocin secretion is stimulated causing uterine contractions.
Oxytocin secretion is stimulated causing uterine contractions. Production and secretion of oxytocin causes the uterus to contract, thus promoting involution and decreasing the risk for maternal hemorrhage and blood loss.
A nurse is providing teaching to a client who is prescribed albuterol (Proventil) via a metered-dose inhaler. After removing the cap from the inhaler and shaking the canister, the nurse should instruct the client to take which of the following actions next? (Move the following steps into the box on the right, placing them in the selected order of performance. All steps must be used.)
The client should hold the mouth piece 1/2 to 2 inches from his mouth, tilt his head back slightly and then open his mouth. Next, he should press the inhaler while taking a deep breath to facilitate delivery of the medication to the air passages. After holding his breath for 10 seconds, the client should resume normal breathing.
A nurse is caring for a school age child who has received a fiberglass cast following a lower extremity fracture. Which instructions should the nurse give the child and his parents about caring for the casted extremity in the first 48 hr? "Use only a toothbrush to scratch under the cast if your skin itches." "Keep the casted leg below the level of the heart at all times." "Apply ice to the cast at the level of the injury to help prevent swelling." "If soiled, clean the cast with soapy water to
"Apply ice to the cast at the level of the injury to help prevent swelling." Immediately following the injury, and for at least the first 48 hr, ice should be applied to the affected limb. This will help to prevent edema and pain, which could lead to impaired circulation.
A nurse is caring for a 3-year-old child who has persistent otitis media. When obtaining the history of the child from her parent, which of the following would be the most appropriate for the nurse to ask regarding the child's recurrent otitis media? "Is the child playing with other children with otitis media?" "Does anyone smoke around, or in the same house as, the child?" "Does the child get water in her ears during a tub bath?" "Has the child had a fever recently?"
"Does anyone smoke around, or in the same house as, the child?" Otitis media is an infection of the middle ear (eustachian tube behind the tympanic membrane). Allergies to common irritants, such as smoke, can cause eustachian tube congestion and chronic otitis media.
An adolescent client who has had no prenatal care is admitted in labor and gives birth to a stillborn preterm fetus. The client is crying and says to the nurse, "Why did this happen to me?" Which of the following responses is appropriate from the nurse at this time? "I understand how you feel." "You are young and can have healthy babies when you are older." "Sometimes this is nature's way." "I am so sorry that this has happened."
"I am so sorry that this has happened." This statement is an example of a therapeutic response that shows empathy for the client's feelings. It is an open-ended statement that allows the client to continue to express her own feelings.
An older adult client is having trouble sleeping and comes to the primary care provider's office for evaluation. Which of the following statements should the nurse recognize as a potential rationale for the sleeping difficulties? "I take a warm shower when getting ready to go to bed." "I frequently have a cup of coffee with my dessert before going to bed." "I usually read a chapter in a book before I go to bed." "I often have a small glass of wine in the evening."
"I frequently have a cup of coffee with my dessert before going to bed." Beverages with caffeine should be avoided in the evening as it may cause stimulation to the CNS and result in sleep disturbances.
A nurse is caring for a client who has had a bone marrow transplant and is on protective isolation. Which of the following statements indicates that the client understands the restrictions of this type of isolation? "I must keep the door to my room closed at all times." "My family will be bringing me fresh flowers today." "I'm really going to miss taking my daily shower." "I should try to avoid straining during bowel movements."
"I must keep the door to my room closed at all times." Protective isolation is prescribed to protect immunocompromised clients from exposure to potentially lethal micro-organisms and includes keeping the door to the room closed at all times.
A client receiving chemotherapy has developed neutropenia. Which statement by the client indicates to the nurse that the client needs further instructions? "I make sure I always keep an antibacterial hand gel in my purse." "I guess my spouse will have to take care of the cat boxes for awhile." "I'm planning a large gathering of friends and family for the holidays." "I will eat a lot of frozen and canned fruits and vegetables."
"I'm planning a large gathering of friends and family for the holidays." A client with neutropenia must be careful to avoid exposure to infection, so this is a statement that warrants more teaching. A client experiencing neutropenia should avoid large crowds of people because a large gathering increases the client's risk for exposure to infection. TEST-TAKING STRATEGY: This question asks which statement indicates that the client needs FURTHER teaching, thus the CORRECT answer is an INCORRECT statement.
A nurse is caring for a client with chronic atrial fibrillation who takes warfarin (Coumadin). The client has early manifestations of Alzheimer's disease. The client's spouse asks the nurse if the client would benefit from taking ginkgo biloba. Which of the following is an appropriate response? "It is likely that ginkgo biloba may interfere with the effectiveness of his other medications." "You should ask the primary care provider if ginkgo biloba is safe." "Ginkgo biloba is most effective in
"It is likely that ginkgo biloba may interfere with the effectiveness of his other medications." Overall, the research has shown that ginkgo biloba may be effective in delaying the mental deterioration of Alzheimer's disease if taken in the early stages. However, ginkgo biloba is likely to alter the effectiveness of warfarin.
A nurse is reinforcing teaching with the family of a child who has Asperger's syndrome. Which comment would indicate to the nurse that adequate learning has taken place? "Aricept may slow the progression of the disorder." "Group therapy is important for children with cognitive delays." "It will help our child if we keep a structured daily routine." "This disorder is related to our child's prematurity."
"It will help our child if we keep a structured daily routine." The child with Asperger's syndrome has a high functioning form of autism spectrum disorder; typically the child will have normal to high cognitive skills. A structured environment can help to minimize the problems these children experience with sudden schedule changes, socialization requirements, and the preference for ritualistic behavior.
A pregnant client who is Hindu is being seen at the women's health center for a 12 week check up. The primary care provider tells the client that she must get more protein in her diet and suggests that the client eat more animal products. Although the client initially states that she agrees, after the primary care provider leaves the examination room, the client tells the nurse that "eating animal products will cause her to miscarry." Which of the following is an appropriate response? "Let's d
"Let's discuss other foods that are also high in protein that you could substitute for meat." Many cultures have beliefs about food that should or should not be consumed during life transitions, such as pregnancy. The nurse is also aware that many Hindu clients are vegetarian due to religious reasons. The nurse should discuss alternative protein sources with the client to help the client identify those consistent with both her religious and traditional medical beliefs.
A nurse is caring for a hospitalized client who is dying. The family has been involved in the client's care for several days. The family is exploring the possibility of caring for the client at home. Which of the following statements indicates that the nurse has a good understanding of family-centered care? "I have contacted various community resources that will be helpful." "I will review the care plan to make changes that are necessary." "Let's set up a meeting time with the primary care pro
"Let's set up a meeting time with the primary care provider to discuss your options for home care." In family-centered care, the client and family help determine their outcomes and goals. Setting up a meeting to discuss this with the provider will give them a sense of autonomy and foster the family-centered care environment.
A community health nurse is conducting a class on body mechanics for county office workers. Which of the following should the nurse include in the teaching? (Select all that apply.) "Sit with your back supported." "Knees should be at the hip level." "Wrist and forearms should be parallel to the ground." "Keep the elbows far away from the body." "Adjust the monitor screen so that you have to tilt your head slightly to look at it."
