Comp 4

pyogenic

producing pus

first stage of labor

1-1.5 cm (onset of labor)

A nurse is developing a care plan for bone marrow suppression, the major dose-limiting adverse reaction to floxuridine (FUDR). How long after drug administration does bone marrow suppression become noticeable?

7 to 14 days Explanation: Bone marrow suppression becomes noticeable 7 to 14 days after floxuridine administration. Bone marrow recovery occurs in 21 to 28 days.

The nurse understands that the client with severe dementia and motor apraxia may be able to perform which action? Balance a checkbook accurately. Brush the teeth when handed a toothbrush. Use confabulation when telling a story. Find misplaced car keys.

Brush the teeth when handed a toothbrush. Explanation: Highly conditioned motor skills, such as brushing teeth, may be retained by the client who has dementia and motor apraxia. Balancing a checkbook involves calculations, a complex skill that is lost with severe dementia. Confabulation is fabrication of details to fill a memory gap. This is more common when the client is aware of a memory problem, not when dementia is severe. Finding keys is a memory factor, not a motor function.

Which finding in a client diagnosed with asthma would require a nurse to take immediate action? Lethargy Diaphoresis Anhidrosis Cough

Lethargy Explanation: Lethargy can be a manifestation of status asthmaticus. Anhidrosis, cough, and diaphoresis should be further assessed.

Multiple Myeloma (MM)

Malignant proliferation of plasma cells Infiltrate bone marrow and aggregate into tumor masses in skeletal system

Latent stage of labor

Phase of 1st stage of labor with 0-4 cm dilated - mother talkative, cheerful, anxious

rheumatoid arthritis

a chronic autoimmune disorder in which the joints and some organs of other body systems are attacked

status asthmaticus

a severe, life-threatening asthma attack that is refractory to usual treatment and places the patient at risk for developing respiratory failure.

A nurse is evaluating a child with acute poststreptococcal glomerulonephritis (APSGN) for signs of improvement. Which finding typically is the earliest sign of improvement? decreased hematuria increased appetite increased energy level decreased diarrhea

decreased hematuria Explanation: Decreased hematuria, a sign of improving kidney function, typically is the first sign that a child with APSGN is improving. Increased appetite, an increased energy level, and decreased diarrhea aren't specific to APSGN.

third stage of labor

delivery of placenta

A primigravid client in early labor with abruptio placentae develops disseminated intravascular coagulation (DIC). Which agent should the nurse expect the health care provider (HCP) to prescribe? magnesium sulfate warfarin sodium fresh-frozen platelets meperidine hydrochloride

fresh-frozen platelets Explanation: To stop the process of DIC, the underlying insult that began the phenomenon must be halted. Treatment includes fresh-frozen platelets or blood administration. The HCP also may prescribe heparin before the administration of blood products to restore the normal clotting mechanism. Immediate birth of the fetus is essential. Magnesium sulfate is given for pregnancy-induced hypertension or preterm labor. Heparin, not warfarin sodium, is used to treat DIC. Meperidine hydrochloride is used for pain relief.

Which of the following is a normal response from an adolescent who has just returned to her room after an open appendectomy? "I will need plastic surgery for this scar." "I am worried about the size of my scar." "I do not want to have any pain." "What will my boyfriend say about the scar?"

"I am worried about the size of my scar." Explanation: Adolescents are concerned about the immediate state and functioning of their bodies. The adolescent needs to know whether any changes (e.g., illness, trauma, surgery) will alter her lifestyle or interfere with her quest for physical perfection. Having a scar may be devastating to the adolescent. The need for plastic surgery cannot be determined at this point. The adolescent has just returned from surgery and has yet to see the scar. Healing has yet to occur. Typically scars become smaller and fade over time. The desire for no pain is unrealistic. Although adolescents are worried about pain and how they will respond, they typically are discharged within 24 hours after an appendectomy with pain well controlled by oral analgesics. The immediate concern of adolescents is the state and functioning of their bodies. After concerns about themselves, then adolescents are concerned about their peer group and their responses. Although the boyfriend's response will matter, this concern would be more common later in the course of the adolescent's recovery.

second stage of labor

the middle stage of labor, in which the infant descends through the vaginal canal; begins when cervix dilated 10 cm

A nurse is preparing to administer a unit of blood to a client with anemia. After its removal from the refrigerator, the blood should be administered within: 1 hour. 2 hours. 4 hours. 6 hours.

4 hours. Explanation: Refrigeration delays the growth of bacteria in the blood. After the blood is removed from the refrigerator, it must be administered within 4 hours. If the blood is administered too rapidly, within 1 or 2 hours, the client could experience fluid overload. Six hours is too long because the extended time out of refrigeration increases the risk of contamination and growth of bacteria.

A primiparous client who underwent a cesarean birth 30 minutes ago is to receive Rho(D) immune globulin. The nurse should administer the medication within which time frame after birth? 12 hours 24 hours 72 hours 48 hour

72 hours Explanation: For maximum effectiveness, Rho(D) immune globulin should be administered within 72 hours postpartum. Most Rh-negative clients also receive Rho(D) immune globulin during the prenatal period at 28 weeks' gestation and then again after birth. The drug is given to Rh-negative mothers who have a negative Coombs test and give birth to Rh-positive neonates. If there is doubt about the fetus's blood type after pregnancy is terminated, the mother should receive the medication.

Which situation violates the a client's privacy? When planning a client's discharge care, medical students discuss his home situation. A nurse allows a nursing student to review a client's chart the day before the student will be working on the unit. A nurse gives a client's family members details of his condition from his medical records A nurse gives a client his chart and stays with him while he reads the new orders.

A nurse gives a client's family members details of his condition from his medical records Explanation: A nurse may not give information about a client to anyone without that client's consent. Nursing students and medical students may review client charts for the purpose of instruction and learning. The client has the right to see his chart. By remaining with the client while he reviews his chart, the nurse can explain notations that are confusing or unclear.

A client received haloperidol 12 hours previously. The client develops an oculogyric crisis and tongue protrusion. Which of the following is a nursing priority intervention? Administering diphenhydramine as ordered Administering midazolam as ordered Administering chlorpromazine as ordered Administering diazepam as ordered

Administering diphenhydramine as ordered Explanation: The client is experiencing a dystonic reaction to the administration of haloperidol that needs to be reversed by diphenhydramine. Chlorpromazine also causes this type of reaction and would not be indicated for use in this client. Midazolam and diazepam would cause drowsiness but do not have the properties to reverse the dystonic state.

A client is taking clozapine and complains of a sore throat. This symptom may be an indication of which adverse reaction? Extrapyramidal reaction Tardive dyskinesia Reye's syndrome Agranulocytosis

Agranulocytosis Explanation: The complaint of a sore throat may indicate an infection caused by agranulocytosis, a depletion of white blood cells. Although extrapyramidal reaction and tardive dyskinesia may occur, a sore throat isn't an indication of these conditions. Reye's syndrome is caused by a virus unrelated to clozapine.

A nurse is caring for a 3-year-old child admitted to the pediatric unit with acetaminophen poisoning. The nurse administers acetylcysteine every 4 hours for 72 hours. Which laboratory findings confirm the effectiveness of the drug therapy? Alanine aminotransferase and aspartate aminotransferase Creatine kinase-MB Blood urea nitrogen and serum creatinine Complete blood count

Alanine aminotransferase and aspartate aminotransferase Explanation: Acetaminophen poisoning causes liver damage, raising the liver enzymes alanine aminotransferase and aspartate aminotransferase. Creatine kinase-MB levels are elevated with heart muscle damage and aren't associated with acetaminophen poisoning. Blood urea nitrogen and serum creatinine levels provide information on renal function and aren't indicators of effectiveness of drug therapy in acetaminophen poisoning. A complete blood count won't give the nurse information on the effectiveness of therapy.

A nurse in the infection prevention and control program is conducting an assessment of infection control practices. The nurse is evaluating the infection control actions taken on the unit for a client with a decreased white blood cell count. Which of the following infection control practices does the nurse consider most important for this client? Diligent adherence to aseptic technique Using antimicrobial soap when providing care Requesting prophylactic antibiotic treatment Implementing respiratory isolation procedures

Diligent adherence to aseptic technique Explanation: The client in this scenario is neutropenic, which places the client at risk for contracting an infection. All measures of aseptic technique must be used to protect the client. The other options do not provide complete protection for the client.

A client is admitted to the hospital with signs and symptoms of diabetes mellitus. Which of the following findings is the nurse most likely to observe in this client? Select all that apply. Excessive thirst Weight gain Edema Excessive hunger Insomnia Frequent, high-volume urination

Excessive thirst Excessive hunger Frequent, high-volume urination Explanation: Classic signs of diabetes mellitus include polydipsia (excessive thirst), polyphagia (excessive hunger), and polyuria (excessive urination). Because the body is starving from the lack of glucose that the cells are using for energy, the client has weight loss, not weight gain. Clients usually do not present with insomnia, however, clients can report fatigue. Fluid retention and edema are not associated with diabetes mellitus.

A client with colorectal cancer has been presented with her treatment options but wishes to defer any decisions to her uncle, who acts in the role of a family patriarch within the client's culture. By which of the following is the client's right to self-determination best protected? Respecting the client's desire to have the uncle make choices on her behalf. Revisiting the decision when the uncle is not present at the bedside. Teaching the client about her right to autonomy. Holding a family meeting and encouraging the client to speak on her own behalf.

Respecting the client's desire to have the uncle make choices on her behalf. Explanation: The right to self-determination (autonomy) means that decision-making should never be forced on anyone. The client has the autonomous right to defer her decision making to another individual if she freely chooses to do so.

A nurse is caring for an Asian-American client after arthroplasty. The nurse plans to help the client ambulate, but is aware that the client may feel threatened by physical closeness. What would be the most appropriate nursing action? Let the client ambulate slowly on his own when he is stable. Explain the purpose and need for assistance during ambulation. Instruct family members to ambulate the client. Ambulate the client without answering his questions.

Explain the purpose and need for assistance during ambulation. Explanation: The nurse should explain the purpose of ambulation, and the need for assistance while ambulating, to the client. This would relieve his anxiety associated with physical closeness. However, the client won't be able to ambulate without assistance. Even though the nurse can instruct a family member to ambulate the client, this is not an appropriate action. Ambulating the client without answering the client's question is non-therapeutic, as the nurse would be performing a procedure without giving adequate explanation.

The nurse is assessing a client who has a chest tube connected to a water-seal chest tube drainage system. According to the illustration shown, what should the nurse do? Clamp the chest tube near the insertion site to prevent air from entering the pleural cavity. Notify the health care provider (HCP) of the amount of chest tube drainage. Add water to maintain the water seal. Lower the drainage system to maintain gravity flow.

Lower the drainage system to maintain gravity flow. Explanation: To promote chest tube drainage, the drainage system must be lower than the client's lungs. The amount of drainage is not abnormal; it is not necessary to notify the HCP. The nurse should chart the amount and color of drainage every 4 to 8 hours. The chest tube does not need to be clamped; the tubing connection is intact. There is sufficient water to maintain a water seal.

A neonate is born 8 weeks premature. At birth, the neonate has no spontaneous respirations, but is successfully resuscitated. Within several hours the neonate develops respiratory grunting, cyanosis, tachypnea, nasal flaring, and retractions. The neonate is diagnosed with respiratory distress syndrome, intubated, and placed on a ventilator. Which nursing action should be included in the neonate's care plan to prevent retinopathy of prematurity? Cover the neonate's eyes while receiving oxygen. Keep the neonate's body temperature low. Monitor partial pressure of oxygen (PaO2) levels. Humidify the oxygen.

Monitor partial pressure of oxygen (PaO2) levels. Explanation: Monitoring PaO2 levels and reducing the oxygen concentration to keep PaO2 within normal limits reduces the risk of retinopathy of prematurity in a premature neonate receiving oxygen. Covering the neonate's eyes and humidifying the oxygen do not reduce the risk of retinopathy of prematurity. Because cooling increases the risk of acidosis, the neonate should be kept warm so that respiratory distress is not aggravated.

