Basic care and comfort

During a postpartum parenting class, a client tells the nurse that to save on the cost of formula, the client has switched her 6-month infant from formula to cow's milk. Which one of the following statements made by the nurse would be the best? "Cow's milk has as lower amounts of protein. The infant will need additional amounts of milk to meet the infant's needs." "Cow's milk has higher amounts of iron, which could interfere with blood volume." "Powdered formula can be blended with cow's milk to supplement." "Cow's milk can be safely given to an infant older than one year of age."

"Cow's milk can be safely given to an infant older than one year of age." The quality and quantity of nutrients in cow's milk differs greatly from those of human milk, and cow's milk does not contain many of the various growth and immunological factors found in human milk. With regard to nutrient content, cow's milk contains great amounts of protein and minerals and smaller amounts of essential fatty acids than human milk. Cow's milk has low iron content, and the iron is poorly absorbed. To lower the risk of iron-deficiency anemia, cow's milk is not recommended before 12 months of age.

The nurse has instructed the client about the correct positioning of the leg and hip following hip replacement surgery. Which statement indicates that the client has understood these instructions? "I may cross my legs as long as I keep my knees extended." "I should avoid bending over to tie my shoes." "I can sit in any chair that I find comfortable." "I should avoid any unnecessary walking for about 3 months after my surgery."

"I should avoid bending over to tie my shoes." Acute flexion and adduction of the hip should be avoided after hip replacement surgery and the client should not bend over to tie the shoes. Slip on shoes that can be positioned with a long handled shoe horn are preferred. The client may not cross (adduct) the legs as this is a risk for dislocating the prosthesis. The client should not sit in low chairs that will require excessive hip flexion to get in or out of. Hip flexion also increases the risk of dislocation.Frequent walks are encouraged to increase muscle strength and provide hip exercises.

A physician orders phenytoin 150 mg by mouth twice per day for a child. The strength of the oral suspension on hand is 30 mg/5 mL. How many milliliters of suspension should the nurse administer with each dose? Record your answer using a whole number.

25 Each dose is 150 mg. There are 30 mg of phenytoin per 5 mL of oral suspension. Set up a proportion relating mg to mL: 150 mg / x mL = 30 mg / 5 mL x = 25 mL The nurse should administer 25 mL of suspension with each dose.

The nurse is planning care for a client who has been experiencing a manic episode for 6 days and is unable to sit still long enough to eat meals. Which choice will best meet the client's nutritional needs at this time? a green salad topped with chicken pieces favorite foods from home a peanut butter sandwich a bowl of vegetable soup

a peanut butter sandwich

The nurse is caring for a 3-year-old child with iron deficiency anemia and providing dietary instructions to the parents. Which of the following should be a priority for the nurse to include in the teaching? urging pasta with tomato sauce recommending lean meats insisting on a banana each day encouraging milk products

recommending lean meats From the list, meat is the food source with the highest iron content.

After giving birth to an 8-lb (3.6-kg) girl, a client asks the nurse what her daughter should receive for the first feeding. For a bottle-fed neonate, the first feeding usually consists of

iron-fortified infant formula.

The nurse is caring for a client with peripheral arterial occlusive disease (PAD). What nursing intervention is most appropriate to reduce platelet aggregation and promote circulation? Administer clopidogrel. Administer cilostazal. Administer atorvastatin. Administer oxycodone.

Administer clopidogrel. Pharmacologic therapy for clients with PAD and claudication include pentoxifylline and cilostazal because these medications increase erythrocyte flexibility and decrease blood fibrinogen concentrations. Aspirin and clopidogrel are antiplatelet agents that prevent the formulation of emboli by reducing platelet aggregation. Statins are used to improve endothelial function. Therefore, clopidogrel should be administered because it is an antiplatelet agent that prevents the formulation of emboli by reducing platelet aggregation.

A client receiving intravenous heparin has developed hematuria and petechiae. What is the nurse's best action?