"Sit with your back supported." "Knees should be at the hip level." "Wrist and forearms should be parallel to the ground." "Sit with your back supported" is correct. Sitting with the back supported while at the computer helps to prevent back strain, which can lead to lower-back disc disease. "Knees should be at the hip level" is correct. Keeping the knees at the hip level while at the computer helps to prevent unnecessary strain on the hips and lower back. "Wrist and forearms should be parallel to the ground" is correct. Keeping the wrist and the forearms parallel to the ground while typing will help to prevent unnecessary strain on the wrists that could result in carpal tunnel syndrome. "Keep the elbows far away from the body" is incorrect. The arms should be kept close to the body. Keeping elbows far way from the body puts undue strain on the shoulders and the arms. "Adjust the monitor screen so that you have to tilt your head slightly to look at it" is incorrect. The head shoul
A nurse is caring for a school age child on a children's mental health unit. What comment by the nurse would foster rapport to engage the client in conversation? "Do you like school?" "Tell me about your favorite video game." "We have another child your age on the unit." "Would you like some juice or milk to drink?"
"Tell me about your favorite video game." This open-ended statement encourages the child to respond with more than just the name of the game. This would foster rapport and encourage communication.
A client admitted with borderline personality disorder is expressing concern about requiring a prolonged hospitalization. What is the therapeutic statement the nurse could make when interacting with this client? "Most clients are only hospitalized for about a week." "Why do you think you'll be hospitalized for a long time?" "This will be over soon. You just need to be patient." "Tell me what concerns you the most about being hospitalized."
"Tell me what concerns you the most about being hospitalized." Clients with borderline personality disorder have a hard time identifying their feelings. This response allows the client to focus on her concerns regarding hospitalization. It is a form of open-ended therapeutic communication.
A client asks the nurse if it is common to experience vaginal yeast infections during pregnancy. Which of the following is an appropriate response? "Have you discussed this with your primary care provider yet?" "The hormonal changes in pregnancy affect the vaginal pH, making yeast infections common." "Only women who are already prone to vaginal yeast infections get them during pregnancy." "Why are you concerned about yeast infections during pregnancy?"
"The hormonal changes in pregnancy affect the vaginal pH, making yeast infections common." This is an information-seeking question, so the therapeutic response is an answer that provides the client with the information that is requested. This therapeutic answer not only tells the client that the infections are common, but also gives the client information about why this occurs.
A nurse is caring for a 3-year-old toddler who is undergoing insertion of pressure equalization (PE) tubes. The toddler's parent asks the nurse, "When will these tubes be removed?" Which of the following responses by the nurse is the most appropriate? "When the doctor determines it is time to remove the tubes, your toddler will be admitted to the ambulatory surgery center." "Unless they need to be replaced, the tubes are permanent." "The tubes remain in place for approximately 1 to 2 years unt
"The tubes remain in place for approximately 1 to 2 years until they fall out on their own." Children generally outgrow PE tubes, and they usually fall out on their own about 1 to 2 years after insertion.
A nurse is talking with an unmarried couple who have come to the family planning clinic for advice. Which of the following is an appropriate response regarding the risks associated with an intrauterine device (IUD)? "If you experience any weight changes, you will need to be refitted for your IUD." "An IUD is more effective when it is used with a spermicidal jelly." "There is an increased risk for ectopic pregnancy when using an IUD." "An IUD should only be used by couples who have completed th
"There is an increased risk for ectopic pregnancy when using an IUD." An IUD is a family planning device that is inserted through the cervix into the uterus to prevent pregnancy. The IUD works by changing the lining of the uterus and fallopian tubes, making it more difficult for fertilization to occur in the uterus. Consequently, a known complication when using the IUD is an increased risk for ectopic pregnancy.
A nurse is talking with a parent of a preschooler. The parent reports that it is very difficult to get her child to go to bed at a proper time consistently. She tells the nurse that the child gets out of bed, enters her room, and cries when told to stay in bed. Which instructions should the nurse give the parent to foster a consistent bedtime for this child? "Use a stable relaxing routine, such as a bath and story time before bed." "Make sure the room is completely dark when placing the child
"Use a stable relaxing routine, such as a bath and story time before bed." Routines are very reassuring to preschoolers because they allow the child to be able to anticipate their environment and adapt appropriately. These actions will help the child to settle down prior to bedtime. They also provide for parental-child interaction prior to bed.
A nurse at the family planning clinic is preparing to teach a class on the use of a diaphragm. Which of the following should the nurse include in the teaching session? "When using a diaphragm, it is necessary to also use spermicidal jelly." "A diaphragm will remain in place until you're ready to have children." "You can leave a diaphragm in longer than 8 hours without any complications." "A diaphragm comes in one size and does not need to be fitted."
"When using a diaphragm, it is necessary to also use spermicidal jelly." A diaphragm is a barrier device used to prevent pregnancy. It is inserted by the client prior to sexual intercourse. Use of a diaphragm alone is not 100% effective at preventing pregnancy, but the use of spermicidal jelly with it increases the effectiveness of the device.
A nurse at an extended care facility hears an assistive personnel (AP) talking with an older adult client with dementia who has periods of confusion. Which of the following statements made by the AP should indicate to the nurse that the AP needs additional teaching about working with clients who have dementia? "We will be serving breakfast in 10 minutes. I will stay here while you get ready." "It's Monday morning. I know that your favorite television shows are on this evening." "I see that you
"You are running late. Let me do your hair for you and brush your teeth." When a client with dementia has periods of confusion, the nurse should allow the client additional time, as needed, to complete activities of daily living and other tasks that the client is able to perform independently. Insisting on completing the task for the client, or attempting to "hurry" the client, may make the client with dementia agitated. Rather, the nurse should encourage independence and provide assistance only if requested or required. In addition, there is no information in the case scenario to indicate that the client is, in fact, "running late."
A nurse is developing a teaching plan for a client diagnosed with type 2 diabetes mellitus. The client states, "I eat pasta every day. I can't imagine giving it up." Which of the following is an appropriate nursing response? "Let's discuss this with your physician; it may not be necessary." "Isn't there another favorite dish you can substitute?" "You don't have to give up pasta, just adjust the amount you eat." "You can use no-added-salt tomato products on your pasta."
"You don't have to give up pasta, just adjust the amount you eat." The American Diabetes Association (ADA) recommends that carbohydrate restriction be individualized for each client as needed. A careful assessment of the client's usual dietary practices and modifications is an important part of teaching the client with diabetes to manage this disease and to ensure long-term success with the ADA diet.
A client is scheduled to have an electroencephalogram (EEG) in the morning. While preparing the client for the EEG, it is appropriate for the nurse to tell the client which of the following? "You will be given a sedative for the procedure, so you won't feel the small electrical shock." "After midnight you will not be able to eat or drink, so be sure you have enough at dinner." "You need to shampoo your hair tonight, and don't put any styling products on it afterwards." "It's common to experien
"You need to shampoo your hair tonight, and don't put any styling products on it afterwards." An electroencephalogram (EEG) is a painless test that records the electrical activity of the brain. During the test, electrodes are attached to the scalp to record the tiny electrical charges released by the nerve cells in the brain. So that the electrodes will adhere properly to the scalp, the client's hair has to be clean and free of oil and hair-care products.
