NCLEX Endurance exam 1

Which suggestions should the nurse include when teaching the parents of a child who has viral tonsillitis? Select all that apply.

Gargle with warm salt water. Give acetaminophen for sore throat. Offer lots of fluids.

While receiving heparin to treat a pulmonary embolus, a client passes bright red urine. What should the nurse do first?

Prepare to administer protamine sulfate.

A physician orders acetaminophen elixir, 160 mg every 4 hours, for a 14-month-old client who weighs 20 lb (9.08 kg). This drug, supplied in a bottle labeled 160 mg/tsp, has a safe dosage of 10 mg/kg/dose. The nurse should administer how many milliliters?

none because this isn't a safe dose. For this client, the safe dose of this drug is 90.8 mg (9.08 kg × 10 mg/kg = 90.8 mg). This dose is equivalent to 2.8 ml. Therefore, the ordered dose isn't safe.

A nurse is teaching a client with a left fractured tibia how to walk with crutches. Which instruction is appropriate?

"All weight should be on the hands." When using crutches, all weight should be on the hands. Constant pressure on the axillae from weight bearing can damage the brachial plexus nerve and produce crutch paralysis. Feet should be 6 to 8 in (15 to 20 cm) apart to provide stability and support. Short strides — not long ones — provide safety and maximum mobility.

The nurse is caring for a child with acute glomerulonephritis. What action is most important for the nurse to do?

Obtain and monitor daily weight. The child with acute glomerulonephritis should be monitored for fluid imbalance, which is done through daily weights. Increasing oral intake and providing sodium supplements aren't part of the therapeutic management of acute glomerulonephritis. Impaired renal function is associated with increased, not decreased, potassium levels.

The nurse is preparing a teaching plan for a 14-year-old child who is newly diagnosed with asthma. Which content should be taught first?

when to seek immediate medical attention The highest priority is to teach what signs or symptoms require immediate medical attention. While peak flow meter could pro-actively prevent an attack, it is not of as great concern as knowing when to seek medical assistance. The client does need to understand what asthma is, and if steriods are ordered long term, it should also be included in the teaching plan, however, neither of these areas for instruction are of highest priority. The ability to breathe takes priority over the other areas.

A nurse-manager has decided to delegate responsibility for the review and revision of the surgical unit's client-education materials. Which statement illustrates the best method of delegation?

Ask the two most proficient staff nurses to form a task force to review and revise client-education materials within the next 6 weeks. Have these nurses solicit input from clients and staff members. Delegation must be clear and precise. The nurse-manager must assign responsibility, identify the task to be accomplished, explain the necessary outcomes, and define the time frame available to complete the work. The remaining options don't clearly define the work to be done, don't clearly assign responsibility or specify desired outcomes, or establish a time frame for completion of the task.

A client with a history of cardiac problems reports severe chest pain. What should be the nurse's first response?

Assess the client's pain. The nurse's first response is to further assess the client's pain. After a thorough assessment, additional appropriate actions may be to notify the HCP, administer an analgesic, and administer oxygen.

A 49-year-old client is admitted to the emergency department frightened and reporting hearing voices telling the client to do bad things. Which intervention should be the nurse's priority?

Assess the nature of the commands by asking what the voices are saying. Safety is the priority. The nurse should ask the client directly about the nature of the auditory commands to ensure the safety of the client and staff. The nurse should never make promises to the client that the nurse may not be able to fulfill. The provider may order a neuroleptic, but the nurse's priority is to address safety.

A nurse is assessing a client with heart failure. To assess hepatojugular reflux, the nurse should

press the right upper abdomen. As the right upper abdomen (the area over the liver) is compressed for 30 to 40 seconds, the nurse observes the internal jugular vein. If the internal jugular vein becomes distended, a client has positive hepatojugular reflux. Hepatojugular reflux, a sign of right-sided heart failure, is assessed with the head of the bed at a 45-degree, not 90-degree, angle.

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 requiring abdominal dressing changes for a wound infection 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 administering 5,000 units heparin subcutaneously to a client (see the accompanying image). The nurse should:

use a shorter needle. Heparin should be administered into subcutaneous tissue at a 90-degree angle using a 27-gauge 5/8-inch (1.6-cm) needle. The medication should not be administered into the muscle. In order to prevent hematoma formation, the nurse should not rotate the tip of the needle or aspirate before injecting the heparin.

Physical examination of an adolescent reveals an abnormally convex angulation in the curvature of the thoracic spine. How should the nurse should document this finding?

kyphosis An abnormally increased convex angulation in the curvature of the thoracic spine is kyphosis. The most common cause of kyphosis in children is related to poor posture. A Dowager's hump in an abnormal outward curvature of the thoracic vertebrae of the upper back associated with osteoporous. Lordosis is the excessive anterior curvature of the lumbar spine due most commonly to an underlying neuromuscular disease or spinal deformity. Scoliosis is a lateral curvature of the spine.

A client has a risk for skin breakdown due to incontinence. Which nursing actions for the client will help with decreasing this risk? Select all that apply.

Maintain a voiding record to determine any patterns of incontinence. Have scheduled toileting every 4 hours. Cleanse the perineal area daily and after each incontinent episode. The client should have scheduled toileting to prevent incontinence and needs perineal care daily and after every incontinent episode to maintain clean and dry skin. A voiding record may help determine any patterns of incontinence with medications, fluid intake, or other reasons. The client should not be encouraged to decrease fluid intake as there is no evidence this is contributing to incontinence and, while adult briefs can be used, they should be changed more frequently to ensure that skin stays dry.

A client asks to be discharged from the healthcare facility against medical advice (AMA). What should the nurse do first?

Notify the physician. If a client requests a discharge AMA, the nurse should notify the physician immediately. If the physician can't convince the client to stay, the physician will ask the client to sign an AMA form, which releases the facility from legal responsibility for any medical problems the client may experience after discharge. If the physician isn't available, the nurse should discuss the AMA form with the client and obtain the client's signature. A client who refuses to sign the form shouldn't be detained because this would violate the client's rights. After the client leaves, the nurse should document the incident thoroughly and notify the physician that the client has left.

An 8-year-old has a body mass index (BMI) for age at the 90th percentile but has no other risk factors. What should the nurse do?

Refer the family to a dietician. Children aged 2 to 20 years with a BMI-for-age at the 90th percentile are considered overweight. If no other risk factors are present, the family should receive dietary counseling to slow the child's weight gain until an appropriate height for weight is attained. Without intervention, the child may become obese. An HCP who specializes in pediatric weight loss should be considered when the child is obese and has complicating factors. Commercial diet programs alone do not include the necessary monitoring for children, thus are rarely appropriate.

One day after an appendectomy, a 9-year-old rates pain at 4 out of 5 on the pain scale but is playing video games and laughing with a friend. What should the nurse document on the child's chart?