Administer protamine sulfate. Heparin is a pharmacotherapeutic agent for those with disorders such as coronary artery disease and other ischemic coronary events, atrial fibrillation, heart valve diseases, stroke, pulmonary embolism, and deep venous thrombosis. But there is a potential for many side effects with the use of this drug. Thrombocytopenia and bleeding events are the most common drug-related problems associated with heparin. Protamine sulfate is the heparin antidote. The administration of any of the other drugs will not aid in coagulation and resolve the bleeding.

A client is receiving morphine sulfate by a patient-controlled analgesia (PCA) system after a left lower lobectomy 4 hours ago. The client reports moderately severe pain in the left thorax that worsens when coughing. What should the nurse do first? Reassure the client that the PCA system is working and will relieve pain. Request a prescription for a cough suppressant Assess the pain using a pain scale and compare to the previous assessment. Encourage the client to take deep breaths and expectorate the mucous that is stimulating the cough.

Assess the pain using a pain scale and compare to the previous assessment. Beginning immediately following surgery, the nurse should assess the client for pain frequently and note changes on the pain scale as a guide to pain management. Reassuring the client is not sufficient when the client is reporting pain. The nurse should encourage the client to cough and take deep breaths; cough suppression is contraindicated because the client must raise and expectorate retained secretions.

A typically developing preschool child is experiencing pain after an appendectomy. Which data collection tool is the most appropriate for the nurse use to assess the pain? visual analog scale FLACC scale numerical pain scale FACES Pain Rating Scale

FACES Pain Rating Scale The nurse should use the FACES pain rating scale for children age 3 or older. The visual analog and numerical scales are used preferred with adults or older children who count well. The faces, legs, activity, cry, consolability (FLACC) scale is a behavioral scale that is appropriate for very small children or nonverbal children.

The client is admitted for a myocardial infarction and has a heparin drip infusing. Which signs and symptoms would prompt the nurse to stop the infusion and notify the prescribing health care provider? Report of upset stomach and nausea Unrelieved chest pain Pain and stiffness to left shoulder New onset bleeding from client's rectum

New onset bleeding from client's rectum Heparin is a medication used to help prevent blood clots, and can be used in the treatment of myocardial infarction to prevent more blood clots. When a client is receiving a heparin infusion, the nurse must be alert to signs and symptoms of bleeding, as the heparin may need to be discontinued. New onset of rectal bleeding would indicate that the nurse should stop the heparin infusion and notify the provider immediately. Unrelieved chest pain, upset stomach and nausea, and left shoulder pain/stiffness are common symptoms during a myocardial infarction, and may necessitate the nurse notify the attending health care provider, but would not be indications for stopping the heparin drip.

The family of a deceased client has yet to make funeral arrangements. What should the nurse expect to be done with the body? Prepare it for storage in the facility's morgue refrigerator. Permit it to remain in the assigned facility bed. Transport it to an offsite facility for storage. Send it to a local mortician for the family to claim.

Prepare it for storage in the facility's morgue refrigerator. The client's body may be placed in the hospital's morgue refrigerator if mortuary arrangements are not made before the client's death. The body is not transported to an offsite faculty for storage. It cannot stay in the assigned facility bed until funeral arrangements are made. It should not be sent anywhere offsite until arrangements are made.

What is the highest nursing priority in the plan of care for a client with peripheral vascular problems? Provide a self-care program for the client and family. Relieve pain caused by decreased circulation. Monitor skin integrity. Promote arterial and venous circulation.

Promote arterial and venous circulation. Maslow's hierarchy defines priorities with physiological needs as the highest priority. In the case of a client with peripheral vascular disease, the highest priority would be tissue perfusion. Once this is established, the nurse can address the problems of pain and skin integrity. It is also important to educate the client and provide a self-care program. However, the client's physiological needs must be met first.

The nurse plans to place graduated compression stockings on a client in the preoperative setting. List in order the steps the nurse will follow. All options must be used.