A group of nursing assistants hired for the medical-surgical floors are attending hospital orientation. Which topic should the educator cover when teaching the group about caring for clients with diabetes mellitus? Obtaining, reporting, and documenting fingerstick glucose levels Treating hypoglycemia Teaching the client dietary changes necessary with diabetes mellitus Assessing the client experiencing a hypoglycemic reaction

Obtaining, reporting, and documenting fingerstick glucose levels Explanation: The educator should teach the nursing assistants how to obtain and document a fingerstick glucose level. She should also teach them normal and abnormal results and the importance of reporting them to the registered nurse caring for the client. Treating hypoglycemia, teaching clients about dietary changes, and assessing clients experiencing hypoglycemic reactions are outside the scope of practice for a nursing assistant. They are the responsibility of the registered nurse.

A nurse is developing a care plan for a client with disseminated intravascular coagulation (DIC). Which nursing intervention should the nurse include? Administer aspirin daily as ordered. Provide mouth care every 4 hours with lemon-glycerin swabs. Administer meperidine (Demerol) I.M. as needed for pain. Place a pressure-reducing mattress on the client's bed.

Place a pressure-reducing mattress on the client's bed. Explanation: A client with DIC is at risk for Impaired skin integrity related to bleeding or ischemia. The nurse should place the client on a pressure-reducing mattress and perform skin care every 2 hours. The nurse should avoid administering any medication that decreases platelet function, such as aspirin. The nurse should perform mouth care using sponge swabs and baking soda solution, not lemon-glycerin swabs, because lemon-glycerin swabs can dry the oral mucosa, which may lead to bleeding. I.M. injections should be avoided in clients with DIC because of the potential for bleeding.

Myesthania Gravis

Myasthenia gravis is a chronic autoimmune neuromuscular disease that causes weakness in the skeletal muscles, which are responsible for breathing and moving parts of the body, including the arms and legs. The name myasthenia gravis, which is Latin and Greek in origin, means "grave, or serious, muscle weakness."

A client who is receiving chemotherapy develops stomatitis. What should the nurse instruct the client to do? Rinse the mouth with full-strength hydrogen peroxide every 4 hours. Use a soft-bristled toothbrush after each meal. Drink hot tea with honey to soothe the painful oral mucosa. Avoid using dental floss until the stomatitis is resolved.

Use a soft-bristled toothbrush after each meal. Explanation: Stomatitis is an inflammation of the mucous membranes of the mouth resulting from chemotherapy. Using a soft-bristled toothbrush prevents further bleeding and irritation to the already irritated gums and mucous membranes. Hydrogen peroxide can further irritate the mouth. Fluids need to be lukewarm instead of hot; dental floss can be used if it is done gently.

A client in surgery has an endotracheal tube (ET) in place. The nurse should call a time-out if which requirements are not in place? Select all that apply. an identification band postoperative pain medication an IV line oxygen administration an anesthetist/anesthesiologist

an identification band an IV line oxygen administration an anesthetist/anesthesiologist Explanation: The nurse is responsible for the client's safety in the operating room. The nurse should call a time-out if the client is not properly identified with an identification band. In addition, an IV line and oxygen should always be established when an ET tube is placed. This practice applies whenever a client's airway is compromised enough for intubation to occur, not only in the operating room environment. An anesthetist or anesthesiologist should be present during surgery to manage the airway. Postoperative pain medication is administered in the recovery room.

A neonate receives an Apgar score at 1 and 5 minutes of age. The 1-minute Apgar score is a good indication of: how well the neonate tolerated labor. how well the neonate has adapted to extrauterine life. how well the neonate stabilizes his temperature after birth. gestational age of the neonate.

how well the neonate tolerated labor. Explanation: Apgar scores, given at 1 and at 5 minutes after birth, indicate how well the neonate tolerated labor and how well he made the transition to extrauterine life. These scores also provide the foundation for additional nursing interventions, if needed. Apgar scores aren't used to determine the gestational age of the neonate.

compartment syndrome

involves the compression of nerves and blood vessels due to swelling within the enclosed space created by the fascia that separates groups of muscles

A client found sitting on the floor of the bathroom in the day treatment clinic has moderate lacerations on both wrists. Surrounded by broken glass, she sits staring blankly at the lacerations. What is the most important action for the nurse to take next to the client? Enter the room quietly and move next to the client to assess her injuries. Call for staff back-up before entering the room and restraining the client. Sit quietly next to her. Approach the client slowly while speaking in a calm voice, calling her by her name, and telling her that the nurse is there to help her.

Approach the client slowly while speaking in a calm voice, calling her by her name, and telling her that the nurse is there to help her. Explanation: Ensuring the safety of the client and the nurse is the priority at this time. Therefore, the nurse should approach the client cautiously while calling her name and talking to her in a calm, confident manner. The nurse should keep in mind that the client shouldn't be startled or overwhelmed. After explaining that she is there to help, the nurse should carefully observe the client's response. If the client shows signs of agitation or confusion or poses a threat, the nurse should retreat and request assistance. The nurse shouldn't attempt to sit next to the client or examine her injuries without first announcing her presence and assessing the dangers of the situation.

A nursing assessment for a client with alcohol abuse reveals a disheveled appearance and a foul body odor. What is the best initial nursing plan that would assist the client's involvement in personal care? Devising a bathing and dressing schedule for each morning Drawing up a schedule and making certain that it is adhered to Bathing and dressing the client each morning until the client is willing to perform self-care independently Assisting the client with bathing and dressing by giving clear, simple directions

Assisting the client with bathing and dressing by giving clear, simple directions Explanation: This action would provide a disorganized client with the necessary structure to encourage participation and support of self-image. The other answers are incorrect because they do not support nurse promotion of client health. The client is not confused and does not require a schedule; however, the client does need some assistance. Full assistance is not required.

When cleaning the skin around an incision and drain site, what should the nurse do? Clean the incision and drain site separately. Clean from the incision to the drain site. Clean from the drain site to the incision. Clean the incision and drain site simultaneously.

Clean the incision and drain site separately. Explanation: When cleaning the skin around an incision and drain, the nurse should clean the incision and drain separately to avoid contaminating either wound. This is applying the principle of working from the least contaminated area to the most contaminated area. In this case, both areas are fresh wounds and should be kept separate.

A neonate is 4 hours of age. Nursing assessment reveals a heart murmur. What should the nurse do? Call the health care provider (HCP) immediately. Continue routine care. Feed the neonate. Further assess for signs of distress.

Further assess for signs of distress. Further assessment for signs of distress is necessary. At 4 hours of age a transient murmur may be heard as the fetal shunts are closing. This is a normal finding. If no other distress is noted, the HCP does not need to be called. Result can be noted on the medical record. Further assessment is needed to know if continuing routine care and feeding are appropriate and safe for the neonate.

A physician has referred a client newly diagnosed with diabetes mellitus to the diabetes nurse-educator. When the nurse brings up the subject, the client states, "I'd rather work with you than with a stranger." What is the nurse's best response? "A diabetes nurse-educator has much more knowledge than I do." "You don't have to worry. Our nurse-educator is really good with clients newly diagnosed with diabetes." "I'll set up a meeting for today. Then you and I can meet to talk about how things went." "Most clients feel this way at first, but you'll soon get over it."

I'll set up a meeting for today. Then you and I can meet to talk about how things went." Explanation: The client may feel overwhelmed and anxious about his diagnosis. He's made a therapeutic connection with the nurse at a vulnerable time in his life when he must address many new issues. Offering to follow up with the client encourages him to move forward and gives him an opportunity to meet with a safe and trusted person afterward. Telling the client that the nurse-educator is more knowledgeable about the subject doesn't help address the client's feelings. Telling the client not to worry or that he'll get over his feelings minimizes the client's feelings and may impair the nurse-client relationship.

A child is receiving amoxicillin for otitis media. Which action should the nurse recommend the mother do when the child develops diarrhea? Begin clear fluids. Withhold food and fluids for 2 hours. Offer yogurt several times a day. Restrict the intake of pizza.

Offer yogurt several times a day. Explanation: Diarrhea is a common adverse effect of amoxicillin because the drug kills normal intestinal bacteria. Yogurt with live cultures helps restore the normal intestinal flora. Restricting the child to clear fluids will not help stop the diarrhea or recolonize the intestine. Withholding food and fluids for 2 hours is suggested when a child vomits. Pizza tends to be spicy and aggravates the diarrhea, but restricting its intake will not help the underlying problem.

An infant is diagnosed with a congenital hip dislocation. On assessment, the nurse expects to note: symmetrical thigh and gluteal folds. Ortolani's sign. increased hip abduction. femoral lengthening.

Ortolani's sign. Explanation: In a child with a congenital hip dislocation, assessment typically reveals Ortolani's sign, asymmetrical thigh and gluteal folds, limited hip abduction, femoral shortening, and Trendelenburg's sign.

Why should the nurse avoid palpating both carotid arteries at one time? The nurse can't assess the pulse accurately unless she palpates the arteries one at a time. Palpating both arteries at one time may cause transient hypertension. Palpating both arteries at one time may cause severe bradycardia. Palpating both arteries at one time may cause severe tachycardia.

Palpating both arteries at one time may cause severe bradycardia. Explanation: The nurse must palpate the carotid arteries one at a time to prevent severe bradycardia and impairment of cerebral circulation. The nurse must also remember to avoid massaging the carotid sinus, located at the bifurcation of the carotid arteries; the resulting bradycardia could lead to cardiac arrest.

active stage of labor

Phase of 1st stage of labor with 5-7 cm dilated and strong contractions every 3-5 minutes

The nurse is caring for a newborn with unrepaired transposition of the great vessels. Which medication should the nurse anticipate giving first for treatment of this defect? Digoxin Furosemide Enalapril Prostaglandin E1

Prostaglandin E1 Explanation: Prostaglandin E1 is necessary to maintain patency of the patent ductus arteriosus, and improve systemic arterial flow in children with inadequate intracardiac mixing. Digoxin, furosemide, and enalapril will treat heart failure when present.

Bleeding Precautions (RANDI)

R - razor (electric) A - aspirin (NO!) N - needles (small gauge) D - decrease needle sticks I - injury (protect from)

RA vs OA

RA is systemic, symmetrical and affects many joints (often hands) with phases of remission and exacerbation. Symptoms include fatigue, weight loss, swelling, deformities. OA caused by wear and tear and often for large weight bearing joints. RA is an autoimmune disorder, which means your body attacks itself. If you have RA, your body interprets the soft lining around your joints as a threat, similar to a virus or bacteria, and attacks it. This attack causes fluid to accumulate within your joint. In addition to swelling, this fluid buildup also causes: pain stiffness inflammation around your joints OA, the most common form of arthritis, is a degenerative joint disorder. People with OA experience a breakdown of the cartilage that cushions their joints. The wearing down of cartilage causes the bones to rub against each other. This exposes small nerves, causing pain. OA doesn't involve an autoimmune process like RA does, but mild inflammation also occurs.

Positive end-expiratory pressure (PEEP) therapy has which effect on the heart? Bradycardia Tachycardia Increased blood pressure Reduced cardiac output

Reduced cardiac output Explanation: PEEP reduces cardiac output by increasing intrathoracic pressure and reducing the amount of blood delivered to the left side of the heart. It doesn't affect heart rate, but a decrease in cardiac output may reduce blood pressure, commonly causing compensatory tachycardia, not bradycardia. However, the resulting tachycardia isn't a direct effect of PEEP therapy itself.

A 10-year-old child must undergo a surgical procedure. What is the child's involvement in the consent process? The child does not need to know about the procedure because the child is a minor. The child must sign the form giving written informed consent. The child must be informed of the procedure and concur with his parent, who is giving written consent. The child only needs to know if the procedure is part of a research protocol.

The child must be informed of the procedure and concur with his parent, who is giving written consent. Explanation: Assent, not consent, must be obtained from any child who is in the concrete operations thought stage of development (usually a child older than age 7). Assent involves knowledge of the procedure and agreement with the person authorized to give written informed consent. A child should always be notified of the treatment plan but is too young to authorize consent. Careful ethical consideration should be given when using any person younger than age 18 in a research protocol.