The child rates pain at 4 out of 5. Administered pain medication as ordered. Pain is what the child says it is, and the nurse must document what the child reports. If a child's behavior appears to differ from the child's rating of pain, believe the pain rating. A child who uses passive coping behaviors (such as distraction and cooperative) may rate pain as more intense than children who use active coping behaviors (such as crying and kicking). Nurses frequently make judgments about pain based on behavior, which can result in children being inadequately medicated for pain.

The nurse is providing follow-up care to a client 10 days after the birth. The nurse would anticipate what outcomes from the new mother? Select all that apply.

The family has adequate support from one another and others. The client has positive comments about her new infant. Lochia is changing from red to pink and is smaller in amount. The client feels tired but can care for herself and her new infant.

The nurse assesses a client who is receiving a tube feeding. Which situation would require prompt intervention from the nurse?

The feeding that is infusing has been hanging for 8 hours. Feeding solutions that have not been infused after hanging for 8 hours should be discarded because of the increased risk of bacterial growth. Sitting the client upright during the feeding helps prevent aspiration of the feeding. A gastric residual of 25 mL is considered acceptable. A gastric residual of 100 to 150 mL, or a residual greater than 100% of the previous hour's intake, indicates delayed emptying. The feeding solution should be at room or body temperature.

Sulfamethoxazole/trimethoprim has been prescribed for a client who has a urinary tract infection. What should the nurse do when administering sulfonamides?

Instruct the client to drink at least eight glasses of water a day. The client who is taking sulfadiazine should be instructed to drink at least eight glasses of water a day to prevent the development of crystalluria. Sulfadiazine should be taken on an empty stomach with a full glass of water. It does not require that the client's urine output be measured and does not affect the color of the urine.

Which discharge instruction would be appropriate for a client who has had a laparoscopic cholecystectomy and has sutures covered by a dressing?

Leave dressing in place until seeing the surgeon at the postoperative visit. After a laparoscopic cholecystectomy when there are sutures covered by a dressing the client should not remove dressings from the puncture sites but should wait until visiting the surgeon. The client may shower 48 hours after surgery. A client can return to work within 1 week, but only if approved by the surgeon and no strenuous activity is involved. The client should report any fever, which could be an indication of a complication.

A client arrives at the emergency department complaining of extreme muscle weakness after minimal effort. The physician suspects myasthenia gravis. Which drug will be used to test for this disease?

edrophonium Edrophonium temporarily blocks the breakdown of acetylcholine, thus increasing acetylcholine level in the blood, and relieves weakness. Because of its short duration of action, edrophonium is the drug of choice for diagnosing myasthenia gravis. It's also used to differentiate myasthenia gravis from cholinergic toxicity. Ambenonium is used as an antimyasthenic. Pyridostigmine serves primarily as an adjunct in treating severe anticholinergic toxicity; it's also an antiglaucoma agent and a miotic. Carbachol reduces intraocular pressure during ophthalmologic procedures; topical carbachol is used to treat open-angle and closed-angle glaucoma.

Immediately after a birth, a nurse assesses the neonate's head for signs of molding. Which factors determine the type of molding?

fetal body flexion or extension Fetal attitude — the overall degree of body flexion or extension — determine coarctation of the aortanes the type of molding in the head of a neonate. Molding is not influenced by maternal age, body frame, weight, parity, or gravidity or by maternal and paternal ethnic backgrounds.

The client with a head injury receives mannitol during surgery to help decrease intracranial pressure. Which finding indicates that the drug is having the desired effect?

Urine output increases. Mannitol is an osmotic diuretic that helps decrease intracranial pressure through its dehydrating effects. The drug is acting in the desired manner when urine output increases. It may be desirable to decrease pulse rate, decrease blood pressure, or relax muscles, but mannitol is not used to accomplish these.

An elderly client who is receiving steroids has secondary diabetes and chronic kidney disease (CKD) and takes insulin. The client has had episodes of hypoglycemia. The nurse should:

continue to monitor the client's blood glucose values. The nurse should continue to monitor glucose in the blood to prevent the client from continuing to experience hypoglycemia. One of the risk factors for hypoglycemia is decreased insulin clearance as with impaired kidney function and/or renal failure. Another risk factor for hypoglycemia is increased glucose utilization when there is too much activity or exercise without enough food. Protein is digested slower than carbohydrate, but with chronic kidney disease (CKD) it is more difficult for the kidneys to rid the body of metabolic waste products.

The nurse is planning care for a client who has just returned to the medical-surgical unit following repair of an aortic aneurysm. What is a priority assessment for this client?

decreased urinary output Following surgical repair of an aortic aneurysm, there is a potential for an alteration in renal perfusion, manifested by decreased urine output. The altered renal perfusion may be related to renal artery embolism, prolonged hypotension, or prolonged aortic cross-clamping during surgery. Electrolyte imbalance and anxiety do not present imminent risk for this client; signs of wound infection are generally not evident immediately following surgery, but the nurse should monitor the incision on an ongoing basis.

Root cause analysis has revealed the source of medication errors in the neonatal intensive care unit. Completion of the performance improvement process requires

developing an action plan to resolve the root causes. An action plan outlines the steps to be taken to resolve the problem. Adult units don't necessarily need to investigate the same problem. Educating unlicensed (unregulated) staff isn't required to complete the improvement process unless unlicensed (unregulated) staff members are involved in the plan. The state board of nursing (provincial or territorial) doesn't need to approve plan interventions.

Rho (D) immune globulin (RhoGAM) is prescribed for a client before she is discharged after a spontaneous abortion. The nurse instructs the client that this drug is used to prevent which condition?

development of Rh-positive antibodies Rh sensitization can be prevented by Rho(D) immune globulin, which clears the maternal circulation of Rh-positive cells before sensitization can occur, thereby blocking maternal antibody production to Rh-positive cells. Administration of this drug will not prevent future Rh-positive fetuses, nor will it prevent future abortions. An antibody response will not occur to Rh-negative cells. Rh-negative mothers do not develop sensitivities if the fetus is also Rh negative.

A man of Chinese descent is admitted to the hospital with multiple injuries after a motor vehicle accident. His pain is not under control. The client states, "If I could be with my people, I could receive acupuncture for this pain." The nurse should respond to the client by understanding that in the Asian culture which is the intended outcome of acupuncture?

restores the balance of energy. Acupuncture, like acumassage and acupressure, is performed in certain Asian cultures to restore the energy balance within the body. Pressure, massage, and fine needles are applied to energy pathways to help restore the body's balance. Acupuncture is not based on a belief in purging evil spirits. Although pain relief through acupuncture can promote tranquility, acupuncture is performed to restore energy balance. In the Western world, many researchers think that the gate-control theory of pain may explain the success of acupuncture, acumassage, and acupressure.