Four clients are brought to the emergency department after sustaining injuries at a bar. They all have an odor of alcohol on their breath, facial lacerations, and bruising of the head and extremities. The triage nurse makes the following additional observations: Client 1: Lethargic. Awakens to name but unable to answer questions regarding date or place. Client 2: Slurred speech. Refuses to answer questions "until a doctor looks at my broken arm." Client 3: Alert and oriented to person, place, an
1 While acute alcohol intoxication may cause lethargy, the nurse should not assume that all of this client's behavior is related to the client's apparent alcohol ingestion. This client's situation includes the potential for a head injury due to facial lacerations and bruising. The nurse must consider that his lethargy and inability to answer questions could indicate a decreased level of consciousness related to acute head trauma. This client is at greatest physiological risk and must be admitted first.
A nurse is caring for an unaccompanied infant who is brought to the emergency department following a multiple car crash. During assessment, the nurse notes that the infant's posterior fontanel is closed, and the anterior fontanel is soft and flat. The infant has six teeth, is able to sit unsupported, and can drink from a cup. The child cries whenever a new person enters the room and is asking for "mama" and "dada." Which of the following is an appropriate age assessment for this child? 12 mont
12 months The nurse knows that the infant must be less than 18 months old due to the anterior fontanel still being open and at approximately 12 months due to the presence of six teeth. The infant's skills - sitting unsupported (8 months), drinking well from a cup (9 months), stranger anxiety (8 months), and ability to say two words (12 months) help the nurse to estimate the infant's age as 12 months.
A nurse in the emergency department cares for several children who all are admitted with symptoms of influenza. After routine laboratory work is obtained from the children, which child should the nurse bring to the primary care provider's attention immediately? 6-year-old child with urine specific gravity of 1.030 2-year-old toddler with BUN level of 25 mg/dL and creatinine level of 0.5 mg/dL 6-month-old infant with WBC count of 24,000/mm3 12-year-old child with positive beta human chorionic g
6-month-old infant with WBC count of 24,000/mm3 This WBC count (normal is 4,000 to 10,000/mm3) is highly elevated for a 6-month-old infant who has manifestations of influenza. A septic work up (blood, urine, and spinal fluid cultures) will need to be done immediately; therefore, the provider should be notified immediately of the infant's condition.
A charge nurse on a pediatric floor receives the results from the morning laboratory work. Which of the following client results will require the nurse call to the primary care provider first? A client who has tetralogy of Fallot and a hematocrit of 56% A client who has chronic renal failure and a serum potassium of 4.5 mEq/L A client who has diabetic ketoacidosis (DKA) and a blood glucose of 375 mg/dL A client who has bronchopulmonary dysplasia (BPD) and a serum PCO2 level of 45 mm Hg
A client who has diabetic ketoacidosis (DKA) and a blood glucose of 375 mg/dL The normal range for a fasting blood glucose is 70 to 100 mg/dL. When treating a client in DKA, the initial goal of therapy is to get the blood glucose level less than 200 mg/dL. To accomplish this, the client should receive regular insulin via continuous IV drip, and the glucose should be monitored hourly. The nurse needs to notify the client's primary care provider immediately of this very elevated level so that the necessary adjustments in the insulin drip dosage can be made.
A nurse is caring for a client with a tracheostomy who is receiving mechanical ventilation. The low-pressure alarm on the ventilator sounds, indicating which of the following to the nurse? Excessive airway secretions A leak within the ventilator circuitry Decreased lung compliance Client is coughing or attempting to talk
A leak within the ventilator circuitry The low-pressure alarm means that either the tubing has come apart or that client has become disconnected from the ventilator tubing. Almost all low-pressure alarms are the result of a malfunction or displacement of connections somewhere between the endotracheal or tracheostomy tube and the ventilator.
A nurse is caring for a 2 year old child who was admitted for laryngotracheobronchitis. The child is placed in a crib with a cool mist tent. Which toy would be most suitable for the child at this time? A stuffed teddy bear A cloth crib gym A plastic fire engine A cardboard picture book
A plastic fire engine Acute laryngotracheobronchitis, or croup, is a condition of respiratory difficulty caused by infection, inflammation, and swelling of the upper airway (larynx, trachea, and bronchus). The cool mist tent is ordered to provide a high-humidity environment to ease the child's work of breathing. Consequently, the nurse selects an age-appropriate toy made of plastic that can be easily wiped clean and dry.
A nurse has delegated an assistive personnel (AP) to provide one on one observation to a client who is recovering from a closed head injury. The nurse notes that the client is impulsive and has experienced one fall. Which of the following actions by the AP indicates to the nurse further teaching is needed? Accompanies the client to physical and occupational therapy Ambulates the client's roommate while the client sleeps Asks another AP to perform this task while at lunch Remains with the clien
Ambulates the client's roommate while the client sleeps One-on-one observation requires constant supervision of the client. The client might wake up while the AP is out of the room, get out of bed, and fall.
A nurse educator is facilitating a group discussion with preschool teachers about child abuse, and is discussing different examples of when teachers should suspect abuse. Which example should the nurse educator use to best illustrate a suspicious finding? Bruising of both knees with sutures on one Arm cast for spiral fracture of the forearm Consistent bedwetting at nap time Frequent, vague reports of a stomach ache or a headache
Arm cast for spiral fracture of the forearm Spiral fractures can only occur from twisting of an appendage, in this case the arm. They are treated by casting the involved limb from the joint above to the joint below the fracture to limit mobility and allow healing. In most instances, spiral fractures of the arm are cited as a example of an abusive injury in children, adults, and older adults.
A nurse is caring for a child who is receiving bleomycin (Blenoxane) IV and is not voiding adequately. What is the appropriate nursing action? Assess the child's hydration status. Stop the medication immediately. Give the child a diuretic. Take no action because a decrease in urine is an expected side effect.
Assess the child's hydration status. The nurse should monitor renal function with bleomycin and other antibiotic antineoplastic medications. Monitoring includes checking laboratory values for BUN and creatinine clearance, as well as I&O.
Due to staffing shortages, an adult medical-surgical nurse is asked to work on a pediatric unit. The nurse has limited experience with pediatric clients. Which of the following actions should the charge nurse take? Provide constant supervision for the adult medical-surgical nurse. Have the adult medical-surgical nurse provide relief for unit nurses during break and lunch times. Assign a unit nurse to act as a resource for the adult medical-surgical nurse. Delegate to the adult medical-surgical
Assign a unit nurse to act as a resource for the adult medical-surgical nurse. Assigning a nurse who usually works on the pediatric unit to work with the adult medical-surgical nurse will provide consistent support.
A nurse on a mental health unit is taking care of a client diagnosed with depression. Which nursing intervention would foster a therapeutic environment for this client? Tell the client that the nurse will talk to him at her request. Allow the client to skip group activities if he chooses. Leave the client alone for frequent rest periods throughout the day. Build trust with the client by sitting quietly with him.
Build trust with the client by sitting quietly with him. Building trust with the client will give him the idea that the nurse is interested in his issues. Establishing client trust encourages him to speak more openly about issues and concerns.
A nurse is participating in a disaster drill with the local health department. Staged victims are being used in the drill to simulate a bomb explosion at a sporting event. The nurse is one of the first responders on the scene and starts to triage the victims. Which of the following actions should the nurse take first? Call out to people who can walk and ask them to move from the incident area to the concession stand. Perform quick head-to-toe assessments of victims. Immediately start cardiopul
Call out to people who can walk and ask them to move from the incident area to the concession stand. All clients who can walk are asked to move away from the incident area to a specific location. This allows the nurse to quickly assess those who may need immediate assistance and reduces the chance of further injury from the disaster to these people.