A nurse administers medications to the wrong client in a hospital. The client has an anaphylactic reaction to one of the medications and expires. What legal actions against the nurse can the family pursue? Select all that apply. There are no legal consequences with the common error. The family can open a legal claim for malpractice against the nurse. The family can open a legal claim for malpractice against the hospital. The family can seek a fair settlement outside the courtroom. The nurse can resign from the hospital and no further legal action will occur.

The family can open a legal claim for malpractice against the nurse. The family can open a legal claim for malpractice against the hospital. The family can seek a fair settlement outside the courtroom. Explanation: The family can open a legal claim for malpractice with the nurse and with the hospital. The family can seek a settlement outside the courtroom. There are legal consequences with a sentinel event. Medication safety errors are not common. The nurse can resign from the hospital but further legal action can be pursued against the nurse.

A health care provider has placed a stat order for a urine specimen for culture and sensitivity stat. What is the best way for the nurse to delegate this task to an unlicensed assistive personnel? We need a stat urine culture on the client in room 101. Please get the urine for culture for the client in room 101. A stat urine has been ordered for the client in room 101. Would you get it? We need to collect urine from the client in room 101 for a stat culture. Please tell me when you send it to the lab.

We need to collect urine from the client in room 101 for a stat culture. Please tell me when you send it to the lab. Explanation: This option not only delegates the task but also provides a checkpoint. To effectively delegate, you need to follow up on what someone else is doing. The other options don't provide for feedback, which is essential for communication and delegation.

anhidrosis

absence of sweating

A nurse is making assignments for the infant unit. The shift's team members include a licensed practical nurse (LPN) with 10 years of experience, a registered nurse (RN) with 3 months of experience, and a client care assistant. Which assignment is most appropriate for the LPN? an infant being discharged to home following placement of a gastrostomy tube an infant just returned from the postanesthesia care unit who requires hourly assessment of vital signs an infant requiring abdominal dressing changes for a wound infection an infant with agonal respirations who is receiving palliative care

an infant requiring abdominal dressing changes for a wound infection Explanation: The infant requiring dressing changes is within an LPN's scope of practice. This care has a predictable outcome. Client and family teaching — such as how to care for a gastrostomy tube — is an RN's responsibility. A client care assistant can be assigned to obtain vital signs and report the findings to the supervising RN. Because the outcome of the infant with agonal respirations is unpredictable, the RN shouldn't delegate this client's care to the LPN.

The nurse is assessing a client who had an episode of autonomic dysreflexia. The nurse should first assess the client for: bowel distention. bladder distention. anxiety. rising intracranial pressure.

bladder distention. Explanation: The dysreflexia occurs from a sympathetic response to autonomic nervous system stimulation. A distended bladder is the most common cause. After placing the client in Fowler's position, the nurse should check the urinary catheter for patency. Bowel distention may also trigger the syndrome. However, the most common cause of autonomic dysreflexia is bladder distention, so the nurse should assess for this first. Anxiety and increased intracranial pressure do not cause autonomic dysreflexia.

A nurse observes that decerebrate posturing is a comatose client's response to painful stimuli. Decerebrate posturing as a response to pain indicates: dysfunction in the cerebrum. risk for increased intracranial pressure. dysfunction in the brain stem. dysfunction in the spinal column.

dysfunction in the brain stem. Explanation: Decerebrate posturing indicates damage of the upper brain stem. Decorticate posturing indicates cerebral dysfunction. Increased intracranial pressure is a cause of decortication and decerebration. Alterations in sensation or paralysis indicate dysfunction in the spinal column.

A client tells the nurse, "Everybody smiles at me because they know that I was chosen by God for this mission." The nurse interprets this statement as which finding? idea of reference thought insertion visual hallucination neologism

idea of reference Explanation: An idea of reference is a person's view that other people recognize that she has an important characteristic or power. Thought insertion refers to a person's belief that others, or a specific other, can put thoughts into her mind. Visual hallucinations involve seeing objects or persons not based on reality. A neologism is a word or phrase that has meaning only to the person using it.

A nurse is assessing a client for neurologic impairment after a total hip replacement. Which finding would indicate impairment in the affected extremity? decreased distal pulse inability to move diminished capillary refill coolness to the touch

inability to move Explanation: Being unable to move the affected leg suggests neurologic impairment. A decrease in the distal pulse, diminished capillary refill, and coolness to touch of the affected extremity suggest vascular compromise.

A nurse suspects that a client with a recent fracture has compartment syndrome. Assessment findings may include: body-wide decrease in bone mass. a growth in and around the bone tissue. inability to perform active movement and pain with passive movement. inability to perform passive movement and pain with active movement.

inability to perform active movement and pain with passive movement. Explanation: With compartment syndrome, the client can't perform active movement, and pain occurs with passive movement. A body-wide decrease in bone mass is seen in osteoporosis. A growth in and around the bone tissue may indicate a bone tumor.

The client with an open femoral fracture was discharged to home and reports having a fever, night sweats, chills, restlessness, and restrictive movement of the fractured leg. The nurse should interpret these findings as the client may be experiencing which complication? a pulmonary embolus osteomyelitis a fat embolus a urinary tract infection

osteomyelitis Explanation: Fever, night sweats, chills, restlessness, and restrictive movement of the fractured leg are clinical manifestations of osteomyelitis, which is a pyogenic bone infection caused by bacteria (usually staphylococci), a virus, or a fungus. The bone is inaccessible to macrophages and antibodies for protection against infections, so an infection in this site can become serious quickly. The client with a pulmonary or fat embolus would develop symptoms of pulmonary compromise, such as shortness of breath, chest pain, angina, and mental confusion. Signs and symptoms of urinary tract infection would include pain over the suprapubic, groin, or back region with fever and chills, with no restrictive movement of the leg.

When teaching the mother of an infant diagnosed with congenital hypothyroidism about daily oral levothyroxine sodium therapy, which sign and symptom should the nurse include as possibly indicating an overdose? anorexia constipation sweating sleepiness

sweating Explanation: Sweating, insomnia, rapid pulse, dyspnea, irritability, fever, and weight loss are all signs indicating levothyroxine overdose. Diminished or absent appetite (anorexia), constipation, and fatigue and sleepiness would suggest thyroid insufficiency.

A 12-year-old with asthma wants to exercise. Which activity should the nurse suggest to improve breathing? soccer swimming track gymnastics

swimming Explanation: Swimming is appropriate for this child because it requires controlled breathing, assists in maintaining cardiac health, enhances skeletal muscle strength, and promotes ventilation and perfusion. Stop-and-start activities, such as soccer, track, and gymnastics, commonly trigger symptoms in asthmatic clients.

Which group has experienced the greatest rise in the incidence of sexually transmitted diseases (STDs) over the past two decades? teenagers divorced people young married couples older adults

teenagers

A child with a poor nutritional status and weight loss is at risk for a negative nitrogen balance. To help diagnose this problem, the nurse anticipates that the physician will order which laboratory test? total iron-binding capacity hemoglobin (Hb) total protein sweat test

total protein Explanation: The nurse anticipates the physician will order a total protein test because negative nitrogen balance may result from inadequate protein intake. Measuring total iron-binding capacity and Hb levels would help detect iron deficiency anemia, not a negative nitrogen balance. The sweat test helps diagnose cystic fibrosis, not a negative nitrogen balance.

A client recently diagnosed with lung cancer tells the nurse that she has been having difficulty sleeping and is often preoccupied with thoughts about how her life has changed. She says, "I wish my life could just go on the way it was." Which issue should the nurse discuss with the client first? preparing a will managing insomnia understanding grief relieving anxiety

understanding grief Explanation: The client is grieving and is telling the nurse that she grieves for the changes occurring in her life since her cancer diagnosis. The nurse can discuss the grief process with the client and offer support at this time. While the client does have insomnia and is anxious, the priority is to help the client manage her grieving. It is premature to discuss preparing a will.

A client returns to the nursing unit following successful synchronized cardioversion using transthoracic chest wall patches. What should the nurse assess when the client returns to the room? Select all that apply. vital signs skin of chest wall arterial puncture site level of consciousness cardiac rhythm

vital signs skin of chest wall level of consciousness cardiac rhythm Explanation: Vital signs give an important initial assessment of this client's status. The client may experience burns from the patches and current used for the cardioversion. Therefore, it is important to assess the skin of the chest wall for redness or burns. Because conscious sedation is used for this procedure, assessing the client's level of consciousness also is an important initial step. Attaching the client to cardiac monitoring is also important to assess rhythm abnormalities. There is no arterial puncture associated with the procedure.

What is the best reason for assessing a neonate weighing 1,500 g at 32 weeks' gestation for retinopathy of prematurity (ROP)? The neonate is at risk because of multiple factors. Oxygen is being administered at a level of 21%. The neonate was alkalotic immediately after birth. Phototherapy is likely to be ordered by the primary health care provider.

The neonate is at risk because of multiple factors. Explanation: ROP, previously called retrolental fibroplasia, is associated with multiple risk factors, including high arterial blood oxygen levels, prematurity, and very low birth weight (less than 1,500 g). In the early acute stages of ROP, the neonate's immature retinal vessels constrict. If vasoconstriction is sustained, vascular closure follows, and irreversible capillary endothelial damage occurs. Normal room air is at 21% oxygen. Acidosis, not alkalosis, is commonly seen in preterm neonates, but this is not related to the development of ROP. Phototherapy is not related to the development of ROP. However, during phototherapy, the neonate's eyes should be constantly covered to prevent damage from the lights.

Lower back pain is a common concern among pregnant clients. Which comfort measure should a nurse include in her teaching plan for a pregnant client? Wear high-heeled shoes. Use an ergonomically correct desk chair. Avoid tilting the pelvis forward. Bend at the waist, not at the knees.

Use an ergonomically correct desk chair. Explanation: The nurse should instruct the client to use an ergonomically correct desk chair to help alleviate lower back pain. Wearing high heels promotes imbalance and falls. The nurse should not instruct the client to avoid tilting the pelvis forward, because standing with her neck and shoulders straight and pelvis tilted forward alleviates stress caused by excess uterine weight. Bending and lifting at the knees (not at the waist) alleviates strain on lower back muscles.

Coombs test

a test for the presence of anti-Rh factor antibodies in the blood (this is often given to pregnant women that are Rh- to see if they will mount an immune response against the blood of their fetus)

A nurse is administering sublingual nitroglycerin to a client. Immediately after administering nitroglycerin, the nurse should expect to administer:

acetaminophen. Explanation: In the early stages of therapy, nitoglycerin commonly causes headache and dizziness. Acetaminophen usually helps decrease nitroglycerin-induced headaches. Although the client may be anxious, lorazepam usually isn't given after nitroglycerin. There is no indication that the client would need insulin or prednisone.

The registered nurse (RN) is working in a 30-bed long-term care facility on the night shift and is working with two licensed practical/vocational nurses (LPN/VN) and four certified nursing assistants (CNA). Which primary care provider and nursing orders are most appropriately delegated to the LPN/VN? Select all that apply. obtaining a stool culture performing catheter care checking a client for liquid stools every 1 hour reorienting the client to person, place, and time administering oral medications obtaining a urine culture

administering oral medications Explanation: The licensed nurse (LPN/VN) can perform any of these orders because the nurse has the education and license needed to perform the orders. The licensed nurse (LPN/VN) must administer the oral medications because of the education and license needed, and all the other orders can be delegated to the CNA.

A 7-year-old child is admitted to the hospital with acute rheumatic fever. When discussing long-term care for the child with the parents, the nurse should teach them that a necessary part of this care is: physical therapy. antibiotic therapy. psychological therapy. anti-inflammatory therapy.

antibiotic therapy. Explanation: A child who has had rheumatic fever is likely to develop the illness again after a future streptococcal infection. Therefore, it is advised that the child receive antibiotic prophylaxis for at least 5 years and sometimes even longer after the acute attack to prevent recurrence.

A client has had a radical neck dissection for laryngeal cancer. Which action is the priority for nursing care immediately following this surgery? maintaining complete bed rest until postsurgical swelling decreases taking vital signs once a shift until the client is stable determining if the client can swallow suctioning the laryngectomy tube as often as needed

suctioning the laryngectomy tube as often as needed Explanation: The nurse must maintain patency of the airway with frequent suctioning of the laryngectomy tube that can become occluded from secretions, blood, and mucus plugs. Once the client is hemodynamically stable, getting out of bed should be encouraged to prevent postoperative complications. Vital signs should be monitored more frequently in a postoperative client. A swallow study is done at approximately 5 to 7 days after surgery, prior to starting oral intake.