A primigravid client at 32 weeks' gestation with ruptured membranes is prescribed to receive betamethasone 12 mg intramuscularly for two doses 24 hours apart. When teaching the client about the medication, what should the nurse include as the purpose of this drug?

to accelerate fetal lung maturity. Corticosteroids, such as betamethasone, are prescribed for clients who are preterm to accelerate fetal lung maturity and reduce the incidence and severity of respiratory distress syndrome. Infection would be treated with antibiotics. Tocolytic therapy is used to reduce contractions. The nurse should monitor the fetal heart rate pattern, but betamethasone will not improve the fetal heart rate.

A multipara is admitted to the birthing room after her initial examination reveals her cervix to be at 8 cm, completely effaced (100%), and at 0 station. Based on these findings, the nurse should recognize that the client is in which phase of labor?

transitional phase The transitional phase of labor occurs as the cervix dilates from 8 to 10 cm; it's the shortest but most difficult and intense phase for the client. The latent phase occurs as the cervix dilates from 0 to 3 cm; this phase is mild in nature. The active phase occurs as the cervix dilates from 4 to 7 cm; this phase is moderate for the client. The expulsive phase begins immediately after the birth and ends with separation and expulsion of the placenta.

Which iron-rich foods should a nurse encourage an anemic client requiring iron therapy to eat?

lamb and peaches Iron-rich foods include lamb and peaches. Shrimp, tomatoes, lobster, squash, cheese, and bananas aren't high in iron content.

The nurse is working in a public health clinic. Four clients present with various skin disorders. Which disorder requires disclosure to public health officials?

measles

The nurse is caring for an older adult male who had open reduction internal fixation of the right hip 24 hours ago. The client is now experiencing shortness of breath and reports having "tightness in my chest." The nurse reviews the recent lab results. The nurse should report which lab results to the health care provider?

troponin: 1.4 mcg/L (1.4 µg/L) Troponin is a cardiac biomarker and is normally almost undetectable in the blood. A level of 1.4 means there has likely been some damage to the heart muscle. Though serum glucose (normal 60 to 100 mg/dL [3.3 to 5.5 mmol/L]) and ESR (normal is less than 20 for males greater than 50 years old) are slightly elevated, this could be explained by normal stress and inflammatory response to surgery. The hematocrit is low (normal 40% to 45% [0.4 to 0.5] for men) but also not unexpected for a client following surgery.

A client is taking vancomycin. The nurse should report which possible side effect to the health care provider?

tinnitus. The client should report tinnitus because vancomycin can affect the acoustic branch of the eighth cranial nerve. Vancomycin does not affect the vestibular branch of the acoustic nerve; vertigo and ataxia would occur if the vestibular branch were involved. Muscle stiffness is not associated with vancomycin.

Which statement by the mother of a child with Wilms' tumor tells the nurse that the mother understands what stage II tumor means?

"The tumor has extended beyond the kidney but was completely removed."

The client with breast cancer is prescribed tamoxifen 20 mg daily. The client states she does not like taking medicine and asks the nurse if the tamoxifen is really worth taking. What should the nurse tell the client?

"This drug has been found to decrease metastatic breast cancer." Tamoxifen is an antiestrogen drug that has been found to be effective against metastatic breast cancer and to improve the survival rate. The drug causes hot flashes as an adverse effect.

An antenatal client is discussing her anemia with the nurse in the prenatal clinic. After a discussion about sources of iron to be incorporated into her daily meals, the nurse knows the client needs further instruction when she responds with which statement?

"I can meet two goals when I drink milk: lots of iron and meeting my calcium needs at the same time." Milk contains a large amount of calcium but contains no iron. Coffee, tea, and caffeinated soft drinks inhibit the absorption of iron. The vitamin C found in orange juice enhances the absorption of iron. Cream of wheat (1 cup/10 mg iron) and molasses (1 tbsp/3.0 mg iron) are considered excellent sources of iron as they contain the indicated amounts of iron.

A client is 36 weeks' gestation and has been admitted to the antenatal unit for gestational hypertension. The client states that she is alone because she has recently moved from another country, and she begins to cry. What is the best response by the nurse?

"Tell me more about how you are feeling." Recent immigrants may be separated from their friends, family, and support systems. There are many variations in how cultural and ethnic beliefs and practices impact how individuals respond to the experience of pregnancy and birth. This nurse's response further explores the client's feelings to assist in a culturally competent and sensitive manner. It would be inappropriate to assume that the client is concerned about the family's living arrangements. It would be inappropriate to ask the client about belonging to any support groups or to refer the client to a social worker at this time. It would be most beneficial at this time to explore the client's feelings to identify what the concerns are and how the client believes the nurse may be able to help.

A client is being admitted with nursing home-acquired pneumonia. The unit has four empty beds in semiprivate rooms. The room that would be most suitable for this client is the one with which other client?

60-year-old client admitted for investigation of transient ischemic attacks. The client with a possible transient ischemic attack is the only client who has not had surgery and is not immunocompromised. The client with a recent surgery and incision should not be exposed to a client with infection. Clients with cancer or alcoholic cirrhosis are very susceptible to infection, and it would not be safe to expose them to a client with a respiratory infection.

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

A client with an uncomplicated term pregnancy arrives at the labor-and-delivery unit in early labor saying that she thinks her water has broken. What is the nurse's best action?

Ask what time this happened and note the color, amount, and odor of the fluid. Gather more information. Noting the color, amount, and odor of the fluid, as well as the time of rupture, will help guide the nurse in the next action. There's no need to immediately call the client's provider or prepare this client for birth if the fluid is clear and birth isn't imminent. Rupture of membranes isn't unusual in the early stages of labor. Fluid collection for microbial analysis is not routine if there's no concern for infection.

An unlicensed nursing personnel (UAP) recorded a client's 0600 blood glucose level as 126 mg/dL (7 mmol/L) instead of 216 mg/dL (12 mmol/L). The UAP did not recognize the error until 0900 but reported it to the nurse right away. What should the nurse do first?

Call the health care provider (HCP). The error should be reported to the HCP promptly; the HCP may write additional prescriptions. The nurse should complete an incident report because a potentially dangerous event happened during the client's care. The nurse should observe the client for symptoms of hyperglycemia but first must call the HCP and complete an incident report. The UAP does not need to be reassigned for this error. The nurse does not need to reprimand the UAP for the error because the UAP already knows an error was made and has reported it to the nurse.

A client has been admitted to the coronary care unit. The nurse observes third-degree heart block at a rate of 35 bpm on the client's cardiac monitor. The client has a blood pressure of 90/60 mm Hg. What should the nurse do first?

Prepare for transcutaneous pacing. Transcutaneous pacemaker therapy provides an adequate heart rate to a client in an emergency situation. Defibrillation and a lidocaine infusion are not indicated for the treatment of third-degree heart block. Transcutaneous pacing is used temporarily until a transvenous or permanent pacemaker can be inserted.