During a change of shift, a nurse is reviewing the medication administration records (MAR) for her assigned clients. The nurse notes that a prescribed dose of a medication is above the recommended safe range, and the dose was administered on the previous shift by a nurse. Which of the following actions should the nurse take? Call the previous nurse to verify that the dose was given. Give the calculated safe dose. Give the dose as prescribed. Call the prescriber to get the dose clarified.
Call the prescriber to get the dose clarified. The nurse needs to clarify the prescribed dose to determine what the next action will be.
A nurse is caring for a toddler with acquired immune deficiency syndrome. During the assessment, the nurse understands that which of the following would indicate an opportunistic infection? Koplik spots Gingivitis Chancre Candidiasis
Candidiasis Candidiasis, or oral thrush, is caused by the overgrowth of Candida albicans, an opportunistic fungus that commonly infects the oral cavity of infants, diabetics, and other clients with immature or compromised immune systems. Candidiasis appears as a cheesy, white plaque that may appear like milk curds on the buccal mucosa and tongue. Thrush is often the initial opportunistic infection noted in a human immunodeficiency virus (HIV) positive child who is developing AIDS.
A client presents to the emergency department following a motor vehicle crash. She reports pain in her left leg, and the nurse notes that the left leg has manifestations of a fracture including bruising, swelling, and displacement of the bones. What action should the nurse take first? Ask the provider to prescribe an x-ray of the leg. Apply ice packs to the affected area. Check neurovascular status distal to the injury. Elevate the affected leg on two pillows.
Check neurovascular status distal to the injury. This action includes checking the circulation, sensation, and movement distal to (below) the level of the injury. If the nurse notes a weak or absent pulse distal to the injury, the limb's circulation is compromised, and immediate action is critical. This is the nurse's highest priority at this time.
At the first prenatal visit, a nurse learns that a pregnant client is lactose intolerant. Which of the following foods should the nurse include on a list of calcium sources for this client? Collard greens Cottage cheese Orange juice Broccoli
Collard greens Collard greens are a good source of lactose-free calcium. One cup of collard greens provides approximately the same amount of calcium as 1 cup of milk.
A nurse is caring for an infant with a cleft palate. The parents ask the nurse when it will be repaired. The nurse replies that the palate is generally repaired between 12 and 18 months of age to prevent the child from experiencing which of the following? Repeated ear infections Nutritional deficits Any memory of the hospitalization Difficulty with language acquisition
Difficulty with language acquisition An infant with a cleft palate may have difficulty acquiring language for two reasons. First, repeated middle ear infections are associated with transient hearing loss that can become permanent. In addition, the palate is used in vocalizing sounds, and the infant may develop poor speech habits.
A provider prescribes sertraline (Zoloft) for a client. The client asks the nurse if he should continue to take St. John's Wort for depression. The nurse should advise the client to do which of the following? Take the medication and herbal supplement together. Discontinue the herbal supplement while taking the medication. Take the herbal supplement and the medication at least 2 hr apart. Tell the client that it is not known whether or not St. John's Wort and sertraline can be used together.
Discontinue the herbal supplement while taking the medication. When taken with the antidepressant sertraline (Zoloft), St. John's Wort, an herbal supplement used in the treatment of mild to moderate depression, may cause an additive effect that could lead to serotonin syndrome. They should not be used concurrently.
A nurse is caring for a client who has been hospitalized due to methicillin-resistant Staphylococcus aureus (MRSA) in the sputum. The dietary assistant asks the nurse what precautions are necessary to enter the client's room with the lunch tray. Which instructions should the nurse provide to the dietary assistant? Don a gown before entering the room and remove it before exiting. Wear a mask at all times while in the client's room. Don gloves when entering the room and use hand sanitizer when e
Don gloves when entering the room and use hand sanitizer when exiting. Clients with MRSA are on contact precautions. In addition to the use of standard precautions and appropriate hand hygiene, contact precautions require that any staff who will have contact with the client's environment must don gloves prior to entering the room. Additional precautions, such as a gown, are required for contact with the client; a mask and goggles could be required if secretions from the infected area could spray into the face. Delivering the tray would require contact with the environment, therefore gloves are required.
An individual wearing a hospital-issued identification badge greets the charge nurse on the postsurgical unit and states, "I am a surgical resident assigned to this unit." The individual then asks the charge nurse for an access code to review a client's online record stating, "I'm not scheduled to attend the computer class until next week." Which of the following actions should the nurse take? Explain that it is against policy to share access codes and refer the resident to his supervisor. Acc
Explain that it is against policy to share access codes and refer the resident to his supervisor. Access codes and passwords should never be shared. Likewise, allowing access to the system for an individual who does not have their own access code is also not permitted. An integral part of computer training is learning about client data security, confidentiality, and signing documents that attest to your intention to follow these federal guidelines. The resident should be politely referred to his supervisor to obtain the information needed or to make arrangements to be trained sooner if necessary.
A nurse is caring for a child with celiac disease. Which of the following nursing assessments is consistent with celiac disease? Elevated sweat chloride Foul-smelling stool Clubbing of the fingernails Jaundice
Foul-smelling stool Foul, fatty stools (steatorrhea) are a manifestation of celiac disease, a malabsorption syndrome.
A nurse is caring for a client who is receiving hemodialysis for the first time. Which of the following indicates to the nurse that the client is at imminent risk for developing dialysis disequilibrium syndrome (DDS)? Elevated BUN Bradycardia Headache Temperature of 39.2° C (102.5° F)
Headache DDS is a central nervous system (CNS) disorder. It is a complication that may develop in clients who are new to dialysis due to the rapid removal of solutes and changes in blood pH levels. Clients beginning hemodialysis are at greatest risk, particularly if the BUN is above 175. DDS is characterized by CNS manifestations of varying severity due primarily to cerebral edema. They include headache, nausea, disorientation, restlessness, blurred vision, and asterixis. More severely affected clients progress to confusion, seizures, coma, and death.
A nurse is caring for a client who has developed hypovolemic shock. Which of the following laboratory values should the nurse expect this client to have? Urine specific gravity of 1.026 Hematocrit of 35% Hematocrit of 55% Urine specific gravity of 1.001
Hematocrit of 55% An elevated hematocrit indicates hypovolemia. Other signs of hypovolemia are a weak pulse, hypotension, decreased central venous pressure, decreased cardiac output, elevated BUN and serum osmolality, increased urine specific gravity and osmolality, and decreased urine output.
The nurse is caring for a toddler who is hospitalized for Pneumocystis carinii pneumonia. The child is taking zidovudine (AZT). Which laboratory tests should the nurse monitor related to this medication? BUN and creatinine Hgb and Hct Chest x-ray and oximetry SGOT (AST) and SGPT (ALT)
Hgb and Hct Zidovudine may cause severe anemia, so it is important to monitor the CBC, which includes the Hgb and Hct, closely for at least the first 2 weeks. As anemia may occur up to 2 to 4 weeks after beginning AZT therapy, the Hgb and Hct are monitored regularly for the first 2 months and then periodically after that.