A primigravid client at 26 weeks' gestation visits the clinic and tells the nurse that her lower back aches when she arrives home from work. The nurse should suggest that the client perform which exercise? tailor sitting leg lifting shoulder circling squatting

tailor sitting Explanation: Tailor sitting, also referred to as cobbler's or butterfly pose, is an excellent exercise that helps to strengthen the client's back muscles and also prepares the client for the process of labor. The client should be encouraged to rest periodically during the day and avoid standing or sitting in one position for a long time. Leg lifts are helpful for leg aches. Shoulder circling exercises are helpful for neck and upper backaches. Squatting is not helpful for alleviating lower backaches.

A client receiving chemotherapy has pruritus. In order to develop a care plan, the nurse should ask if the client about which measure? wearing clothes made from 100% cotton sleeping in a cool, humidified room increasing fluid intake to at least 3,000 mL per day taking daily baths with a deodorant soap

taking daily baths with a deodorant soap Explanation: Use of deodorant or fragrant soaps is drying to the skin. Cotton clothing gives the least irritation to skin. A cool, humidified environment adds to the client's comfort as well as providing hydration for skin comfort. Fluid intake of 3,000 mL/day is recommended for adequate hydration.

The mother of a 3-year-old child tells the nurse her child is "fussy" and not as "easygoing" as her other children. She is having difficulty feeding the child because he fusses and cries when she serves a meal. The nurse should instruct the mother to: allow the child to determine when feeding should occur. not to feed the child if he cries. provide structured feeding times and routines. give the child finger foods and let him eat when he wants.

provide structured feeding times and routines. Explanation: Each child has unique temperaments and energy levels, and parents must adapt parenting strategies for each child. Children who are easily upset do better in structured environments where they can learn what to expect. Easy-going children can manage flexible feeding times. Not feeding the child when he cries will not promote nutrition and does not provide the structure that will help the child learn appropriate eating behaviors. Children who are very active and always "on the go" respond well to eating food that can be carried in their hand, and eating more frequently.

A client diagnosed with schizophrenia is brought to the hospital from a group home where he became agitated, threw a chair at another client, and has been refusing medication for 8 weeks. The client exhibits a flat affect, is not caring for his hygiene, and has become increasingly withdrawn and asocial. The health care provider prescribes treatment with risperidone to improve the client's negative and positive symptoms of schizophrenia. When evaluating the drug's effectiveness on the client's negative symptoms, the nurse should expect improvement in which symptom? apathy, affect, social isolation agitation, delusions, hallucinations hostility, ideas of reference, tangential speech aggression, bizarre behavior, illusions

apathy, affect, social isolation Explanation: When determining the effectiveness of risperidone, the nurse would expect improvement in the client's negative symptoms of apathy, flat affect, and social withdrawal. Delusions, hallucinations, illusions, and ideas of reference are positive symptoms of schizophrenia. Agitation, hostility, and aggression are also the result of the positive symptoms.

A client presents to the OB triage unit with no prenatal care and painless bright red vaginal bleeding. Which interventions are most indicated? applying an external fetal monitor and completing a physical assessment applying an external fetal monitor and performing a sterile vaginal examination obtaining a fundal height assessment on the client obtaining fundal height and performing a sterile vaginal examination

applying an external fetal monitor and completing a physical assessment Explanation: Bright red vaginal bleeding without contractions could indicate a placenta previa. A sterile vaginal exam should never be done on a woman with a known or suspected placenta previa. Applying the external fetal monitor will allow the nurse to assess fetal status. A complete physical assessment of the client is indicated. A fundal height is used to monitor fetal growth during pregnancy but does not provide information related to vaginal bleeding.

A client in cardiac rehabilitation would like to eat the right foods to ensure adequate endurance on the treadmill. Which nutrient is most helpful for promoting endurance during sustained activity? protein carbohydrate fat water

carbohydrate Explanation: The stored glucose of muscle glycogen is the major fuel during sustained activity. Glucose production slows as the body begins to depend on fat stores for glucose and fatty acids. Protein is not the body's preferred energy source. Fat is a secondary source of energy. Water is not an energy source, although sufficient water is required to engage in aerobic activity without causing dehydration.

A client with renal dysfunction of acute onset comes to the emergency department complaining of fatigue, oliguria, and coffee-colored urine. When obtaining the client's history to check for significant findings, the nurse should ask about: chronic, excessive acetaminophen use. recent streptococcal infection. childhood asthma. family history of pernicious anemia.

recent streptococcal infection. Explanation: A skin or upper respiratory infection of streptococcal origin may lead to acute glomerulonephritis. Other infections that may be linked to renal dysfunction include infectious mononucleosis, mumps, measles, and cytomegalovirus. Chronic, excessive acetaminophen use isn't nephrotoxic, although it may be hepatotoxic. Childhood asthma and a family history of pernicious anemia aren't significant history findings for a client with renal dysfunction.

Following a transsphenoidal hypophysectomy, the nurse should assess the client for which sign of a potential complication? cerebrospinal fluid (CSF) leak fluctuating blood glucose levels Cushing's syndrome cardiac arrthymias

cerebrospinal fluid (CSF) leak Explanation: A major focus of nursing care after transsphenoidal hypophysectomy is the prevention of and monitoring for a CSF leak. CSF leakage can occur if the patch or incision is disrupted. The nurse should monitor for signs of infection, including elevated temperature, increased white blood cell count, rhinorrhea, nuchal rigidity, and persistent headache. Hypoglycemia and adrenocortical insufficiency may occur. Monitoring for fluctuating blood glucose levels is not related specifically to transsphenoidal hypophysectomy. The client will be given IV fluids postoperatively to supply carbohydrates. Cushing's disease results from adrenocortical excess, not insufficiency. Monitoring for cardiac arrhythmias is important, but arrhythmias are not anticipated following a transsphenoidal hypophysectomy

The nurse is facilitating a group of clients with schizophrenia when one client says, "I like to drive my car, bar, tar, far." This client is exhibiting: clang association. echolalia. echopraxia. neologisms

clang association. Explanation: Linking words together based on their sounds rather than their meanings is called clang association. Echolalia is the involuntary parrot like repetition of words spoken by others. Echopraxia refers to meaningless imitation of others' motions. Neolgisms are words that a person invents

A 62-year-old female is taking long-acting morphine 120 mg every 12 hours for pain from metastatic breast cancer. She can have 20 mg of immediate-release morphine every 3 to 4 hours as needed for breakthrough pain. The health care provider (HCP) should be notified if the client uses more than how many breakthrough doses of morphine in 24 hours? seven four two one

seven Explanation: If the maximum dose specified by the prescription is required every 3 to 4 hours for breakthrough pain, the HCP should be notified to increase the long-acting medication or rotate to another type of opioid. Around-the-clock dosing is mandatory to achieve a steady state of analgesia. The rescue dose for breakthrough pain is administered over and above the regularly scheduled medication. If three to four analgesic doses are required every 24 hours, the sustained-release around-the-clock dose should be increased to include the amount used for previous breakthrough pain while maintaining a dose for future breakthrough pain. (return)

The client with a peptic ulcer is prescribed antibiotics and bismuth salts. The nurse explains that this combination of medications will: prepare his bowel for surgery. eradicate the Helicobacter pylori bacteria. prevent future ulcers from forming. prevent bleeding from the ulcer.

eradicate the Helicobacter pylori bacteria. Explanation: H. pylori is present in 70% of clients with peptic ulcers. Bacteriostatic or bacteriocidal antibiotics are given to eradicate the bacteria from the gastric mucosa. Bismuth salts suppress the H. pylori bacteria and help to heal the mucosa. Although sometimes indicated, surgery for peptic ulcer is much less common now that the role of H. pylori in the development of gastric ulcers is understood. The bowel preparation for gastric surgery does not include bismuth salts. While treatment for H. pylori drastically reduces the recurrence rate, 10% of clients treated for H. pylori will have a recurrence of peptic ulcer disease. While effective treatment will eliminate the possibility of complications, antibiotics and bismuth salts will not directly prevent bleeding.

An adolescent is diagnosed with iron deficiency anemia. After emphasizing the importance of consuming dietary iron, the nurse asks the client to select iron-rich breakfast items from a sample menu. Which selection demonstrates knowledge of dietary iron sources? grapefruit and white toast pancakes and a banana ham and eggs bagel and cream cheese

ham and eggs Explanation: Good sources of dietary iron include red meat, egg yolks, whole wheat breads, seafood, nuts, legumes, iron-fortified cereals, and green, leafy vegetables. Fresh fruits and milk products contain only small amounts of iron. White bread isn't a good iron source.

The son of an older adult reports that his father just "stares off into space" more and more in the last several months but then eagerly smiles and nods once the son can get his attention. What further assessments should the nurse make? dementia hearing loss anger depression

hearing loss Explanation: Blank looks, decreased attention span, positioning of the head toward sound, and smiling/nodding in agreement once attention is gained are all behaviors that indicate hearing loss in adults. It is common to confuse sensory deficits for a change in cognitive status. The nurse should focus assessments of sensory function on considering any pathophysiology of existing or new-onset deficits and consider all client factors that might contribute to deficits.

A client had posterior packing inserted to control a severe nosebleed. After insertion of the packing, the nurse should observe the client for which finding? vertigo Bell's palsy hypoventilation loss of gag reflex

hypoventilation Explanation: Posterior packing may alter the respiratory status of the client, especially in older adults clients, causing hypoventilation. Clients should be observed carefully for changes in level of consciousness, respiratory rate, and heart rate and rhythm after the insertion of the packing. Vertigo does not occur as a result of the insertion of posterior packing. Bell's palsy, a disorder of the seventh cranial nerve, is not associated with epistaxis or nasal packing. Loss of gag reflex does not occur as a result of the insertion of posterior packing.

Apraxia

inability to perform particular purposive actions, as a result of brain damage.

A client with an inflammatory ophthalmic disorder has been receiving repeated courses of a corticosteroid ointment, one-half inch in the lower conjunctival sac four times a day as directed. The client reports a headache and blurred vision. The nurse suspects that these symptoms represent: common adverse reactions to corticosteroid therapy. expected drug effects that should diminish over time. incorrect ointment application. increased intraocular pressure (IOP).

increased intraocular pressure (IOP). Explanation: Headache and blurred vision are symptoms of increased IOP, such as from glaucoma. Ophthalmic corticosteroids may trigger an episode of acute glaucoma in susceptible clients. Although the effects of some drugs may diminish with continued use, this doesn't happen with ophthalmic corticosteroids. Incorrect ointment application doesn't cause headache or blurred vision.

A nurse is assessing a client's abdomen after abdominal surgery. Place the assessment techniques in the order in which the nurse should conduct them. All options must be used. 1 inspection 2 auscultation 3 percussion 4 palpation

inspection auscultation percussion palpation Explanation: When assessing a client's abdomen, the nurse should first inspect the contour and symmetry of the abdomen. Next, the nurse should auscultate for bowel sounds. Auscultation is performed before percussion and palpation because these latter techniques can alter the character of the bowel sounds. Percussion and palpation are the last steps of physical assessment of the abdomen.

Which condition should the nurse assess when completing the history and physical examination of a client diagnosed with osteoarthritis? anemia osteoporosis weight loss local joint pain

local joint pain Explanation: Osteoarthritis is a degenerative joint disease with local manifestations such as local joint pain. Rheumatoid arthritis has systemic manifestation such as anemia and osteoporosis. Weight loss occurs in rheumatoid arthritis, whereas most clients with osteoarthritis are overweight.

Which facility would the nurse rank as the lowest priority to expand when developing a community-based service program for clients with chronic mental illnesses? partial hospitalization programs psychiatric home care residential services long-term hospitals

long-term hospitals Explanation: For a community-based program, the need for long-term hospitalization is least needed if the other services, such as partial hospitalization programs, psychiatric home care, and residential services, are available and accessible.