A nurse is caring for a client with a nursing diagnosis of fluid volume deficit related to impaired thirst mechanism. Which outcome would the nurse determine as most appropriate for this client?

The client's intake and output are balanced. During the planning step of the nursing process, the nurse identifies expected client outcomes, establishes priorities, and develops the care plan. This outcome provides measurable data showing resolution of the problem of deficient fluid volume that was identified in the nursing diagnosis statement. The other statements do not resolve the problem of fluid volume deficiency.

The nurse is evaluating infection control practices performed by a spouse on a loved one who has methicillin resistant Staphylococcus aureus (MRSA) in a right leg wound. Which actions indicate that the spouse requires further teaching? Select all that apply.

The spouse places soiled dressing supplies in the kitchen garbage can. Sheets with wound drainage are washed in lukewarm water.

The nurse is caring for a client on a second course of antibiotics to eliminate osteomyelitis. It is most essential for the nurse to instruct on which aspect of daily care?

a diet high in protein and nutrients. It is essential for the nurse to instruct on a diet that is high in protein and nutrients to increase healing and strengthen the immune system. This, in addition to the second course of antibiotics, may be sufficient to eliminate the osteomyelitis. Opioids may be needed for pain management but this is not most essential. Bed rest is not common in care and assistive devices are used only in the acute period.

A client receiving radiation to the head and neck area as treatment for laryngeal cancer develops ulcerations and bleeding of the oral mucosa. What should the nurse consider as the primary goal for this client?

adequate nutrition The client who has oral ulcerations related to the adverse effects of radiation is at risk for impaired nutrition. Adequate nutrition is important for healing of the ulcerations and therefore is the most important goal of those listed. The need for food and water is highest on Maslow's hierarchy, followed by the need for comfort (pain), anxiety, and self-esteem.

A nurse is caring for a client with status asthmaticus. Which medication should the nurse prepare to administer?

an inhaled beta2-adrenergic agonist An inhaled beta2-adrenergic agonist helps promote bronchodilation, which improves oxygenation. Although an I.V. beta2-adrenergic agonist can be used, the client needs be monitored because of the drug's greater systemic effects. The I.V. form is typically used when the inhaled beta2-adrenergic agonist doesn't work. A corticosteroid is slow acting, so its use won't reduce hypoxia in the acute phase.

A nurse is caring for a client with a fractured hip. The client is combative, confused, and trying to pull out necessary I.V. lines and an indwelling urinary catheter. The nurse should

assess the client for pain. The nurse should assess the client for possible causes of the behavior, such as pain. A client should never be left alone while the nurse summons assistance. All staff members must receive annual instruction on the use of restraints and the nurse should be familiar with the facility's policy. In most settings, the nurse must have a physician's order before restraining a client.

Which meal would be most appropriate for an adolescent with glomerulonephritis with severe hypertension?

baked chicken, rice, beans, orange juice The best selection of food would include no added salt or salty food. Because sodium cannot be excreted due to the oliguria and to avoid increasing the hypertension, a low-salt diet is recommended. Most canned foods have sodium added as a preservative. Ham, hot dogs, canned peas, canned carrots, corn chips, pickles, and milk are high in sodium.

A client with an intravenous (I.V.) site is experiencing pain. The nurse understands that pain with infusion is a sign of:

catheter position at the insertion site due to movement. The catheter pressing against the vein causes the pain. This would be a common result due to normal movement of the client throughout the day. The other choices should not cause pain at insertion.

A client with a bleeding peptic ulcer is admitted to an acute care facility. As part of therapy, the physician orders cimetidine I.V. Infusing this medication too rapidly may cause

hypotension When given by rapid I.V. infusion, cimetidine may cause profound hypotension and other cardiotoxic effects. Tetany and bronchospasms aren't associated with cimetidine. Although the drug may cause hallucinations, this adverse reaction doesn't result simply from rapid administration.

A nurse is assessing a client and obtains the following findings: abdominal discomfort, mild diarrhea, and a temperature of 100°F (37.8°C). The nurse questions the client about a past diagnosis of what condition?

inflammatory bowel disease (IBD)

A client is experiencing an acute myocardial infarction (MI) and I.V. morphine is ordered. The nurse knows that morphine is given because it

lowers resistance, reduces cardiac workload, and decreases myocardial oxygen demand. When given to treat acute MI, morphine eliminates pain, reduces venous return to the heart, reduces vascular resistance, reduces cardiac workload, and reduces the oxygen demand of the heart. Morphine doesn't increase myocardial contractility, raise blood pressure, or increase venous return.

When admitting an elderly client for nausea and vomiting that has lasted for 3 days, the nurse should assess for which clinical findings?

poor skin turgor. In a client with persistent nausea and vomiting, the nurse should anticipate that the client may be dehydrated and exhibit signs of a fluid deficit, such as poor skin turgor. Other typical findings include lethargy, dry mucous membranes, tachycardia, weight loss, and decreased urine output. Blood pressure is usually within normal limits in the case of a mild to moderate fluid deficit because of the compensatory mechanisms of sympathetic nervous system stimulation of the heart (causing tachycardia) and peripheral vasoconstriction.

The parents of a child with occasional generalized seizures want to send the child to summer camp. The parents contact the nurse for advice on planning for the camping experience. Which type of activity should the nurse and family decide the child should most avoid?

rock climbing A child who has generalized seizures should not participate in activities that are potentially hazardous. Even if accompanied by a responsible adult, the child could be seriously injured if a seizure were to occur during rock climbing. Someone also should accompany the child during activities in the water. At summer camps, hiking and swimming would occur most commonly as group activities, so someone should be with the child. Tennis would be considered an appropriate, nonhazardous activity for a child with generalized seizures.

A client is scheduled for bowel resection with anastomosis involving the large intestine. The nurse formulates the nursing diagnosis of Risk for infection. The nurse knows that the risk for infection is most likely related to

the presence of bacteria at the surgical site.

A 12-year-old child is sent home for pediculosis after being at camp for 1 week. The mother thinks others at camp have it. The mother asks the nurse how her son could have gotten pediculosis. How should the nurse reply?

"Children who sleep close to someone who has it get it more easily." Children at camp are at higher risk for developing pediculosis because of the close contact with others. Pediculosis is spread person to person or on other objects that are shared, such as helmets, combs, or other personal items used near the hair. Lice are not transmitted by animals or pets or during swimming.

A client with a history of suicidal thoughts and depression has just attended an outpatient day therapy group session. The nurse hears from the client that they plan to forgo lunch and the afternoon session, stating, "I just need to go home and have a nap." What would be the day therapy nurse's best response?