The disaster plan for a hospital has been initiated following a community flood. Which of the following actions is the responsibility of the nurse during the disaster? Turn client televisions in order for them to be kept informed of the disaster. Identify the stable clients in the intensive care unit (ICU) who can be transferred to the medical-surgical floor. Ask family members to come to the hospital to provide support to clients. Make announcements of the status of the disaster on the public
Identify the stable clients in the intensive care unit (ICU) who can be transferred to the medical-surgical floor. Transferring the stable clients from the ICU to the medical-surgical floor allows for more intensive care beds to be used in the event that the clients from the external disaster (flood region) are deemed critically ill. As part of the disaster plan, the charge nurse will compile a list of clients who require a level of care that is consistent with the level of care that can be provided on a medical-surgical unit.
A home care nurse is discussing fire safety with a homebound client. The nurse identifies which of the following safety measure to help protect the client in case of a fire? Use a night light in the bedroom. Reduce water temperature. Keep stairs free from clutter. Keep a phone close to the bed.
Keep a phone close to the bed. Most fires happen during the night. Placing a phone close to the bed enables the client to call the fire department quickly. The client should bring the phone (if portable) with him if he tries to exit the house. The client should be familiar with the exits, have working smoke alarms, and have a flashlight near the bed.
A nurse on the antepartum unit is caring for a client who is at 28 weeks of gestation and expecting twins. The client reports feeling "lightheaded." Which position should the nurse assist the client into at this time? Lateral Fowler's position Trendelenburg Prone with lower extremities elevated
Lateral The lateral, or side-lying position (especially left side-lying), provides for the best uteroplacental blood flow. This is the most appropriate position for improving both maternal and fetal circulation in the pregnant client who is feeling faint.
A nurse in a rehabilitation facility is observing an assistive personnel (AP) help a client transfer from the bed to a wheelchair. Which action taken by the AP indicates to the nurse an understanding of the proper technique to use for this type of transfer? Locks the brakes on the bed and the wheelchair before moving the client Tells the client to reach for the side arms of the wheelchair while transferring Lowers the bed so that it is lower than the wheelchair seat Places the wheelchair on th
Locks the brakes on the bed and the wheelchair before moving the client Prior to starting the transfer, the AP should ensure that both the wheelchair and the bed are stationary and will not shift when the client moves into the chair. Therefore, locking the brakes on the bed and the wheelchair is an important action.
A nurse is admitting a client to the medical unit and asks if the client has an advance directive. The client states "I have a document with me that names someone who can make health care decisions for me if I am not able." The client is referring to which of the following documents? Informed consent form Living will document Do-not-resuscitate directive Medical power of attorney document
Medical power of attorney document This type of advance directive names a surrogate who can make health care decisions for the client if he is unable to do so. This document may also be called a health care proxy.
A nurse is caring for a client who has recently had a myocardial infarction (MI). The client calls the nurse to report some manifestations similar to those the client experienced the day of the MI. Which of the following should alert the nurse to the possibility of a recurrence? (Select all that apply.) Nausea and vomiting Diaphoresis and dizziness Chest and left arm pain Anxiety and feelings of doom Leg cramps and restlessness
Nausea and vomiting Diaphoresis and dizziness Chest and left arm pain Anxiety and feelings of doom
A nurse is caring for an infant with dehydration. Which of the following is the most accurate assessment for hydration status? Obtain daily weights. Check for the presence of tears. Palpate the fontanel. Assess skin turgor.
Obtain daily weights. Daily weights are the most sensitive indicator of fluid balance in clients of all ages. Daily weights are especially critical in children under 2 years of age because a greater portion of body weight is composed of fluid.
A nurse is caring for a client who is scheduled for discharge this morning and does not speak English. The client's child arrives accompanied by a neighbor to pick up the client. Both the child and neighbor speak the client's native language and English fluently. Which of the following actions should the nurse take when providing discharge instructions? Have a hospital staff member who speaks the client's language translate. Ask the client's neighbor to translate the information. Obtain the se
Obtain the services of a translator. Medical information should be communicated by a qualified medical interpreter who speaks the client's native language. Federal law provides that the hospital is required to provide a qualified medical interpreter to translate the client's health care information into the client's native language.
A nurse is preparing to care for a client in balanced skeletal traction with a femur fracture. Which of the following is an appropriate nursing intervention for this client? Offering the client a diet high in fluid and fiber Encouraging active range of motion of the affected leg Removing the weights prior to repositioning the client Performing daily pin site care with isopropyl alcohol
Offering the client a diet high in fluid and fiber An immobilized client is at risk for constipation. The nurse should encourage a diet high in fluid and fiber to promote gastrointestinal function.
In planning care for a child with severe reactive airway disease, the nurse knows that when chronic steroid use is indicated, inhaled steroids are preferred over oral steroids for which of the following reasons? Inhaled steroids are less likely to cause thrush. Oral steroids in liquid preparations taste bad. Oral steroids can slow linear growth in children. Inhaled steroids are more effective for acute bronchospasm.
Oral steroids can slow linear growth in children. Chronic use of oral steroids in children can result in decreased linear growth. Inhaled steroids are also preferred because they deliver the anti-inflammatory agent directly to the local target area (the client's airways) without the risks of side effects associated with oral administration of steroids, such as immunosuppression and adrenal suppression.
A nurse is caring for a gravida 3 para 3 client who has had a precipitous delivery. During the fourth stage of labor, which nursing assessment must be performed every 10 to 15 min to prevent the most common complication due to this type of delivery? Monitor the level of consciousness. Obtain the blood pressure. Palpate the fundus. Assess the perineum.
Palpate the fundus. A precipitous delivery is one in which the client delivered suddenly or excessively fast. Regardless of the cause of the rapid delivery, uterine atony can result, causing postpartum hemorrhaging. Although fundal assessment is always appropriate following delivery, this situation requires a more frequent examination of the fundus, as well as the amount of lochia.
When assessing a child with lymphocytic leukemia who is being treated with vincristine (Oncovin), the nurse should give the highest priority to which of the following reports? Paraesthesia Alopecia Fatigue Constipation
Paraesthesia The greatest risk to the client is neurotoxicity. Vincristine, a cell-cycle specific chemotherapy agent, interrupts cellular reproduction at mitosis. One of its side effects is neurotoxicity. An early finding with neurotoxicity is paresthesia, or numbing, of the peripheral extremities. As the neurotoxicity progresses, the client may develop autonomic and central nervous system dysfunction. If paresthesia occurs, the child's provider must be notified immediately, since a change in the dosage or therapy may be indicated.
A nurse is caring for a child who is diagnosed with strabismus. The nurse explains to the parents that to prevent the development of amblyopia, it will be necessary to do which of the following? Patch the unaffected eye. Administer mydriatic eye drops daily. Obtain prescription eyeglasses. Administer IV antibiotics.
Patch the unaffected eye Amblyopia is a disorder of the eye in which unilateral central blindness occurs as a result of another condition, such as strabismus. In strabismus, muscle weakness allows one eye to wander so that the child cannot focus on an object with both eyes at the same time. This confusion causes the brain to ignore the signals from the weak eye in favor of the strong one. This will result in central blindness if not treated by 6 years of age. To strengthen the weak eye muscles, the unaffected eye is patched.