A nurse must apply an elastic bandage to a client's ankle and calf. She should apply the bandage beginning at the client's: lower foot. ankle. lower thigh. knee.

lower foot. Explanation: An elastic bandage should be applied from the distal area to the proximal area. This method promotes venous return. In this case, the nurse should begin applying the bandage at the client's foot. Beginning at the ankle, lower thigh, or knee will not promote venous return.

A nurse is assessing a client with nephrotic syndrome. The nurse should assess the client for which condition? hematuria massive proteinuria increased serum albumin level weight loss

massive proteinuria Explanation: Nephrotic syndrome is characterized by massive proteinuria caused by increased glomerular membrane permeability. Other symptoms include peripheral edema, hyperlipidemia, and hypoalbuminemia. Because of the edema, clients retain fluid and may gain weight. Hematuria is not a symptom related to nephrotic syndrome.

Which nursing intervention is the highest priority when a client is placed in restraints? monitoring the client every 15 minutes assisting with nutrition and elimination performing range-of-motion exercise for each limb, one at a time changing the client's position every 2 hours

monitoring the client every 15 minutes Explanation: Safety of the client and staff is the utmost priority. Therefore, the client must be monitored closely and frequently, such as every 15 minutes, to ensure that the client is safe and free from injury. Assisting with nutrition and elimination, performing range-of-motion exercises on each limb, and changing the client's position every 2 hours are important after the safety of the client and staff is ensured by close, frequent monitoring.

As part of the respiratory assessment, a nurse observes the neonate's nares for patency and mucus. The information obtained from this assessment is important because: neonates are obligate nose breathers. nasal patency is required for adequate feeding. problems with nasal patency may cause flaring. a deviated septum will interfere with breathing.

neonates are obligate nose breathers. Explanation: Neonates are obligate nose breathers and have no ability to breathe through their mouths. Therefore, blocked nares contribute to respiratory distress in the neonate. Nasal patency is unnecessary for neonate feeding. Nasal flaring may indicate respiratory distress. A deviated septum doesn't cause significant breathing difficulties.

limbic system

neural system (including the hippocampus, amygdala, and hypothalamus) located below the cerebral hemispheres; associated with emotions and drives.

A pregnant client is diagnosed with group B streptococcus chorioamnionitis. The nurse should expect to administer which medication to prevent fetal transmission? penicillin G potassium I.V. to the client. amoxicillin trihydrate P.O. to the client. ceftriaxone I.M. to the neonate immediately after delivery. methylprednisolone I.V. to the client.

penicillin G potassium I.V. to the client. Explanation: Administering penicillin G potassium I.V. before delivery will prevent fetal transmission of group B streptococcus infection. Amoxicillin P.O. isn't effective against chorioamnionitis caused by group B streptococcus. Treatment with penicillin G potassium should begin before delivery to prevent fetal transmission. Steroids, such as methylprednisolone, aren't bacteriocidal.

Which sign or symptom is related primarily to small-bowel obstruction rather than large-bowel obstruction? profuse vomiting cramping abdominal pain abdominal distention high-pitched bowel sounds above the obstruction

profuse vomiting Explanation: Profuse vomiting is the classic sign of small-bowel obstruction and rarely occurs with large-bowel obstruction. Abdominal discomfort is present in both small- and large-bowel obstructions. Abdominal distention occurs with both small- and large-bowel obstruction but is more common in large-bowel obstruction. High-pitched bowel sounds indicate hyperperistalsis, which occurs early in obstruction.

The nurse is teaching a client and family about phenelzine. Which food should the nurse instruct the client to avoid? eggs chicken peanut butter sour cream

sour cream Explanation: Because phenelzine is a monoamine oxidase inhibitor, the client should avoid foods high in tyramine to prevent the development of hypertensive crisis. Foods and beverages high in tyramine include sour cream, aged cheeses, yogurt, red wine, beer, bananas, avocados, salami, sausage, bologna, caffeinated coffee and colas, and chocolate. High-protein foods that have undergone protein breakdown by aging, fermentation, pickling, or smoking should be avoided. Hypertensive crisis, evidenced by occipital headache, stiff neck, nausea and vomiting, sweating, nosebleed, dilated pupils, tachycardia, and constricting chest pain, can occur with this food-drug combination. Eggs, chicken, and peanut butter are not foods high in tyramine and can be included in the client's diet.

The expected outcome of withholding food and fluids from a client who will receive general anesthesia is to help prevent: constipation during the immediate postoperative period. vomiting and possible aspiration of vomitus during surgery. pressure on the diaphragm with poor lung expansion during surgery. gas pains and distention during the immediate postoperative period.

vomiting and possible aspiration of vomitus during surgery. Explanation: Oral food and fluids are withheld before surgery when a client receives general anesthesia primarily to help prevent vomiting and possible aspiration of stomach contents. Constipation after surgery is influenced by multiple factors, such as the nature of the surgery, the postoperative diet, and use of opioid analgesics. Food and fluids are not withheld prior to surgery to relieve pressure on the diaphragm and increase lung expansion. Withholding food and fluids before surgery does not eliminate gas pains or abdominal distention in the postoperative period. General anesthesia and manipulation of abdominal contents can cause peristaltic action to cease temporarily. This leads to abdominal distention and gas pain.

The health care team determines that the family of an infant with failure to thrive who is to be discharged will need follow-up care. Which approach would be the most effective method of follow-up? daily phone calls from the hospital nurse enrollment in community parenting classes twice-weekly clinic appointments weekly visits by a community health nurse

weekly visits by a community health nurse Explanation: The most effective follow-up care would occur in the home environment. The community health nurse can be supportive of the parents and will be able to observe parent-infant interactions in a natural environment. The community health nurse can evaluate the infant's progress in gaining weight, offer suggestions to the parents, and help the family solve problems as they arise.

The client with diagnosed borderline personality disorder tells the nurse, "You're the best nurse here. I can talk to you and you listen. You're the only one here that can help me." Which response by the nurse is most therapeutic? "Thank you; you're a good person." "All of the nurses here provide good care." "Other clients have told me that too." "Mary and Sam are good nurses too."

"All of the nurses here provide good care." Explanation: The most therapeutic response is "All of the nurses here provide good care." This statement corrects the client's unrealistic and exaggerated perception. "Splitting," defined as the inability to integrate good and bad aspects of an individual and the self, is a hallmark behavior of a client with borderline personality disorder. The client sees his or her self and others as all good or all bad. Components of "splitting" include behaviors that idealize and devalue others. It is a defense that allows the client to avoid pain and feelings associated with past abuse or a current situation involving the threat of rejection or abandonment. The other statements promote the client's idealistic view and do nothing to help correct the client's distortion.

A client with Alzheimer's disease is going to live with his daughter who does not work outside of the home. The nurse determines that the daughter needs further education when she makes which statement? "I have put special locks on all the doors that Dad will not be able to unlock." "Dad said that what he missed most while he was here was using his aftershave." "Dad will be in a bedroom that has nothing for him to trip over getting to the bathroom." "I have taken the knobs off of the stove so he will not be able to turn it on."

"Dad said that what he missed most while he was here was using his aftershave." Explanation: The client with Alzheimer's dementia should not have access to toiletries that could be swallowed (such as aftershave) unless closely supervised. Putting special locks on all the doors is appropriate to prevent wandering, thus maintaining the client's safety. Placing the client in a room that has nothing to trip over is appropriate to reduce the client's risk of falling. Taking the knobs off of the stove is appropriate to prevent possible burns.

Client placed on fetal monitor. No fetal movement or reactivity noted over 20 minutes on the monitor. No fetal HR heard. Client repositioned with no change. HCP notified. The obstetric nurse is performing a nonstress test on a 30 week primigravida client sent from a health care provider's office. The client reports a decrease in fetal movement over the past 24 hours. The nurse documents the above nursing note. Which nursing statement is appropriate at this time? "Let's have you change your position and lie on your left side." "I will check with the health care provider to see if further tests are needed." "I bet you are excited about the baby." "Have you done anything different today?"

"I will check with the health care provider to see if further tests are needed." Explanation: At this time, fetal demise is anticipated due to a lack of fetal heart rate and movement. An ultrasound may be ordered to confirm status. Having the client lie on her side is not necessary if a fetal demise is suspected. Talking about the baby is inappropriate at this time. Asking if the client did something differently today may be interpreted as blaming the client for the fetal demise.

A client is diagnosed with Addison's disease. Which of the following statements by the client to the nurse would require further instruction? "I will use salt substitute to flavor my foods." "I will take my medication with food to decrease gastrointestinal upset." "I will include at least three servings of calcium in my daily dietary intake." "I will wear sunscreen when I go outdoors."

"I will use salt substitute to flavor my foods." Explanation: The Addison's client will have high potassium, low sodium, and low calcium and exhibit hyperpigmentation due to the deficit of corticosteroids. Using a salt substitute requires further instruction, as salt substitutes contain potassium. The client with Addison's disease has high levels of potassium. Steroids tend to cause stomach distress, so it is appropriate to take with food to decrease these symptoms. Increasing calcium is encouraged, and sunscreen is appropriate due to the hyperpigmentation of the skin.

Four months ago, the son and daughter of a client who was in a vegetative state gave consent for a feeding tube and agreed to long-term care placement. Nurses in the long-term care facility note that the son and daughter have recently become more distraught over their mother's condition. One day while visiting together, the son and daughter approach the nurse about having the feeding tube removed. Which statement by the nurse best explains the legal rights of individuals in this situation? "It's too late; there is nothing that can be done now." "I understand your concern; it has to be difficult to see your mother like this." "Legally, there are no time constraints on previous decisions made." "Are you looking for other means of nutritional support?"

"Legally, there are no time constraints on previous decisions made." Explanation: Telling the client's children that there are no time contraints on previous decisions made best explains the legal rights of the family in this situation. Next, the nurse should notify the physician of the family's request so measures can be initiated to withdraw care. Telling the family that nothing can be done gives incorrect information about the family's legal rights. Expressing empathy is a therapeutic response; however, it doesn't address the family's legal rights. Asking the family if they're looking for other means of nutritional support is an inappropriate response that doesn't address the family's concerns.

A client who has been diagnosed with bladder cancer is scheduled for an ileal conduit. Prior to surgery, what comment by the client indicates that the client understands the procedure? "This is a temporary procedure that can be reversed later." "I will urinate through my rectum." "My urine will come out through an opening on my abdomen." "My urine will go from my bladder into a drainage bag."

"My urine will come out through an opening on my abdomen." Explanation: An ileal conduit is a permanent urinary diversion in which a portion of the ileum is surgically resected and one end of the segment is closed. The ureters are surgically attached to this segment of the ileum, and the open end of the ileum is brought to the skin surface on the abdomen to form the stoma. The client must wear a pouch to collect the urine that continually flows through the conduit. The bladder is removed during the surgical procedure, and the ileal conduit is not reversible. Diversion of urine to the sigmoid colon is called a ureteroileosigmoidostomy. An opening in the bladder that allows urine to drain externally is called a cystostomy.

Rheumatoid Arthritis Treatment

-goal of tx: reduce inflammation and pain, promote joint function, and prevent joint destruction and deformity -Pharmacological management includes NSAIDs to reduce inflammation and pain -Corticosteroid meds may be desirable during severe flare-ups or when the patient's condition is not responding to NSAIDs -Disease-modifying antirheumatic meds are slow-acting and take weeks or months to become effective, however, they have the ability to slow the progression of joint destruction and deformity -PT interventions include passive and active ROM, heating and cooling agents, splinting, patient education, energy conservation, body mechanics, and joint protection techniques

A nurse is administering medications to a client diagnosed with hepatitis B. When the nurse hands the client his/her medications, the client says, "I would rather not take that pill or any others. I know there is no cure for hepatitis B." The nurse recognizes that the client is expressing feelings of hopelessness about the diagnosis. Select the best responses by the nurse. Select all that apply. "You can lead a long and fairly healthy life if you are compliant with your medications." "You seem frustrated. Would you like to talk?" "I'm going to let the physician talk to you." "Legally, I am obligated to give you this medication." "You have the right to refuse any medications. Would you like to discuss your feelings about this disease?"