Ask the client to sit for a few minutes to discuss missing the afternoon session. The client is demonstrating a behavior that should be further assessed. The nurse should take the time to assess the client's thoughts, feelings, and behaviors. While the client may truly just need the rest, the client may be upset, or employing a pattern of behavior that is part of the problem. Regardless, the nurse should investigate this and also assess for safety. Asking a closed question, such as "Are you angry?" would not assist this assessment, nor would it be therapeutic to focus on rules of the program or the client's interest or enjoyment of the food.

On the first postpartum day, the nurse is caring for a primiparous client who has recently emigrated from Asia and speaks only a little English. The nurse observes that the client has been bottle-feeding her neonate on occasion, but most of the neonatal care is being performed by the client's mother-in-law. Which action would be most appropriate?

Determine whether this is a cultural practice for the client and her family. In many Asian cultures, the 30 days after the birth of the neonate is a time for the mother to heal from the birth. The appropriate action by the nurse is to determine whether this is a cultural practice for this client and her family. If so, the client is behaving within her cultural practices. Teaching should be provided to both the mother and her mother-in-law. There is no indication that bonding is not taking place. Lack of bonding might be indicated if the client did not show any interest in the neonate. Documenting the client's maternal behavior in her medical record is a routine task. However, the nurse should not assume that this behavior is unusual because it may be reflective of the client's cultural framework. A home visit is not warranted unless there is evidence of infant neglect or the family needs additional follow-up or teaching.

A nurse is developing a teaching plan for sleep hygiene. Which interventions should the nurse include? Select all that apply.

prepare the room for sleep and turn off distracting noise participate in a bedtime routine avoid caffeine, alcohol, and nicotine before bedtime Caffeine, alcohol, and substances such as nicotine act as stimulants, avoiding them should help promote sleep. Maintaining a cool temperature in the room will facilitate optimal sleep. Excessive fullness or hunger can disrupt or interfere with sleep. A regular sleep-wake time facilitates physiologic patterns, rather than waiting until an individual begins to feel tired. The room should be conducive to sleep. Eliminate distractions such as a television or radio. Participation in a relaxation, prayer, or meditation routine can help prepare an individual for a restful night.

A child is admitted to the pediatric unit with a fracture of the hip. The physician orders Russell traction. This type of traction is

skin traction applied to a lower extremity, with the extremity suspended above the bed. Russell traction is skin traction applied to a lower extremity, with the extremity suspended above the bed and a sling placed under the knee. Skeletal traction applied to a lower extremity is called 90-90 traction. Skin traction applied to an extended lower extremity is called Buck's extension traction. Skin traction applied bilaterally to the lower extremities is called Bryant's traction.

The parents of a school-age child with a brain tumor have elected to have only comfort measures instituted for their dying child. The child has been experiencing significant discomfort and has been receiving pain medication. A nurse knows that the pain-management principle most effective in controlling the child's pain is:

striving to prevent pain by routine administration of pain medication. When providing comfort measures for a child, the nurse should strive to prevent pain by providing routine pain medication. Although the nurse should administer pain medication promptly, the goal of treatment should be to prevent pain rather than simply respond to it. Assessing pain with an age-appropriate tool is important; however, the effective assessment of pain shouldn't take precedence over the effective treatment of pain. Alternating stronger opioid medications with nonopioid medications may be effective, but the nurse should individualize the treatment to meet the child's needs.

Which nursing intervention is appropriate for a client with an arm restraint?

monitoring circulatory status every 2 hours. A nurse must assess the circulatory status of a restrained extremity every 2 hours to prevent circulatory impairment. To make sure the restraint is secure without compromising the circulation, the nurse should leave approximately one fingerbreadth between the restraint and the extremity. Tying a restraint to the side rail or an immovable bed part may cause client injury if the rail or bed is moved before the restraint is released. The restrained arm or leg should be flexed slightly to allow joint movement without reducing the effectiveness of the restraint.

A client is experiencing intertrigo caused by friction between the inner thighs. Which action should the nurse take to help this client?

Apply lubricating lotion over the affected areas. Friction between the inner thighs can be reduced by applying a lubricant over the affected areas. An antihistamine would be used for an allergic reaction. Because there is no evidence that the affected area was caused by a fungus, an antifungal agent would not be appropriate. Warm soaks may cause further irritation to the affected skin areas and should not be used.

A nurse is examining a client in active labor, who has had spontaneous rupture of the amniotic membrane, and notes a protruding umbilical cord. What is the priority nursing action?

Place the client in knee-chest position. A Trendelenburg or knee-chest position takes the weight of the fetus off the umbilical cord, allowing blood to flow. The cord should never be pushed back into the uterus, as this could damage the cord, obstruct the flow of blood through the cord to the fetus, or introduce infection into the uterus. The client should not be instructed to push, as she is only in active labor, and emergency surgery may be necessary. The cord should be wrapped in a sterile saline-soaked gauze.

A school nurse is teaching 4th graders about preventing injuries when riding bicycles, skateboarding, or using scooters. Indicate which is the best way for the nurse to motivate the children to use safety equipment?

Present slides of famous athletes wearing protective gear. Children of this age will identify with peers and role models. "Scare tactics" do not appeal to the intellect of the child. Showing an animated movie may make a point but not necessarily gain compliance as it does not appeal to reality thinking of this age group. Asking children what they know is a good way to determine a starting point for teaching.

A nurse caring for a client at a health care facility has to maintain a medical record for the client. Which of the following is a use of the medical record?

To investigate the quality of care in the agency. Medical records may occasionally be used to investigate the quality of care in the agency. A medical record is not used to transmit health records between insurance companies, to inform family and others concerned about the client's care, or to release the entire health record for research, as these actions would jeopardize the individual's right to privacy.

A client has an intracapsular hip fracture. The nurse should conduct a focused assessment to detect which change near the fracture?

shortening of the affected leg With an intracapsular hip fracture, the affected leg is shorter than the unaffected leg because of the muscle spasms and external rotation. The client also experiences severe pain in the region of the fracture.

According to Erikson's theory of development, chronic illness will have the greatest impact on which client?

11-year-old According to Erikson, an 11-year-old client is working through the stage of industry versus inferiority. Chronic illness may interfere with this stage of development in an 11-year-old client because the client may not be able to accomplish tasks, which prevents the client from achieving a sense of industry. A 1-year-old (trust versus mistrust), a 3-year-old (autonomy versus shame and doubt), and a 41-year-old (generativity versus stagnation) are less likely to be impacted by the chronic illness; the younger age is less likely to be aware of the impact of chronic illness while the older adult would be more likely to adjust to the impact of chronic illness.

Which amount of daily milk intake should the nurse include in the plan of care for a 15-month-old?