A nurse is providing teaching to a client who is prescribed doxycycline (Vibramycin) for actinomycosis. The nurse should observe the client for which of the following? Photosensitivity Constipation Ototoxicity Discoloration of teeth
Photosensitivity Doxycycline is a tetracycline antibiotic. Photosensitivity is an adverse effect of tetracyclines in which the skin reacts abnormally to light, especially ultraviolet radiation or sunlight. The result is an intense sunburn reaction with erythema, maculas, and gray-blue patches. Prevention involves avoiding direct exposure to sunlight and ultraviolet light and using a sunscreen with a sun protection factor (SPF) of 15 or greater.
A client is admitted with a suspected diagnosis of tuberculosis. Which nursing action is of highest priority? Place the client on airborne isolation. Initiate the prescribed antimicrobial therapy. Ask the client about potential community exposures. Teach the client the manifestations of tuberculosis.
Place the client on airborne isolation. Clients strongly suspected of having tuberculosis (TB) should be placed on airborne isolation precautions immediately because of the highly communicable nature of the infection. Airborne precautions prevent transmission of infectious agents that remain infectious over long distances when suspended in the air, including Mycobacterium tuberculosis, the agent that causes TB.
A nurse working at a senior center notes that a client who is in the early stages of Alzheimer's disease has been having problems with orientation. Which of the following actions should the nurse take to improve the client's level of orientation? Encourage the client to participate in the group activities. Have the client attend daily reminiscence therapy sessions. Post a large calendar on the bulletin board. Place a wander alert electronic alarm bracelet on the client's wrist.
Post a large calendar on the bulletin board. Posting a large calendar in a central location will assist this client with orientation.
A nurse on an oncology unit receives a report about the postoperative clients assigned to the nurse's team. Which client should the nurse see first? Postoperative day 1: Chest tube placement following lobectomy for small-cell carcinoma. Finding: Chest tube with 20 to 50 mL/hr of bright red bloody drainage Postoperative day 2: Colectomy with creation of an ostomy due to colon cancer. Finding: Ostomy bag full of bright red bloody drainage Postoperative day 2: Excision of abdominal mass with pl
Postoperative day 2: Colectomy with creation of an ostomy due to colon cancer. Finding: Ostomy bag full of bright red bloody drainage An ostomy bag full of blood is an ominous finding at any time. It indicates that the client's bowel is hemorrhaging and must be reported to the client's surgeon immediately. The client may require fluid replacement, transfusion, and additional surgery to repair the bleeding vessel.
A nurse caring for a client with hypocalcemia should expect to see which of the following on the client's ECG? Flattened T-wave Prolonged QT interval Shortened QT interval Widened QRS
Prolonged QT interval Manifestations of hypocalcemia include tingling, numbness, tetany, seizures, abdominal cramps, prolonged QT intervals, and hypotension. Causes include decreased parathyroid function, chronic renal disease, massive blood transfusions, and diarrhea.
After an exploratory laparotomy, a client is admitted to the medical surgical unit with an indwelling urinary catheter and a Jackson Pratt (JP) drainage tube. Which finding should indicate to the nurse that the client may be experiencing a postoperative complication? Pain scale score of 5 out of 10 Urine output of 65 mL/hr 20 mL of bright red drainage from the JP drain Pulse oximetry of 85%
Pulse oximetry of 85% Clients who are recovering from abdominal surgery should have an oxygen saturation of 90 to 100%. A client with an oxygen saturation of 85% is poorly oxygenated.
A nurse is planning to delegate care of a postoperative client following an appendectomy. Which of the following should the nurse delegate to an assistive personnel (AP)? Teach the client to use the patient-controlled analgesia pump. Record urinary output after emptying the indwelling urinary catheter. Get the client out of bed and to the chair for the first time after surgery. Check the client's abdominal wound dressing.
Record urinary output after emptying the indwelling urinary catheter. Emptying an indwelling urinary catheter and recording I&O is within the scope of practice for an AP.
A nurse manager notes that several staff members are late in completing an annual mandatory educational session related to restraint safety. Which of the following actions should the nurse plan to take? Make a general announcement at the next staff meeting asking all employees to check their compliance with the requirement. Post a list in the employee break room naming those who are in noncompliance and the date that the requirement must be completed. Speak to each noncompliant employee indivi
Send an e-mail to each noncompliant employee that includes a link to future upcoming educational sessions. E-mail provides a simple, yet efficient way for the nurse manager to get the news out to each noncompliant employee without embarrassing anyone with a public announcement. In addition, including the appropriate link in the e-mail facilitates the employee's compliance by helping the employee to identify upcoming session(s) that coordinate with the employee's work schedule.
A nurse is caring for a client who is receiving IV ampicillin (Unasyn). Which of the following actions should the nurse take first if the client develops urticaria and dyspnea? Administer diphenhydramine (Benadryl). Call the primary care provider. Obtain an oximetry reading. Stop the ampicillin infusion.
Stop the ampicillin infusion. The greatest risk to the client is an allergic reaction that may progress to anaphylaxis. The nurse should stop the infusion immediately so that further exposure to the client of the potential allergen is halted. TEST-TAKING STRATEGY: This question requires you to choose a priority action for a client with drug toxicity when all the actions appear plausible. Any time that a question involving medication toxicity requires you to make a choice about which action the nurse should take first, a choice that has the nurse discontinuing the client's exposure to the medication or toxic substance should always be the first choice.
A nurse is administering a transfusion of packed RBCs. Which of the following actions should the nurse take first if a transfusion reaction is suspected? Notify the primary care provider. Obtain a set of vital signs. Stop the infusion. Send the IV bag and tubing to the laboratory.
Stop the infusion. The greatest risk to the client is a life-threatening event such as circulatory collapse. Therefore, the first action the nurse should take is to stop the infusion to prevent any further administration of blood.
A nurse is assessing a client who is prescribed rosiglitazone (Avandia). For which of the following should the nurse monitor? Fever Swollen ankles Tinnitus Urinary retention
Swollen ankles Rosiglitazone is prescribed, along with diet and exercise, to treat type 2 diabetes. Rosiglitazone can lead to fluid retention, exacerbation of heart failure, and an increased incidence of angina and myocardial infarction.
A nurse is providing discharge instructions to a client who is prescribed metoprolol (Toprol-XL). Which of the following instructions should the nurse include? (Select all that apply.) Do not suddenly stop taking this medication. Take medication right before bedtime. Avoid exposure to the sunlight. Take radial pulse daily. Chew sugarless gum to relieve dry mouth.
Take radial pulse daily is correct. The client should take a radial pulse daily and report a heart rate less than 60/min. Chew sugarless gum to relieve dry mouth is correct. Chewing sugarless gum or sucking on sugarless candy can help relieve dry mouth caused by metoprolol. Do not suddenly stop taking this medication is correct. There is an increased risk of angina, hypertension, and possible myocardial infarction when metoprolol, a beta blocker, is discontinued suddenly. If the provider discontinues the medication it should be gradually reduced over 1 to 2 weeks to prevent worsening of manifestations.
A nurse has been notified by the post anesthesia care unit that a client who has had a subtotal thyroidectomy is returning to the nursing unit. Which emergency equipment should the nurse have available on the unit for this client? Cardiac monitor Defibrillator Thoracotomy tray Tracheostomy tray
Tracheostomy tray In the event of laryngeal edema or tetany, respiratory distress could result in airway obstruction. Emergency intubation may be difficult due to laryngeal swelling, and endotracheal intubation may increase the risk for hemorrhage by increasing tension on the incision during insertion. A tracheostomy tray should be easily accessible.