"You can lead a long and fairly healthy life if you are compliant with your medications." "You seem frustrated. Would you like to talk?" "You have the right to refuse any medications. Would you like to discuss your feelings about this disease?" Explanation: The nurse needs to explore the client's refusal and feelings to better intervene and educate the client about the disease. A better understanding will lead to better compliance. Getting the physician is passing off a problem rather than addressing it.

The decision is made to involuntarily admit a client to a psychiatric hospital on an emergency detention. The nurse explains the involuntary hospitalization process to the client. Which of the following statements made by the nurse would not be accurate about the involuntary admission process? "You're in the hospital because the psychiatrist who saw you earlier thinks that you are unable to care for yourself right now." "You're free to talk to a lawyer if you'd like to do so." "You cannot leave the hospital until the primary health care provider thinks you can take care of yourself." "You cannot have any visitors while you're here involuntarily."

"You cannot have any visitors while you're here involuntarily." Explanation: Clients have a right to see visitors regardless of admission status. Involuntary hospitalization requires a psychiatrist state-of-need. Any client admitted involuntarily has the right to legal counsel. The client's release requires medical approval.

A client was diagnosed with type 2 diabetes mellitus five years ago, and has now started insulin therapy. What is the most important information to teach the client? "Your diabetes was not controlled with several drugs, so insulin therapy is the next step." "This therapy is not usually warranted." "All clients with type 2 diabetes mellitus need insulin therapy." "This therapy is only temporary."

"Your diabetes was not controlled with several drugs, so insulin therapy is the next step." Explanation: For treatment of type 2 diabetes mellitus, oral agents are started at the lowest effective dose and increased every one to two weeks until the client reaches the desired blood glucose control or the maximum dosage. If the maximum dosage of one agent does not control blood glucose levels, a second agent with a different mechanism of action may be added. Insulin therapy is indicated for the patient with type 2 diabetes mellitus when blood glucose cannot be controlled with the use of two or three different antidiabetic agents. This is the standard therapy, and the therapy would be lifelong.

Osteoarthritis treatment

1. Acetaminophen 2 if not controlled, NSAIDs, like indomethacin, 3 celecoxib for GI bleeding 4 no glucocorticoids

Which client cannot sign out against medical advice? A pregnant 15-year old with vaginal spotting An adult client with ST elevation on the electrocardiogram A client who drank a bottle of vodka one hour ago A minor who has been emancipated by court order

A client who drank a bottle of vodka one hour ago Explanation: A client who is intoxicated is not competent to sign out against medical advice. A pregnant teen is considered an adult. A competent adult client can discharge against medical advice for any reason. A legally emancipated minor is considered an adult.

The nurse performs the initial assessment and reports the following findings to the health care professional: The client's contractions started 5 hours ago and are now coming every 3 minutes and lasting for 60 seconds. The cervix is 100% effaced and 5 cm dilated, the membranes are intact, and the presenting part is well applied to the cervix and is at -1 station. The nurse recognizes that the client is in which stage of labor? Second Latent Active Third

Active Explanation: Because the cervix is dilating (5 cm) and has fully effaced (100%), the woman appears to be in active labor. Active labor is characterized by cervical dilation of 4-7 cm. The regular uterine contractions are effective in facilitating fetal descent through the pelvis because the presenting part is well applied on the cervix and is at -1 station. Second refers to the second stage of labor (begins when the cervix is 10 cm dilated), which this client is not yet experiencing. Latent phase is characterized by the onset of regular contractions and cervical dilation of 0-4 cm. Third refers to the third stage of labor, which is the time between birth and the completed birth of the placenta.

Fat embolism causes

Although release of bone marrow fat into the circulation may be a cause, fat embolism may arise due to conditions such as widespread trauma or diseases that alter lipid metabolism in the body. Typically, fat embolism occurs suddenly 12-36 hours after an injury.

A client admitted to the hospital for chemotherapy states that he's been using a peppermint-scented candle at home to help control nausea. Which interventions would the nurse plan to promote comfort for this client? Telling the client she may use his scented candles Asking the client to try using peppermint oil in place of scented candles Asking the physician to increase the client's antinausea medication Asking the physician to order a sedative for the client to use during chemotherapy

Asking the client to try using peppermint oil in place of scented candles Explanation: Aromatherapy may affect the brain's limbic system, causing relaxation, evoking positive emotional memories, and decreasing the need for antiemetics. Such alternative therapies may increase a client's feeling of control over illness. Because this client associates positive feelings with the scent of peppermint, the nurse should encourage him to continue using that scent, but she should ask the client to use scented oil rather than a candle. Fire of any kind, even a candle, is a hazard in the hospital — especially when oxygen is being used. Increasing the client's nausea medication or ordering a sedative could cause dangerous adverse effects and wouldn't be best practice.

Which of the following ethical principles supports expectant mothers when conflicts between maternal and fetal rights arise during childbirth? Autonomy Justice Nonmaleficence Jurisprudence

Autonomy Explanation: The principle of autonomy supports conflicts between maternal and fetal rights. The woman has the right to choose for herself what she believes to be in her best interest versus the well being of the fetus. This is the concept of self-determination, of being in charge of one's person rather than another person determining what behavior or decision represents justice. Nonmaleficence refers to doing no harm. The client has the right to make choices that align with her belief system.

A primigravid client at 34 weeks' gestation is experiencing contractions every 3 to 4 minutes lasting for 35 seconds. Her cervix is 2 cm dilated and 50% effaced. While the nurse is assessing the client's vital signs, the client says, "I think my bag of water just broke." Which intervention would the nurse do first? Check the status of the fetal heart rate. Turn the client to her right side. Test the leaking fluid with nitrazine paper. Perform a sterile vaginal examination.

Check the status of the fetal heart rate. Explanation: The priority is to determine whether a prolapsed cord has occurred as a result of the spontaneous rupture of membranes. The nurse's first action should be to check the status of the fetal heart rate. Complications of premature rupture of the membranes include a prolapsed cord or increased pressure on the fetal umbilical cord inhibiting fetal nutrient supply. Variable decelerations or fetal bradycardia may be seen on the external fetal monitor. The cord also may be visible. Turning the client to her right side is not necessary. If the cord does prolapse, the client should be placed in a knee-to-chest or Trendelenburg position. Checking the fluid with nitrazine paper and vaginal examination are appropriate once the status of the fetus has been evaluated.

A nurse is taking a client's blood pressure and fails to recognize an auscultatory gap. What should the nurse do to avoid recording an erroneously low systolic blood pressure?

Inflate the cuff at least another 30 mm Hg after she can't palpate the radial pulse. Explanation: The nurse should wrap an appropriate-size cuff around the client's upper arm and then place the diaphragm of the stethoscope over the brachial artery. The nurse should then rapidly inflate the cuff until she can't palpate or auscultate the pulse, then continue inflating until the pressure rises another 30 mm Hg. Having the client lie down, inflating the cuff to at least 200 mg, and taking blood pressure readings in both of the client's arms aren't appropriate measures.

A nurse has noticed an increase in the development of pressure ulcers on the nursing unit. Given the seriousness of the matter, what should the nurse do first? Formally report her concerns to the nurse-manager. Begin an investigation concerning potential causes of the pressure ulcers. Review the charts of the clients involved to assess for patterns and trends. Do nothing; this problem isn't the nurse's responsibility.

Formally report her concerns to the nurse-manager. Explanation: A nurse who identifies issues involving quality of care must follow the chain of command. Although there may be a need for an investigation, the nurse shouldn't initiate one without discussion with the nurse-manager. Charts should be reviewed after a formal investigation is established. The nurse's responsibilities include identifying and reporting issues and concerns involving client care.

A client diagnosed with acute myelocytic leukemia has been receiving chemotherapy. During the last 2 cycles of chemotherapy, the client developed severe thrombocytopenia requiring multiple platelet transfusions. The client is now scheduled to receive a third cycle. How can the nurse best detect early signs and symptoms of thrombocytopenia? Perform a cardiovascular assessment every 4 hours. Check the client's history for a congenital link to thrombocytopenia. Monitor daily platelet counts. Closely observe the client's skin for petechiae and bruising.

Closely observe the client's skin for petechiae and bruising. Explanation: The nurse should closely observe the client's skin for petechiae and bruising. Daily laboratory testing may not reflect the client's condition as quickly as subtle changes in the client's skin. Performing a cardiovascular assessment every 4 hours and checking the clients history for a congenital link to thrombocytopenia don't help detect early signs and symptoms of thrombocytopenia.

Which medication would the nurse expect the provider to prescribe as prophylaxis against Pneumocystis carinii pneumonia for a client with leukemia? Co-trimoxazole Oral nystatin suspension Prednisone Vincristine

Co-trimoxazole Explanation: The most common cause of death from leukemia is overwhelming infection. P. carinii infection is lethal to a child with leukemia. As prophylaxis against P. carinii pneumonia, continuous low dosages of co-trimoxazole are typically prescribed. Oral nystatin suspension would be indicated for the treatment of thrush. Prednisone isn't an antibiotic, and increases susceptibility to infection. Vincristine is an antineoplastic agent.

The nurse is administering a medication to a client with myeloid leukemia and does not know the use, dose, or side effects. To obtain the most up-to-date information about this drug, what should the nurse do? Check a commercially published drug guide. Read a pharmacology textbook. Consult the drug guide provided by the clinical agency. Review information at the drug manufacturer's website.

Consult the drug guide provided by the clinical agency. Explanation: The most current pharmacology information is found in the clinical agency's drug guide, that may be available on electronic sources that are frequently updated and can be transmitted to a handheld device or by logging into the internet or hospital's intranet, if available. A commercially published drug guide and pharmacology textbooks are outdated once published and, therefore, may not have current information. The manufacturer's website has the potential for bias.

A health care provider (HCP) prescribes a lengthy X-ray examination for a client with osteoarthritis with severe pain. Which action by the nurse would demonstrate client advocacy? Contact the X-ray technician to see if the lengthy session can be divided into shorter sessions. Contact the HCP to determine if an alternative examination could be scheduled. Request a prescription for acetaminophen prior to the examination. Request padding and careful positioning for the hard X-ray table.

Contact the X-ray technician to see if the lengthy session can be divided into shorter sessions. Explanation: Shorter sessions will allow the client to rest between the sessions. Changing the HCP's prescription to a different examination will not provide the information needed for this client's treatment. Acetaminophen is a nonopioid analgesic and an antipyretic, not an anti-inflammatory agent; thus, it would not help this client avoid the adverse effects of a lengthy X-ray examination. Although the X-ray table is hard, it is not possible to provide padding and obtain the needed diagnostic X-rays.

A primigravida is admitted to the labor area with ruptured membranes and contractions occurring every 2 to 3 minutes, lasting 45 seconds. After 3 hours of labor, the client's contractions are now every 7 to 10 minutes, lasting 30 seconds. The nurse administers oxytocin as prescribed. What is the expected outcome of this drug? The cervix will begin to dilate 2 cm/h. Contractions will occur every 2 to 3 minutes, lasting 40-60 seconds, moderate intensity, resting tone between contractions. The cervix will change from firm to soft, efface to 40% to 50%, and move from a posterior to anterior position. Contractions will be every 2 minutes, lasting 60 to 90 seconds, with intrauterine pressure of 70 mm Hg.

Contractions will occur every 2 to 3 minutes, lasting 40-60 seconds, moderate intensity, resting tone between contractions. Explanation: The goal of oxytocin administration in labor augmentation is to establish an adequate contraction pattern to enhance the forces of labor. The expected outcome is a pattern of contractions occurring every 2 to 3 minutes, lasting 40 to 60 seconds, of moderate intensity with a palpable resting tone between contractions. Other contraction patterns will cause the cervix to dilate too quickly or too slowly. Cervical changes in softening, effacement, and moving to an anterior position are associated with use of cervical ripening agents, such as prostaglandin gel. Cervical dilation of 2 cm/h is too rapid for the induction/augmentation process.

The nurse is caring for a client receiving digoxin who has begun vomiting and reports seeing colorful halos around the lights in the room. Which of the following actions should the nurse implement? Select all that apply. Discontinue administration of digoxin. Begin continuous electrocardiographic monitoring. Determine serum digoxin and electrolyte levels. Insert nasogastric tube. Administer low flow oxygen.