2 to 3 cups (500 to 750 mL) Toddlers around the age of 15 months need 2 to 3 cups (500 to 750 mL) of milk per day to supply necessary nutrients such as calcium. A daily intake of more than 3 cups (750 mL) of milk may interfere with the ingestion of other necessary nutrients.

A child with a body surface area (BSA) of 0.82 m2 has been prescribed actinomycin 2.5 mg/m2 intravenously. What is the correct amount to be given? Record your answer using two decimal places.

2.05 mg 0.82 m2 × 2.5 mg/m2 = 2.05 mg

An employee health nurse is assisting a stressed working mother with value clarification. Which of the following best defines value clarification?

A process by which people come to understand their own values and value systems. Value clarification is a process by which people come to understand their own values and value systems. A value is a belief about the worth of something, about what matters, that acts as a standard to guide one's behavior. A value system is an organization of values in which each is ranked along a continuum of importance, often leading to a personal code of conduct. Ethics is a systematic inquiry into principles of right and wrong conduct, of virtue and vice, and of good and evil, as they relate to conduct.

A client states, "If my heart stops beating, I do not want to be resuscitated." Which action would the nurse take?

Ask if the client discussed this with the healthcare provider. When a client is admitted to a hospital, the nurse is responsible for providing information about the client's rights to information, informed consent, timely responses to requests for services, and treatment refusal. The primary right to decide belongs to the client or family, but a healthcare provider's order must be obtained and should describe the actions that the nurses would take if the client requires CPR. The nurse would ask if the client has discussed these wishes with the healthcare provider in order to assist with obtaining the written order. A notarized advance directive is not needed to establish the client's wishes.

A client is diagnosed with rheumatoid arthritis, an autoimmune disorder. When teaching the client and family about autoimmune disorders, the nurse should provide which information?

Autoimmune disorders include connective tissue (collagen) disorders. Connective tissue disorders are considered autoimmune disorders. Clients with autoimmune disorders may have either false-positive or false-negative serologic tests for syphilis. Other common laboratory findings in these clients include Coombs-positive hemolytic anemia, thrombocytopenia, leukopenia, immunoglobulin excesses or deficiencies, antinuclear antibodies, antibodies to deoxyribonucleic acid and ribonucleic acid, rheumatoid factors, elevated muscle enzymes, and changes in acute phase-reactive proteins. No cure exists for autoimmune disorders; treatment centers on controlling symptoms. Autoimmune disorders aren't distinctive; they share common features, making differential diagnosis difficult.

If a client's central venous catheter accidentally becomes disconnected, what should a nurse do first?

Clamp the catheter. If a central venous catheter becomes disconnected, the nurse should immediately apply a catheter clamp. If a clamp isn't available, the nurse may place a sterile syringe or catheter plug in the catheter hub. After cleaning the hub with alcohol or povidone-iodine solution, the nurse must replace the I.V. extension set and restart the infusion. Calling the physician, applying a dry sterile dressing to the site, and telling the client to take a deep breath aren't appropriate interventions at this time.

A nurse on a labor and birth unit goes to the cafeteria for lunch with colleagues. One colleague begins talking about a newer staff member and says, "I heard that she does not have any labor and birth nursing experience." Which of the following is the nurse's most appropriate action?

Discuss the colleague's behavior in private. This behavior is unprofessional and breaches client confidentiality as per the American Nurses Association (Canadian Nurses' Association) Code of Ethics. The nurse is obligated to approach the colleague and discuss inappropriate behaviors. Therefore, it is inappropriate to ignore the comment. Discussing this in private demonstrates professional conduct rather than confronting the colleague immediately. It is inappropriate to ask how the colleague knows this information because doing so would contribute to the unprofessional behavior.

A client is receiving chemotherapy for cancer. The nurse reviews the client's laboratory report and notes that the client has thrombocytopenia. To which nursing diagnosis should the nurse give the highest priority?

Ineffective tissue perfusion: Cerebral, cardiopulmonary, GI These are all appropriate nursing diagnoses for the client with thrombocytopenia. However, the risk of cerebral and GI hemorrhage and hypotension pose the greatest risk to the physiological integrity of the client.

A nurse is caring for a client with a low calcium level. Place the following options in chronological order to indicate the regulatory feedback mechanism of parathyroid hormone (PTH) release in relation to calcium levels. All options must be used.

Low serum calcium level stimulates parathyroid gland. Parathyroid gland releases PTH. Calcium is reabsorbed. High serum calcium level inhibits PTH secretion.

A client receiving digoxin has a serum magnesium level of 0.9 mg/dL (0.57 mmol/L). What is the nurse's best action?

Notify the healthcare provider. The decreased magnesium level can potentiate digoxin toxicity, and the healthcare provider should be notified. The digoxin should not be administered until the nurse receives clarification from the healthcare provider. Increasing fluids is not appropriate. Calcium gluconate is administered for hypermagnesemia.

A newly hired nurse on unit orientation prepares to administer vitamin K to a neonate. The nurse draws up 1 mg of vitamin K and prepares to administer a subcutaneous injection in the left, lateral anterior thigh. Which action by the nurse preceptor is best?

Stop the nurse and ask that the injection techniques be reevaluated. Vitamin K should be administered by I.M. injection. Therefore, the nurse preceptor should stop the nurse and have injection techniques reevaluated by the nurse. The nurse preceptor can praise the nurse after the injection is administered correctly. The nurse preceptor can distract the neonate by talking calmly, but the nurse preceptor should first stop the nurse from administering the medication by the wrong route. The injection should be administered by the I.M. route, not by the Z-track method.

When developing the plan of care for a neonate, what measure should the nurse include to prevent heat loss from conduction?

Warm the stethoscope before using it. Because a neonate has poor thermal stability, reducing heat loss is very important. Conduction involves the loss of heat to a cooler surface by direct skin contact. Cold stethoscopes, cold hands, and cold scales can all cause heat loss by conduction. Therefore, warming the stethoscope before using it would be appropriate. Drying the neonate with sterile towels prevents heat loss from evaporation, the loss of heat when water is converted to a vapor. Keeping the neonate away from windows prevents heat loss from radiation. Radiation losses occur when heat is transferred from a heated body surface to a cooler solid object not in direct contact with the body. Administering warm oxygen prevents heat loss from convection, loss of heat from the warm body surface to cooler air currents.

A client with end-stage renal failure has an internal arteriovenous fistula in the left arm for vascular access during hemodialysis. What should the nurse instruct the client to do? Select all that apply.

Wear wrist watch on the right arm. Avoid sleeping on the left arm. Assess fingers on the left arm for warmth. The nurse instructs the client to protect the site of the fistula. The client should avoid pressure on the involved arm such as sleeping on it, wearing tight jewelry, or obtaining BP. The client is also advised to assess the area distal to the fistula for adequate circulation, such as warmth and color. When the client is hospitalized, the nurse posts a sign on the client's bed not to draw blood or obtain BP on the left side; the client is also instructed to be sure that none of the health care team members do so.