Review medical record and medical orders for graduated compression stockings. Identify the client and explain procedure. Place the client in supine position. Apply powder or lotion to legs. Turn the stocking inside out and ease the stocking over the foot and heel. Smoothly pull the stocking over the ankle and calf. When applying graduated compression stockings, the nurse should first review the medical record and verify the medical order for application. The nurse should then identify the client and explain the procedure to alleviate anxiety and prepare the client for what to expect. The nurse then places the client in a supine position to reduce congestion of blood in vessels. The nurse then applies powder or lotion to the legs to reduce friction and ease the application. Next, the nurse turns the stocking inside out as this technique provides for easier application and with the heel pocket down, eases the stocking over the foot and heel. The nurse then smoothly pulls the stocking up over the heal and calf, making sure there are no wrinkles, as wrinkles may compromise circulation.

A nurse is taking an admission history, including a medication list, from a client. The listing of which herbal medication would prompt the nurse to ask the client more questions regarding any history of depressive symptoms? ginkgo biloba echinacea St. John's wort ephedra

St. John's wort St. John's wort has been found to have serotonin-elevating properties, similar to prescription antidepressants and is sometimes used to treat depression. The nurse, however, should keep in mind that close monitoring may be necessary. Ginkgo biloba is used to enhance mental acuity. Echinacea has immune-stimulating properties. Ephedra is a naturally occurring stimulant that is similar to ephedrine. The U.S. Food and Drug Administration and the Canadian Food and Drug Act and Regulations prohibit the sale of products containing ephedra.

A child has chickenpox. The parent asks how to care for the lesions. What should the nurse tell the parent? Soak in a hot tub for 30 minutes three times a day. Take an antihistamine, and use calamine lotion on the closed lesions. Take acetaminophen, and use an antibiotic ointment on the lesions. Remove lesions' crusts as they form.

Take an antihistamine, and use calamine lotion on the closed lesions. Use of an antihistamine and calamine lotion are recommended to help decrease the itching.The child can have a bath in cool water, but soaking in a hot tub will dry out the skin. Use of oatmeal baths helps decrease itching.Acetaminophen should be used only if the child has a fever. Antibiotic ointment may be used if lesions are infected.The father should only remove loose crusts that rub and irritate the child.

The nurse has completed instilling fluid with a bladder irrigation and does not have a return of the fluid into the catheter bag. What is the next action the nurse should do?

The simplest method to ensure drainage of the catheter is to check the tubing for kinks in the tubing that would affect drainage. After this, palpating the bladder for distention, notifying the healthcare provider, and changing the urinary catheter would be the next steps in troubleshooting this situation.

An older adult with a hip fracture is to use an alternating air pressure mattress at home to prevent pressure ulcers while recovering from surgery. The nurse is showing the client's family how to place the mattress (see below). What should the nurse instruct the family to do? An older adult with a hip fracture is to use an alternating air pressure mattress at home to prevent pressure ulcers while recovering from surgery. The nurse is showing the client's family how to place the mattress (see below). What should the nurse instruct the family to do? Turn the mattress over so the air cells face the mattress of the bed, and cover the mattress with a bed sheet. Put a thick pad over the pressure mattress to prevent soiling, and place the bed sheet on top of the pad. Make the bed with the bedsheet on top of the pressure mattress. Place the sheet on the bed, and then remove the pillow to allow full use of the mattress on the neck.

Turn the mattress over so the air cells face the mattress of the bed, and cover the mattress with a bed sheet. Put a thick pad over the pressure mattress to prevent soiling, and place the bed sheet on top of the pad. Make the bed with the bedsheet on top of the pressure mattress. Place the sheet on the bed, and then remove the pillow to allow full use of the mattress on the neck. To obtain best results, one sheet should be used to cover the mattress. The air cells should be facing up as shown. Thick pads should not be used; if the client is incontinent, a "breathable" incontinent pad can be added. The client can use a pillow as needed.