Discontinue administration of digoxin. Begin continuous electrocardiographic monitoring. Determine serum digoxin and electrolyte levels. Explanation: Symptoms of digoxin toxicity include severe sinus bradycardia, colorful halos around lights, nausea, anorexia, and vomiting. If digoxin toxicity is suspected, the steps the nurse should implement include to discontinue administration of drug; begin continuous electrocardiographic monitoring for cardiac dysrhythmias; administer any appropriate antidysrhythmic drugs as ordered; determine serum digoxin and electrolyte levels; administer potassium supplements for hypokalemia if indicated, as ordered; institute supportive therapy for gastrointestinal symptoms (nausea, vomiting, or diarrhea); and administer digoxin antidote (digoxin immune fab) if indicated, as ordered. Inserting a nasogastric tube or administering oxygen is not appropriate for digoxin toxicity.

A nurse is assessing the chest of a 4-month-old infant. The nurse identifies the ratio of the anteroposterior-to-lateral diameter as 1:2. Which actions should the nurse take next? Document the findings in the client's medical record. Obtain an order for a chest X-ray. Observe for substernal retractions. Auscultate for adventitious lung sounds.

Document the findings in the client's medical record. Explanation: This is a normal finding and requires no further action. As this is a normal finding, a chest X-ray is unnecessary. All the other responses suggest a respiratory disorder and that further evaluation is needed.

Early labor vs active labor vs transition stage:

Early Labor Phase -The time of the onset of labor until the cervix is dilated to 3 cm. Active Labor Phase - Continues from 3 cm. until the cervix is dilated to 7 cm. Transition Phase - Continues from 7 cm. until the cervix is fully dilated to 10 cm

A client is undergoing testing to confirm a diagnosis of myasthenia gravis. The nurse explains that a diagnosis is made if muscle function improves after the client receives an I.V. injection of a medication. What is the medication the nurse tells the client he'll receive during this test? Cyclosporine Edrophonium Immunoglobulin G Azathioprine

Edrophonium Explanation: The most useful and reliable diagnostic test for myasthenia gravis is the edrophonium test. Within 30 to 60 seconds after injection of edrophonium, most clients with myasthenia gravis will demonstrate a marked improvement in muscle tone that lasts about 4 to 5 minutes. Cyclosporine, an immunosuppressant, is used to treat myasthenia gravis, not to diagnose it. Immunoglobulin G is used during acute relapses of the disorder. Azathioprine is an immunosuppressant that's sometimes used to control myasthenia gravis symptoms.

A client with a terminal diagnosis is anxious and concerned about the fact that breathing is taking so much energy and eating is very difficult. Most of the client's time is spent in bed, and the family is very concerned about recuperation. What is the best action by the nurse? Explore other ways to control symptoms and address the family's concerns more effectively. Reinforce the meaning of supportive care to the family and restrict their visits so the client has more rest time. Provide support for the family and encourage the client to become more actively involved in the care. Determine where the client is regarding the stages of dying and discuss the findings with the family.

Explore other ways to control symptoms and address the family's concerns more effectively. Explanation: Trying other nursing measures may more effectively relieve the client's distress. These need to be explored. It is important to examine other ways to alleviate the other symptoms by ensuring rest periods just prior to eating and better pain management. In addition, it is the nurse's role to advocate and to support the client while explaining what is happening to the family. The client would need to request restriction of visits, and the client is the person who needs the support, then the family. Right now is not the right time to discuss stages of dying; addressing breathing problems is the priority.

The nurse is caring for a child with an acute exacerbation of asthma. Oral methylprednisolone has been ordered. Which of the following actions is most important for the nurse to take when administering this medication? Give the medication with food. Give the medication 2 hours before meals. Do not give other medications with methylprednisolone. Give the medication at bedtime.

Give the medication with food. Explanation: Giving the medication with food helps reduce gastric irritation. Oral doses of corticosteroids should be given in the morning.

When caring for the neonate of a mother with gestational diabetes, which finding is most indicative of a hypoglycemic episode? Hyperalert state Jitteriness Positive Babinski's reflex Serum glucose level of 60 mg/dl (3.3 mmol/L)

Jitteriness Explanation: Hypoglycemia in a neonate is expressed as jitteriness, lethargy, diaphoresis, and a serum glucose level below 40 mg/dl (2.2 mmol/L). A hyperalert state suggests neurologic irritability and isn't associated with blood glucose levels. A positive Babinski's reflex is a normal finding in neonates and isn't associated with hypoglycemia. A serum glucose level of 60 mg/dl (3.3 mmol/L) is a normal level.

To promote early and efficient ambulation for a client after an above-the-knee amputation, the nurse is aware that the leg will need to be positioned in which way? In a flexed position Extended and abducted In functional alignment Slightly raised when moving the stump

In functional alignment Explanation: Muscles that originate at the vertebrae or pelvic girdle and insert on the femur act to abduct, adduct, flex, extend, and rotate the femur. Normal body alignment should be maintained because it facilitates the safe and efficient use of muscle groups for balance and stability. Functional alignment is essential for all bone repair.

A pregnant client's hepatitis B report reads "HBsAg = positive." Which of the following correctly describes the client's hepatitis B status? Susceptible Infected Immune A carrier

Infected Explanation: The presence of HBsAg in serum (i.e., HBsAg = positive) identifies an infected person in either an acute or chronic carrier state. To be considered immune, the presence of Anti-HBs with a negative HBsAg is identified in the serum. A carrier refers to those clients who have had a positive serum HBsAg for longer than 6 months but are often unaware they are a carrier because they display no signs or symptoms, do not develop chronic hepatitis, and do not require treatment.

Atropine sulfate is included in the preoperative prescriptions for a client undergoing a modified radical mastectomy. What is the expected outcome of this drug?

Inhibit oral and respiratory secretions. Explanation: Atropine sulfate, a cholinergic blocking agent, is given preoperatively to reduce secretions in the mouth and respiratory tract, which assists in maintaining the integrity of the respiratory system during general anesthesia. Atropine is not used to promote muscle relaxation, decrease nausea and vomiting, or decrease pulse and respiratory rates. It causes the pulse to increase.

A client receiving thyroid replacement therapy develops influenza and forgets to take her thyroid replacement medicine. The nurse understands that skipping this medication puts the client at risk for developing which life-threatening complication?

Myxedema coma Explanation: Myxedema coma, severe hypothyroidism, is a life-threatening condition that may develop if thyroid replacement medication isn't taken. Although thyroid storm is life-threatening, it's caused by severe hyperthyroidism. Myocardial infarction and congestive heart failure may eventually occur in the client with hypothyroidism who is untreated or undertreated for long periods of time.

A nurse is interviewing a client about his past medical history. Which preexisting condition may lead the nurse to suspect that a client has colorectal cancer? Duodenal ulcers Hemorrhoids Weight gain Polyps

Polyps Explanation: Colorectal polyps are common with colon cancer. Duodenal ulcers and hemorrhoids aren't preexisting conditions of colorectal cancer. Weight loss — not gain — is an indication of colorectal cancer.

A primigravid client whose cervix is 7 cm dilated with the fetus at 0 station and in a left occipitoposterior (LOP) position has severe back pain. What intervention is most indicated? Provide firm pressure to the client's sacral area. Prepare the client for a cesarean birth. Prepare the client for a precipitate birth. Maintain the client in a left side-lying position.

Provide firm pressure to the client's sacral area. Explanation: The client who has back pain during labor experiences marked discomfort because the fetus is in an LOP position. This pain is much greater than when the fetus is in the anterior position because the fetal head impinges on the sacrum in the course of rotating to the anterior position. Application of firm pressure to the sacral area can help alleviate the pain. Problems of severe back pain during labor do not typically require a cesarean birth. The health care provider (HCP) may elect to do an episiotomy, but it is not necessarily required. It is unlikely that a primigravid client with a fetus in an LOP position will have a precipitous birth; rather, labor is usually more prolonged. A hands-and-knees position or a right side-lying position may help to rotate the fetal head and thus alleviate some of the back pain.

Which nursing intervention is most appropriate for a client with multiple myeloma? Monitoring respiratory status Balancing rest and activity Restricting fluid intake Preventing bone injury

Preventing bone injury Explanation: When caring for a client with multiple myeloma, the nurse should focus on relieving pain, preventing bone injury and infection, and maintaining hydration. Monitoring respiratory status and balancing rest and activity are appropriate interventions for any client. To prevent such complications as pyelonephritis and renal calculi, the nurse should keep the client well hydrated — not restrict his fluid intake.

A client diagnosed with acute pancreatitis is being transferred to another facility. The nurse caring for the client completes the transfer summary, which includes information about the client's drinking history and other assessment findings. Which assessment findings confirm his diagnosis? Recent weight loss and temperature elevation Presence of blood in the client's stool and recent hypertension Presence of easy bruising and bradycardia Adventitious breath sounds and hypertension

Recent weight loss and temperature elevation Explanation: Assessment findings associated with pancreatitis include recent weight loss and temperature elevation. Inflammation of the pancreas causes a response that elevates temperature and leads to abdominal pain that typically occurs with eating. Nausea and vomiting may occur as a result of pancreatic tissue damage that's caused by the activation of pancreatic enzymes. The client may experience weight loss because of the lost desire to eat. Blood in stools and recent hypertension aren't associated with pancreatitis; fatty diarrhea and hypotension are usually present. Presence of easy bruising and bradycardia aren't found with pancreatitis; the client typically experiences tachycardia, not bradycardia. Adventitious breath sounds and hypertension aren't associated with pancreatitis.

A nurse and an unlicensed assistive personnel (UAP) are caring for clients in a labor and birth unit. Which task should the nurse assign to the UAP? Perform a fundal check on a 2-day postpartum client. Remove a fetal monitor, and assist a client to the bathroom. Give ibuprofen 800 mg by mouth to a newly postpartum client. Teach a new mother how to bottle-feed her infant.

Remove a fetal monitor, and assist a client to the bathroom. Explanation: Removing a fetal monitor from a client and assisting her to the bathroom are within the realm of practice of a UAP. Performing a fundal check is an assessment, which is a responsibility of a RN. A UAP is not permitted to administer medication by any route. Education is also part of the professional nursing role. Although a UAP can assist a mother with bottle-feeding, the formal client education must be completed and validated by the nurse.

agonal respirations

Slow, shallow, irregular respirations or occasional gasping breaths; sometimes seen in dying patients.

A client has a throbbing headache when nitroglycerin is taken for angina. What should the nurse instruct the client to do? Take acetaminophen or ibuprofen. Limit the frequency of using nitroglycerin. Take the nitroglycerin with a few glasses of water. Rest in a supine position to minimize the headache.

Take acetaminophen or ibuprofen. Explanation: Headache is a common side effect of nitroglycerin that can be alleviated with aspirin, acetaminophen, or ibuprofen. The sublingual nitroglycerin needs to be absorbed in the mouth, which will be disrupted with drinking. Lying flat will increase blood flow to the head and may increase pain and exacerbate other symptoms, such as shortness of breath.

The registered nurse (RN) is teamed with a licensed practical/vocational nurse (LPN/VN) in caring for a group of cardiac clients on a pediatric unit. Which action by the LPN/VN indicates the nurse should intervene immediately? The LPN/VN assists a child to the bathroom 2 hours after a cardiac catheterization. The LPN/VN places an infant having a cyanotic episode in a knee-chest position. The LPN/VN checks a child's apical heart rate prior to administering digoxin. The LPN/VN brings breakfast to a child who is scheduled for an electrocardiogram.

The LPN/VN assists a child to the bathroom 2 hours after a cardiac catheterization. Explanation: Because the femoral artery is usually used as the access site during a cardiac catheterization, children are required to remain on bed rest (with the head only slightly elevated) for several hours after the procedure to avoid arterial bleeding at the site. A knee chest position is the correct position for an infant during a cyanotic episode as it will create peripheral resistance to the extremities, shunting blood to the heart. The apical heart rate is assessed prior to administering this medication; administration can be performed by an experienced LPN/VN, although medication is checked with the RN prior to administration. Because echocardiography is noninvasive, there is no need to withhold meals before this procedure.