When developing a nutritional plan for a child who needs to increase protein intake, the nurse should suggest which foods? Select all that apply.

cooked dry beans peanut butter yogurt

A client with a diagnosis of respiratory acidosis is experiencing renal compensation. What function does the kidney perform to assist in restoring acid-base balance?

returning bicarbonate to the body's circulation. The kidney performs two major functions to assist in acid-base balance. The first is to reabsorb and return to the body's circulation any bicarbonate from the urinary filtrate; the second is to excrete acid in the urine. Retaining bicarbonate will counteract an acidotic state. The nephrons do not sequester free hydrogen ions.

After doing well for a period of time, a child with leukemia develops an overwhelming infection. The child's death is imminent. Which statement offers the nurse the best guide in making plans to assist the parents in dealing with their child's imminent death?

Parents are especially grieved when a child does well at first but then declines rapidly. It has been found that parents are more grieved when optimism is followed by defeat. The nurse should recognize this when planning various ways to help the parents of a dying child. It is not necessarily true that knowing about a poor prognosis for years helps prepare parents for a child's death. Death is still a shock when it occurs. Trust in health care personnel is not necessarily destroyed when a death is untimely if the family views the personnel as having done all that was possible. It is not more difficult for parents to accept the death of an older child than that of a younger child.

The nurse is assessing a client, who has lung cancer with spinal metastasis, for pain. The client tells the nurse that the ordered opioid medication helps, but there is still a shooting pain down the client's left leg. Identify the best pharmacologic measure to address this pain.

an adjuvant, such as gabapentin. The pain that this client is describing is classic neuropathic pain. The fact that the client has spinal metastasis is more evidence of this. Opioids and ibuprofen do not fully address neuropathic pain.

The client is having mild pain and inquires about what medications they can use. Which analgesic will the nurse teach the client to use for mild pain? Select all that apply.

ibuprofen acetaminophen naproxen Ibuprofen, acetaminophen, and naproxen are all analgesics that are used for mild pain. Fentanyl and hydrocodone are opioids and should be avoided for treatment of mild pain. They are more appropiate for moderate to severe pain.

A client with acute mania is to receive lithium carbonate 600 mg PO three times daily and 2 mg of haloperidol PO at bedtime. Which action should the nurse take?

Give the medications as prescribed. Lithium commonly is combined with an antipsychotic agent, such as haloperidol, or a benzodiazepine such as lorazepam. Antipsychotic agents, such as haloperidol, are prescribed to produce a neuroleptic effect until the lithium, produces a clinical response. After a clinical response is achieved, the antipsychotic agent usually is discontinued. Additionally, the dosages of each drug listed are appropriate. Therefore, the nurse would administer the drugs as prescribed.

A client in a catatonic state is admitted to the inpatient unit. The client is emaciated, stares blankly into space, and does not respond to verbal or tactile stimuli. Which nursing intervention is a priority?

assessing the client's nutritional and hydration status Priority is placed on immediate physical needs over psychosocial needs. In this situation, nutritional needs are the priority for a client in a catatonic state. Providing therapeutic communication, emotional stimulation, and a safe, nurturing, supportive environment and orienting the client to the environment are all appropriate actions, but the client's immediate physical needs must be met first.

A client with a history of polysubstance abuse is admitted to the facility. The client reports nausea and vomiting 24 hours after admission. The nurse who assesses the client notes piloerection, pupillary dilation, and lacrimation. The nurse suspects that the client is going through withdrawal from which substance?

opioids Piloerection, pupillary dilation, and lacrimation are specific to opioid withdrawal. A client with alcohol withdrawal would show elevated vital signs. There is no real withdrawal from cannabis. Symptoms of cocaine withdrawal include depression, anxiety, and agitation.

The nurse is caring for a client with end-stage kidney disease. What arterial blood gas results are most closely associated with this disorder?

pH 7.20, PaCO2 36, HCO3 14- Metabolic acidosis occurs in ESKD because the kidneys are unable to excrete increased loads of acid. Decreased acid secretion results from the inability of the kidney tubules to excrete ammonia (NH3-) and to reabsorb sodium bicarbonate (HCO3-). There is also decreased excretion of phosphates and other organic acids.

A client who had a left thoracoscopy sustained an injury secondary to the surgery position. The nurse should assess the client for which sign?

tingling in the arm. A client who had a left thoracoscopy is placed in the lateral position, in which the most common injury is an injury to the brachial plexus. Numbness and tingling in the arm suggests a brachial plexus injury. There is no undue pressure on the ankles or knees during thoracic surgery.

A nurse suspects that a child, age 4, is being neglected. Which question should the nurse ask the parents to best assess the child's nutritional status?

"What did your child eat for breakfast?" The nurse should ask what the child ate for breakfast in order to obtain objective information about the child's nutritional intake. Asking if the child has always been so thin, is a picky eater, or eats enough would elicit subjective replies that would be open to interpretation.

A client who has been diagnosed with peripheral artery disease (PVD) is being discharged. What statement by the client indicates the client needs further instruction?

"I should wipe any injury with iodine on a cotton ball." The client should avoid using iodine or over-the-counter medications. Iodine is a highly toxic solution. An individual who has known PVD should be seen by a health care provider (HCP) for treatment to avoid infection. The client with PVD should avoid heating pads and crossing the legs, and should wear leather shoes. A heating pad can cause injury, which, because of the decreased blood supply, can be difficult to heal. Crossing the legs can further impede blood flow. Leather shoes provide better protection.

The nurse is instructing an unlicensed assistive personnel (UAP) on the prevention of postoperative pulmonary complications. Which statement indicates that the UAP has understood the nurse's instructions?

"I will have the client take 5 to 10 deep breaths every hour." Having the client deep breathe hourly is the most appropriate action for the UAP to take to help prevent pulmonary complications. The client should be turned at least every 2 hours or as needed for this particular client. Keeping the client's head elevated will not prevent pulmonary complications. Suctioning the client is not a UAP's responsibility, nor does it prevent pulmonary complications.

A client is diagnosed with Addison's disease. Which statement by the client to the nurse would require further instruction?

"I will use salt substitute to flavor my foods." 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.

The mother of an infant with flat feet asks the nurse what she can do about the problem. Which response from the nurse is the most appropriate?

"Infants have a fat pad below the arch, making it look like flat feet when they are not." Infants have a fat pad below the arch, giving the appearance of flat feet. Exercises will not correct flat feet. Flat feet cause no other orthopedic problems in infants. Corrective shoes will have no effect on strengthening the arches of the child's feet.

During a prenatal visit, the client has told the nurse that she intends to give birth at a spiritual retreat center that is distant from population centers or healthcare facilities. What is the nurse's best response?