One day after cataract surgery, the client is having discomfort from bright light. What should the nurse advise the client to do? Dim lights in the house and stay inside for one week. Attach sun shields to existing eyeglasses when in direct sunlight. Use sunglasses that wrap around the side of the face when in bright light. Patch the affected eye when in bright light.

Use sunglasses that wrap around the side of the face when in bright light To prevent discomfort from bright light the client should wear sunglasses that cover the front and side of the face, thus minimizing light that comes into the eye from any direction. It is not necessary to remain in dim light or inside. Attaching sun shields or sunglasses to existing glasses will not cover the eye sufficiently, and bright light will come in on the side of the face. It is not necessary to patch the affected eye.

A client with Addison's disease has fluid and electrolyte loss due to inadequate fluid intake and to fluid loss secondary to inadequate adrenal hormone secretion. As the client's oral intake increases, which fluids would be most appropriate? coffee and milkshakes chicken broth and juice milk and diet soda water and eggnog

chicken broth and juice

During a prenatal visit, a pregnant client with cardiac disease and slight functional limitations reports increased fatigue. To help combat this problem, the nurse should advise the client to: eat three well-balanced meals per day. exercise 1 hour before each meal. take a vitamin and mineral supplement. divide daily food intake into five or six meals.

divide daily food intake into five or six meals. To combat fatigue, the nurse should advise the client to divide her daily food intake into five or six meals eaten throughout the day to minimize the energy expenditure associated with consuming three larger meals. Exercising before meals would increase fatigue, interfering with the client's nutritional intake. Vitamin and mineral supplements are appropriate for anyone, not specifically pregnant clients, and have little effect on fatigue.

The nurse is planning the care for a client with risk factors for atherosclerosis. What should the nurse include in the teaching plan for this client as modifiable risk factors? Select all that apply.

e-cigarette use hypertension stress

A child with cystic fibrosis has been admitted to the pediatric unit. What type of diet should the nurse request for the client?

high-calorie, high-protein high-calorie, high-protein diet is necessary to ensure adequate growth. Some children require up to two times the recommended daily allowance of calories (increased calorie diet includes foods high in fat and balanced carbohydrates). Pancreatic enzyme activity is lost and malabsorption of fats, proteins, and carbohydrates occurs.

A pediatric client is given morphine for postoperative pain following a fracture repair. As the nurse is assessing the client for pain 4 hours later, his parent leaves the room, and the child begins to cry. What assessment does the nurse make about the child's pain? not in pain, because he was medicated 4 hours ago less tolerant of pain because he is upset in pain because he is crying not in pain because the crying began after the parent leaves

less tolerant of pain because he is upset

The client sustained a tibia fracture and a cast was applied. The client is reporting increasing pain when flexing toes. Which symptoms does the nurse assess as associated with compartment syndrome? Select all that apply. petechiae paresthesia pulselessness palpitations pain

paresthesia pain pulselessness The symptoms associated with compartment syndrome include pain, pallor, paresthesia, pulselessness, and paralysis. Palpitations and petechiae are not included in these symptoms.

The nurse teaches a pregnant client about the need to take supplemental vitamins with iron during her pregnancy. The nurse should instruct the client to take the iron with which liquid to promote maximum absorption? milk tea hot chocolate orange juice

orange juice Absorption of supplemental iron and nonmeat sources of iron is enhanced by combining them with meat or a good source of vitamin C. An acidic environment enhances iron absorption. Therefore, taking the iron on an empty stomach or with orange juice would be most effective. If gastrointestinal upset occurs, the client may take the drug with meals. However, doing so reduces iron absorption by 40% to 50%.Because milk interferes with the absorption of iron, the client should avoid taking the iron with milk.Tea has been shown to interfere with the absorption of iron. Therefore, the client should avoid taking the iron with tea.Hot chocolate, a milk product, interferes with iron absorption. Thus, the client should avoid taking the iron with hot chocolate.