A client asks the nurse what factors affect how long it will take for a hip to heal following hip replacement surgery. What are the best responses by the nurse? Select all that apply. The age of the client The height of the client The gender of the client The client's comorbidities The client's marital status

The age of the client The client's comorbidities Explanation: The age and comorbidities of the client are important because they can affect the blood supply to the fracture, which can affect the healing process. An older client, or one with comorbidities such as hypertension and diabetes, will have slower bone healing due to a decrease in blood supply. The height of the client does not directly delay bone healing. The client's gender and marital status have no effect on healing.

A nurse has received change-of-shift-report and is briefly reviewing the documentation about a client in the client's medical record. A recent entry reads, "Client was upset throughout the morning." How could the charting entry be best improved? The entry should include clearer descriptions of the client's mood and behavior. The entry should avoid mentioning cognitive or psychosocial issues. The entry should list the specific reasons that the client was upset. The entry should specify the subsequent interventions that were performed.

The entry should include clearer descriptions of the client's mood and behavior. Explanation: Entries in the medical record should be precise, descriptive, and objective. An adjective such as "upset" is unclear and open to many interpretations. As such, the nurse should elaborate on this description so a reader has a clearer understanding of the client's state of mind. Stating the apparent reasons that the client was "upset" does not resolve the ambiguity of this descriptor. Cognitive and psychosocial issues are valid components of the medical record. Responses and interventions should normally follow assessment data but the data themselves must first be recorded accurately.

A primigravida at 8 weeks' gestation tells the nurse that she wants an amniocentesis because there is a history of hemophilia A in her family. The nurse informs the client that she will need to wait until she is at 15 weeks' gestation for the amniocentesis. Which is the most appropriate rationale for the nurse's statement regarding amniocentesis at 15 weeks' gestation? Fetal development needs to be complete before testing. The volume of amniotic fluid needed for testing will be available by 15 weeks. Cells indicating hemophilia A are not produced until 15 weeks' gestation. Performing an amniocentesis prior to 15 weeks' gestation carries a greater infection rate.

The volume of amniotic fluid needed for testing will be available by 15 weeks. Explanation: The volume of fluid needed for amniocentesis is 15 mL, and this is usually available at 15 weeks' gestation. Fetal development continues throughout the prenatal period. Cells necessary for testing for hemophilia A are available during the entire pregnancy but are not accessible by amniocentesis until 12 weeks' gestation. Amniocentesis carries a slight risk of infection regardless of when the procedure is performed.

A client, age 50, visits the physician for a routine checkup. The history reveals that the client was diagnosed with a spinal curvature at age 45. The nurse knows that life-threatening complications can occur if the progressive spinal curvature exceeds 65 degrees. Which region of the spine should the nurse assess for complications? Cervical Thoracic Lumbar Sacral

Thoracic Explanation: The nurse should assess the thoracic region of the spine because a progressive curvature of more than 65 degrees in this region may lead to cardiopulmonary failure as well as less serious signs and symptoms, such as fatigue, back pain, decreased height, and cosmetic deformity. Although a curvature may affect any part of the spine, life-threatening complications aren't associated with curvature of the cervical, lumbar, or sacral regions.

What is the most important assessment for the nurse to make when administering tamsulosin to a client with benign prostatic hyperplasia (BPH)? Voiding pattern Size of the prostate Creatinine clearance Serum testosterone level

Voiding pattern Explanation: The alpha-adrenergic blocker tamsulosin relaxes the smooth muscle of the bladder neck and prostate, so the urinary voiding symptoms of BPH are reduced in many clients. These drugs do not affect the size of the prostate, renal function, or the production or metabolism of testosterone.

A registered nurse (RN) has been paired with a licensed practical nurse (LPN) for the shift. Whose care should the RN delegate to the LPN? a 2-year-old child who nearly drowned 2 days earlier a 19-month-old infant who had surgery for a fractured tibia 12 hours ago a 6-month-old infant who has gastroenteritis and vomits every 30 minutes a 17-month-old infant who lost consciousness 2 hours earlier because of a head injury

a 2-year-old child who nearly drowned 2 days earlier Explanation: The nurse can delegate care of the near-drowning victim to an LPN. Children recover quite quickly from near-drowning experiences; acute care isn't necessary. The infant who has undergone surgery is still under the effects of anesthesia and requires close observation for dehydration, pain, and signs of adverse reactions. The infant with gastroenteritis also requires close monitoring for signs of dehydration. The infant who lost consciousness will need to be monitored most closely. The child's status could quickly become very critical.

The nurse has just received the change of shift report on the following clients on the labor, birth, recovery, and postpartum unit. Which of these clients should the nurse assess first? an 18-year-old single primigravid client, in labor for 9 hours, with cervical dilation at 6 cm, 0 station, contractions occurring every 5 minutes, and receiving epidural anesthesia a 24-year-old primiparous client who gave vaginal birth to a 7-lb, 3-oz (3,260-g) boy 1 hour ago, has a firm fundus and scant lochia rubra, and is attempting to breastfeed a 26-year-old multigravid client, in labor for 8 hours, with cervical dilation at 8 cm, 1+ station, contractions every 3 to 4 minutes, and receiving no anesthesia a 30-year-old multipara who gave birth to a 6-lb, 5-oz (2,863-g) girl by cesarean owing to fetal distress 3 hours ago, has a firm fundus and scant lochia rubra, and is receiving morphine by patient-controlled analgesia

a 26-year-old multigravid client, in labor for 8 hours, with cervical dilation at 8 cm, 1+ station, contractions every 3 to 4 minutes, and receiving no anesthesia Explanation: The client who should be assessed first is the multigravid client who has been in labor for 8 hours and whose cervix is 8 cm dilated at 1+ station with contractions every 3 to 4 minutes. A multigravid client typically has a shorter labor than a primigravid, and this client's station is 1+, which means that birth of the fetus is imminent.

fascia

a band or sheet of fibrous connective tissue that covers, supports, and separates muscle

A client being treated for complications of chronic obstructive pulmonary disease needs to be intubated. The client has previously discussed his wish to not be intubated with his girlfriend of 5 years, whom he's designated as his health care power of attorney. The client's children want their father to be intubated. A nurse caring for this client knows that: clients commonly confer health care power of attorney on someone who shares their personal values and beliefs. the client's girlfriend is responsible for national legislation regarding surrogate decision makers. the children's biological relationship with their father supersedes his girlfriend's wishes. health care providers must honor the children's wishes to avoid a lawsuit.

clients commonly confer health care power of attorney on someone who shares their personal values and beliefs. Explanation: The health care power of attorney is someone who can make decisions when the client can't. Clients tend to select individuals who share their personal values and beliefs as their health care power of attorney. Family members and designated surrogates don't always agree; state laws regarding surrogate decision makers may differ. The legal rights of a health care power of attorney in regards to health care decisions supersede those of family members. The law designates the health care power of attorney as the person to make decision; violating this designation could result in a lawsuit.

When conducting a psychoeducational group session on relapse prevention for clients dually diagnosed with chronic schizophrenia and alcohol abuse, the nurse should use which approach? strong confrontation techniques a nondirective leadership style concrete concepts and simplified material an unstructured format

concrete concepts and simplified material Explanation: The nurse should use concrete concepts and simplified material when conducting a psychoeducational group for clients with chronic schizophrenia and alcohol abuse or dependency. Clients with dual diagnosis experience difficulties in concentration and memory due to the effects of schizophrenia and the use of alcohol. Groups should be structured with simplified material and concrete concepts. Handouts and simple homework assignments may be helpful for the clients to review and apply concepts learned in the group session. Strong confrontation techniques would increase the anxiety level, possibly resulting in clients' being unable to tolerate the group. A nondirective leadership style is not appropriate for this group because a lack of leadership would result in a lack of therapeutic value for the clients. Clients with cognitive deficits would have increased difficulty deriving any benefit from the group. Appropriate structure is necessary to help clients with cognitive deficits to focus.

A neonate born several hours ago shows signs of a tracheoesophageal fistula (TEF). During the initial assessment, what does the nurse expect to find? continuous drooling diaphragmatic breathing a slow response to stimuli passage of frothy meconium

continuous drooling Explanation: Signs of a TEF include continuous drooling, excessive oral secretions, and choking and coughing, which are especially pronounced during feeding. TEF doesn't cause diaphragmatic breathing, a slow response to stimuli, or passage of frothy meconium.

A nurse is calling report to the medical-surgical floor staff regarding a client with acute diverticulitis. Which symptoms does the nurse anticipate? Select all that apply. esophagitis cramping pain in the left lower abdominal quadrant bowel irregularity heartburn intervals of diarrhea hiccuping

cramping pain in the left lower abdominal quadrant bowel irregularity intervals of diarrhea Explanation: Acute diverticulitis is a common digestive disease typically found in the large intestine. Signs and symptoms of acute diverticulitis include bowel irregularity, intervals of diarrhea, abrupt onset of cramping pain in the left lower abdomen, and a low-grade fever. Esophagitis, heartburn, and hiccuping are not signs of the disorder.

A client is undergoing a diagnostic workup for suspected testicular cancer. When obtaining the client's history, the nurse checks for known risk factors for this type of cancer. Testicular cancer has been linked to: testosterone therapy during childhood. sexually transmitted disease. early onset of puberty. cryptorchidism.

cryptorchidism. Explanation: Cryptorchidism (failure of one or both testes to descend into the scrotum) appears to play a role in testicular cancer, even when corrected surgically. Other significant history findings for testicular cancer include mumps orchitis, inguinal hernia during childhood, and maternal use of diethylstilbestrol or other estrogen-progestin combinations during pregnancy. Testosterone therapy during childhood, sexually transmitted disease, and early onset of puberty aren't risk factors for testicular cancer.

The client is admitted to the hospital for alcohol detoxification. Which intervention should the nurse use? Select all that apply. taking vital signs monitoring intake and output placing the client in restraints as a safety measure reinforcing reality if the client is disoriented or hallucinating explaining to the client that the symptoms of withdrawal are temporary

taking vital signs monitoring intake and output reinforcing reality if the client is disoriented or hallucinating explaining to the client that the symptoms of withdrawal are temporary Explanation: For the client experiencing symptoms of alcohol withdrawal, the nurse monitors vital signs and intake and output, reinforces reality for the client who is confused, disoriented, or hallucinating, explains that the symptoms of withdrawal are temporary, reduces stimulation, and stays with the client if he is confused or agitated. The nurse administers medications to prevent the progression of symptoms, such as seizures and delirium tremens, and to ensure the client's safety. Restraints are not used as a precautionary measure. Restraints are used only as a least restrictive measure to protect the client and others when the client is a danger to himself or others.

A registered nurse (RN) has been "care-paired" with a licensed practical nurse (LPN) during the evening shift. Whose care should the RN assign to the LPN? the 2-year-old child who has started eating soft, solid foods following a tonsillectomy a 12-month-old infant who has a white blood cell (WBC) count of 34/μl and a fever a 17-month-old infant with a contusion as a result of a motor vehicle accident 4 hours earlier a 22-month-old infant with type 1 diabetes who has a blood glucose level of 277 mg/dl (15.37 mmol/L).

the 2-year-old child who has started eating soft, solid foods following a tonsillectomy Explanation: The nurse can delegate care of the child who had the tonsillectomy to the LPN because that child is stable and likely preparing for discharge. The infant with a WBC count of 34/μl and fever requires close monitoring for additional signs of infection. Infection could lead to sepsis or septic shock. Although the infant with contusions from the motor vehicle accident may be stable, children sometimes experience delayed reactions to injury. This infant requires close monitoring for signs or injury or shock. The RN should care for the infant with type 1 diabetes, who could become ill very quickly.

Several high-school seniors are referred to the school nurse because of suspected alcohol misuse. When the nurse assesses the situation, what would be most important to determine? what they know about the legal implications of drinking the type of alcohol they usually drink the reasons they choose to use alcohol when and with whom they use alcohol

the reasons they choose to use alcohol Explanation: Information about why adolescents choose to use alcohol or other drugs can be used to determine whether they are becoming responsible users or problem users. The senior students likely know the legal implications of drinking, and the nurse will establish a more effective relationship with the students by understanding motivations for use. The type of alcohol and when and with whom they are using it are not the first data to obtain when assessing the situation.