A nurse observes tachycardia, dyspnea, dry cough, and distended neck veins in a client with leukemia who is receiving a blood transfusion of packed red blood cells. Which intervention should the nurse use to prevent these manifestations with the client's next transfusion? Warm the unit of blood to room temperature before administering it. Administer acetaminophen (Tylenol) prior to the blood transfusion. Give an antihistamine prior to the transfusion. Use a transfusion pump to regulate and mai
Use a transfusion pump to regulate and maintain the flow rate. These are the manifestations of a hypervolemic reaction due to circulatory overload, likely if the blood is transfused too rapidly for the client's size or condition. To prevent this problem with future transfusions, the nurse must ensure that the proper amount of blood is transfused and that a transfusion pump is used to regulate the flow rate.
A nurse is planning recreational activity for a young adult client with an acute exacerbation of schizophrenia. Assuming that the client is capable of all of the following, which activity should the nurse consider appropriate? Walking with a staff member around the gated grounds Playing ping-pong in the dayroom with another client Shooting baskets with several other clients in the gym Riding on the stationary bike alone in the fitness room
Walking with a staff member around the gated grounds This client should be encouraged to participate in nonthreatening, noncompetitive physical activities. This also provides an opportunity for verbal interaction with a member of the health care team.
A client with an acute visual disturbance describes it as a "curtain" pulled over the visual area with occasional flashes of light. The nurse should notify the provider immediately of the possibility of cataracts. angle-closure glaucoma. a detached retina. macular degeneration
a detached retina. The retina is the thin layer of light-sensitive tissue on the back of the wall of the eye. A detached retina is a medical emergency in which the retina of the eye peels away from its underlying layer of support tissue. Without immediate treatment, the entire retina can detach, leading to permanent vision loss. Manifestations include a sudden onset of decreased peripheral or central vision, dark floaters, flashes of light, and a shadow or curtain over a part of the visual field.
A client's provider informs the nurse that the client's abdominal aortic aneurysm (AAA) is extending. The nurse must assess the client for increases in blood pressure and respiratory rate. jugular-vein distention and peripheral edema. abdominal pain with the onset of back pain. retrosternal chest pain radiating to the left arm.
abdominal pain with the onset of back pain. An aortic aneurysm is a weak spot in the wall of the aorta, the primary artery that carries blood from the heart to the head and extremities and allows the aorta to expand and increase in diameter. Increasing abdominal and back pain indicates that the aneurysm is extending downward and pressing on the lumbar sacral nerve roots.
A client comes to the emergency department reporting fever and severe upper left quadrant abdominal pain. The primary care provider suspects pancreatitis. Based on this information, the nurse expects to see an elevation in the client's serum amylase and lipase. potassium and sodium. calcium and phosphorus. hemoglobin and hematocrit.
amylase and lipase. With pancreatitis, laboratory results typically show elevated serum amylase and lipase up to two or three times the expected values. Liver enzymes may also be elevated, depending on the cause of pancreatitis. Serum glucose may also be elevated (hyperglycemia) due to inflammation of the pancreas
A new computerized charting system is going to be implemented in a health care organization. This change has been initiated by the organization's leadership and not the nurse managers. Before implementing the new system, the nurse manager should first discuss with the charge nurses their responsibility in implementing the change. post a sign-up sheet for in-service training sessions about the method. ask informal leaders to participate in the early implementation process. announce the change i
announce the change in a staff meeting, allowing time for staff comments. It is important that the staff get important information related to changes in the system that impact their daily job performance directly from the manager. Using the nursing process as a priority setting framework, the nurse manager should first collect more data by allowing time for staff comment. This will allow the nurse to take further steps when implementing the new system.
During a client care unit meeting, the nurse manager discusses potential problems with data security related to confidential client information. The nurse manager explains that safe, effective environments where client information may be discussed include areas closed off from the public. outside the door of a client's room. lunch breaks in the cafeteria. in the hallway near the nurse's station.
areas closed off from the public. Client information may be discussed in a room on the unit with a closed door to prevent accidental disclosure of a client's personal health information.
A nurse is developing a plan of care for a client with gastroesophageal reflux disease (GERD). Because of the complications commonly associated with this disorder, the nurse plans to monitor the client for aspiration. infection. anemia. weight loss.
aspiration. Aspiration is a common complication associated with GERD. GERD results when the esophageal sphincter malfunctions, allowing gastric acid and undigested food to back up into the esophagus placing the client at risk for aspiration. GERD is characterized by effortless, uncontrolled regurgitation whether the client is in an upright position or reclining. The most common results of regurgitation are heartburn and indigestion, but aspiration is also possible. Therefore, the client should be monitored for crackles in the lung fields, which is an indication of aspiration.
A client with extensive deep partial and full thickness burns has been prescribed a topical antimicrobial drug. The nurse understands that the goal of this therapy is to reduce bacterial growth. scarring. skin graft size. pain.
bacterial growth. The use of topical antimicrobial drugs (particularly broad-spectrum antimicrobials) is an important intervention to help prevent bacteria from entering the body when the protective covering of skin is impaired, as with burns. A topical antimicrobial is generally used on deep partial-thickness (2nd-degree) and full-thickness (3rd-degree) burn wounds to provide a protective barrier, along with the dressing, between bacteria and the exposed body tissues.
A client who has been treated for a transient ischemic attack (TIA) is being discharged. The nurse's discharge teaching plan related to this admission should reinforce the importance of monitoring blood glucose using a glucometer. blood pressure at regular intervals. pulse rate with aerobic exercise. temperature and sensation in the feet.
blood pressure at regular intervals. TIAs are caused by a temporary disturbance of blood supply to the brain, resulting in brief neurologic dysfunction. One third of clients who have had a TIA later have recurrent TIAs, and another one third have cerebrovascular accidents (CVA) that results in permanent nerve cell loss. The most common causes of TIAs is atherosclerotic plaque in the carotid arteries and hypertension. Consequently, managing hypertension is important in reducing the risk of CVA.
A client who has been treated for a transient ischemic attack (TIA) is being discharged. The nurse's discharge teaching plan related to this admission should reinforce the importance of monitoring blood pressure at regular intervals. blood glucose using a glucometer. pulse rate with aerobic exercise. temperature and sensation in the feet.
blood pressure at regular intervals. Transient ischemic attacks (TIA) are caused by a temporary disturbance of blood supply to the brain, resulting in brief neurologic dysfunction. One third of clients who have had a TIA later have recurrent TIAs, and another one third have a cerebrovascular accident (CVA) that results in permanent nerve cell loss. The most common causes of TIA are atherosclerotic plaque in the carotid arteries and hypertension. Consequently, managing hypertension is important in reducing the risk of CVA.
A client with Addison's disease comes to the emergency department reporting nausea, vomiting, diarrhea, and abdominal pain. To prevent Addisonian crisis, the nurse anticipates that the provider will prescribe IV administration of calcium. potassium. insulin. corticosteroids.
corticosteroids. Addison's disease is characterized by adrenal gland hypofunction and inadequate production of glucocorticoids. Acute adrenal insufficiency can be a life-threatening event, with severe fluid and electrolyte imbalances. Without treatment, sodium levels fall and potassium levels increase. Rapid infusion of IV fluids, such as 0.9% sodium chloride boluses, with administration of high dose corticosteroids, such as hydrocortisone sodium succinate (Solu-Cortef), are started as soon as venous access is established.
A client diagnosed with acute systemic lupus erythematosus (SLE) is to begin treatment for systemic manifestations. The nurse should recognize that the preferred classification of medications to be used is corticosteroids. antimalarials. nonsteroidal anti-inflammatories. cytotoxics.
corticosteroids. Corticosteroids, such as prednisone (Deltasone), are the treatment of choice for systemic manifestations of SLE because of their rapid anti-inflammatory action.
A primary care provider prescribes 10 units of insulin glargine (Lantus) and 4 units of NPH insulin (Humulin N) to be given subcutaneously at 1700. The nurse should plan to draw up each insulin dose into a separate insulin syringe and then combine the doses into one tuberculin syringe to inject simultaneously. draw the insulin glargine (Lantus) into an insulin syringe first, and then draw up the NPH insulin into the same syringe. draw the NPH insulin into an insulin syringe first, and then d
draw the insulin glargine (Lantus) into one insulin syringe and the NPH insulin into a different insulin syringe and inject separately. Insulin glargine (Lantus) cannot be mixed with any other insulin.
A nurse is reviewing the laboratory data of a client who reports symptoms that suggest systemic lupus erythematosus (SLE). If this diagnosis is accurate, the nurse expects to note an increased platelet aggregation. red blood cell count. hemoglobin and hematocrit. erythrocyte sedimentation rate (ESR).
erythrocyte sedimentation rate (ESR). SLE is a chronic systemic autoimmune disease that causes skin, heart, lung, and kidney inflammation. Like most autoimmune diseases, a series of exacerbations and remissions is typical and, while it varies considerably in severity, clients typically die from end-stage renal disease. Diagnosis is based on the client's history of manifestations and serologic tests. Most clients with an exacerbation of SLE will have an increased ESR.
A clinic nurse is caring for an older adult client with an in-the-canal hearing aid. The client states that the hearing aid is making a whistling sound. The nurse explains that whistling in hearing aids is often caused by low battery power. excessive wax in the ear canal. a volume setting that is too low. a crack in the ear tube.
excessive wax in the ear canal. Whistling from the hearing aid can be caused by a poor seal with the ear mold, an ear infection, excessive wax in the ear canal, or a malfunction. Ear molds should be cleaned regularly, turned off and removed at night, and protected from water and direct heat.
A nurse is planning care for a client admitted with syndrome of inappropriate antidiuretic hormone (SIADH). The nurse expects the treatment for this client to include increased fluids with hypertonic sodium chloride and fludrocortisone (Florinef). fluid restriction plus hypertonic sodium chloride and furosemide (Lasix). physiological amounts of hypotonic sodium chloride solution and vasopressin (Pitressin). isotonic 0.9% sodium chloride to replace urine output plus desmopressin (DDAVP).
fluid restriction plus hypertonic sodium chloride and furosemide (Lasix). SIADH is a disorder of water intoxication caused by the inappropriate, continuous secretion of ADH by the posterior pituitary gland, causing hypervolemia and hyponatremia. Treatment of SIADH may include fluid restriction, sodium replacement with small amounts of sodium chloride, and IV furosemide (Lasix).
A nurse is helping plan a health fair for adults in the community. One booth will focus on primary and secondary prevention actions for colorectal cancer. The nurse should include information on the prevention and treatment of constipation. benefits of a diet low in cruciferous vegetables. new types of ostomy appliances available. importance of colonoscopy screening starting at age 50.
importance of colonoscopy screening starting at age 50. Screening exams for colorectal cancer are considered secondary prevention (early detection of disease). While it is recommended that some high-risk clients have a colonoscopy before age 50, most clients should have a baseline colonoscopy done at age 50.
A client diagnosed with multidrug resistant tuberculosis (MDR TB) has been prescribed ethambutol (Myambutol). The nurse plans to instruct the client that it is likely he will experience large purple bruises on the legs. orange-red urine and bodily secretions. yellowing of the sclera. loss of red/green color discrimination.
loss of red/green color discrimination. Ethambutol (Myambutol) is an antitubercular drug that impairs ribonucleic acid synthesis. A common adverse reaction associated with the use of ethambutol is the loss of red/green color discrimination.
During preoperative teaching for a client scheduled for laser assisted in situ keratomileusis (LASIK) surgery, the nurse should tell the client that he may need to wear reading glasses after the surgery. can drive home after the procedure. should continue to wear his contact lenses until the day of the surgery. will not have to wear glasses after the surgery.
may need to wear reading glasses after the surgery. LASIK is a type of refractive laser eye surgery ophthalmologists perform to correct myopia, hyperopia, and astigmatism, which are common causes of nearsightedness. However, many people develop presbyopia (farsightedness) with age and may need reading glasses, despite having had LASIK surgery.
A nurse is caring for a postoperative client following a hip arthroplasty. In the client's medical record, the nurse notes a history of chronic obstructive pulmonary disease (COPD). The nurse knows that the oxygen delivery system appropriate for the client is a simple face mask. continuous positive airway pressure (CPAP) device. bag-valve-mask device. nasal cannula.
nasal cannula. A nasal cannula delivers precise concentrations of oxygen; therefore, it is an appropriate device for a client with COPD who requires a precise percentage of inspired oxygen.
A client has pseudomembranous colitis caused by clostridium difficile. The priority nursing intervention for this client is performing hand hygiene before and after contact with the client. reducing the client's anxiety due to isolation procedures. assisting the client in making nutritional choices to reduce diarrhea. monitoring the client's intake and output closely for signs of fluid deficit.
performing hand hygiene before and after contact with the client. C. difficile is a spore-forming, gram-positive anaerobic bacillus that produces two virulent exotoxins that attack the lining of the intestine. The toxins destroy cells and produce pseudomembranes, patches (plaques) of inflammatory cells, and decaying cellular debris on the interior surface of the colon. The spores of C. difficile are easily transported from one client to another without hand hygiene.
A nurse participating in a community health fair is giving general information to clients who have an elevated reading during a blood pressure screening. While explaining the meaning of the results to a client, the nurse should provide the client with written information including the numeric value of the client's blood pressure. encourage the client to go directly to the nearest emergency room to be evaluated. reassure the client that hypertension can be cured with proper medication. explain
provide the client with written information including the numeric value of the client's blood pressure. When a client has an elevated reading at a hypertension screening, the nurse should encourage the client to see the provider for further evaluation. To help facilitate this process, the nurse should give the client a written record of the blood pressure result obtained at the screening so that the client can share it with the provider.
A clinic nurse is assessing a 66 year old client a for a routine physical. The client is new to the area and does not have old medical or immunization records available. When the nurse asks if the client has received the pneumococcal vaccine, the client replies, "I am not sure but I haven't had any immunizations in at least 5 years." The nurse should recognize that in this circumstance it is unsafe for the client to receive another vaccination. the client will need a series of three injections
the client should receive the pneumococcal vaccine. One dose of the pneumococcal vaccine should be given to all clients age 65 or older. If the client received the immunization more than 5 years ago and was less than 65 years of age, the CDC recommends a one-time revaccination.