"It sounds like you have given this a lot of consideration. What is it about giving birth there that will be special for you?" Asking about what the woman hopes to gain or experience is an empathic and therapeutic way of initiating dialogue about this client's decision. Offering a warning will likely sever any follow-up discussion. Ultimately, clients do not need permission to enact a care plan. Acknowledging that non-hospital births are increasingly common is appropriate, but it is helpful to follow a statement with a question.

The client with a spinal cord injury asks the nurse why the dietitian has recommended to decrease the total daily intake of calcium. Which response by the nurse would provide the most accurate information?

"Lack of weight bearing causes demineralization of the long bones." Long-bone demineralization is a serious consequence of the loss of weight bearing. An excessive calcium load is brought to the kidneys, and precipitation may occur, predisposing to stone formation. Excessive intake of dairy products may promote constipation. However, this is not the most accurate reason for decreasing calcium intake. Immobility does not increase calcium absorption from the intestine. Dairy products do not necessarily contribute to weight gain.

A client with psoriasis is scheduled for ultraviolet B (UVB) phototherapy. Which statement by the client indicates a correct understanding of this form of treatment?

"Phototherapy can slow down the production of skin cells." The use of phototherapy slows down the production of epidermal cells, thereby reducing the occurrence of scales on the client's skin. Psoriasis is a lifelong condition that is not cured. Itching is an expected clinical manifestation occurring after phototherapy. The use of creams or lotions is often helpful in reducing itching and is not contraindicated.

A nurse is verifying a medication calculation completed by a nursing student prior to administration. The adult client is to receive ampicillin 150 mg/kg/day I.V. divided in 6 even doses with a maximum dose of 12 g/day. The client's weight is 80 kg. How many mg/dose will the client receive? Record your answer using whole number.

2,000 mg/dose The nurse should verify that the total dosage will not exceed the maximum dosage of 12 g/day. 150 mg/kg / day x 80 kg = 12,000 mg/day ÷ 6 doses = 2,000 mg per dose

A client admitted to the hospital for chemotherapy states that using a peppermint-scented candle at home to helps control nausea. Which interventions would the nurse plan to promote comfort for this client?

Asking the client to try using peppermint oil in place of scented candles 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 the client to continue using that scent, but 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.

The nurse is admitting a client directly from a healthcare clinic. The healthcare provider's orders are illegible. What should the nurse do next? Select all that apply.

Call the healthcare provider to clarify orders. Hold all orders. If the nurse cannot correctly interpret the components of a medication order, the nurse should hold the orders and call the healthcare provider for clarification. The only person that can interpret the components of the orders are the person who wrote the orders.

A physical therapist has instructed the nursing staff on how to perform range-of-motion (ROM) exercises for an infant with torticollis. The nurse is uncomfortable when the infant cries and grimaces during the exercises. What is the most important action for the nurse to take?

Call the physical therapist. The only cure for the torticollis is exercise or surgery. The physical therapist is the expert in exercise and should be called for assistance in this situation. The primary health care provider should only be called if there is concern over the orders written, or an abnormal development in the child.

A nurse is caring for a woman who gave birth to her baby boy 2 hours ago. The nurse notes the woman's perineal pad contains some small clots and a moderate amount of lochia has accumulated under her buttocks. What is the first action the nurse should take at this time?

Check fundus for position and consistency. While the greatest risk of postpartum hemorrhage is within the first hour following birth, a woman can develop an early postpartum hemorrhage anytime within the first 24 hours post-birth. As soon as the nurse notices an increased amount of lochia and clots, the fundus must be assessed for firmness and position. Normally, it should be firm, midline, and either just above or below the umbilicus. Massaging the fundus if it is not firm will assist with a uterine contraction to help decrease blood loss postpartum. Administering oxytocin would not be the first action for the nurse to take. Performing an in-and-out catheterization at this time is not appropriate. The nurse should assist the woman to the washroom to void on her own first. The nurse can measure the blood loss by measuring the perineal pad; however, this would be done after the nurse has first assessed the fundus.

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?

Consult the drug guide provided by the clinical agency. 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 client admitted with anorexia nervosa lost 30 lb (13.6 kg) during the previous 3 months. When planning this client's care, what should a nurse select as a priority intervention?

Consult with a dietitian about the client's dietary needs. The nurse must first assess and plan interventions for the client's nutrition and other immediate physical needs. The nurse should consult with a dietitian to determine the client's dietary requirements, set nutritional goals, and explore ways to meet those goals. Obtaining strict intake and output, providing a safe environment during mealtime, and instructing the client to eat at least 1000 calories a day are also important interventions. However, they don't meet basic physical needs and aren't priority interventions at this time.

A 5-year-old child exhibits signs of extreme restlessness, short attention span, and impulsiveness. Which intervention by the nurse would be therapeutic for this child?

Define behaviors that are acceptable and behaviors that are not permitted. Children need to know what behaviors are acceptable and what behaviors are unacceptable. They feel more secure when limits are clear and when policies concerning their behavior are consistently enforced. Increasing sensory stimulation tends to increase hyperactive and impulsive behavior. Limiting opportunities to verbalize anger and frustration tends to increase stress and frustration for the child. Physical activities are needed to help the child expend energy, reduce anxiety, and increase self-worth.

A woman with preeclampsia is receiving magnesium sulfate via infusion pump at 1 g/h. The nurse's assessment includes temperature 36.7°C; pulse 78; respirations 12/minute; blood pressure 128/82 mm Hg; urinary output 90 mL in last 4 hours via urinary catheter; patellar-tendon reflex absent; ankle clonus absent; fetal heart rate 120 beats/min; cervix 4 cm dilated, 80% effaced, station -1. Which is the most appropriate action for the nurse to take?

Discontinue the magnesium sulfate infusion and notify the health care provider (HCP). The nurse must be alert to signs of magnesium sulfate toxicity that include loss of deep tendon reflexes, which is often the first sign (patellar-tendon response is the most common reflex tested); urinary output decreases (should have at least 30 mL/h); and respirations decrease (12 respirations/min is low and could be developing respiratory distress). The first action would be to stop magnesium sulfate infusion and notify the HCP. The urinary catheter tubing maybe kinked; however, looking at all findings would indicate the woman is experiencing magnesium sulfate toxicity. It is not a priority to obtain a urine sample. Documentation is extremely important to complete; however, the nurse must intervene by stopping the magnesium sulfate and notifying the primary care provider. Increasing fluid intake at this point is not appropriate with a woman who has magnesium sulfate toxicity. Intake and output should be ongoing for a client on intravenous fluids and magnesium sulfate and a diagnosis of preeclampsia.

A client is stabilized in the emergency department and moved to the neurologic intensive care unit with a diagnosis of spinal cord injury at level C4-C5. The nurse is working with an experienced unlicensed assistive personnel (UAP). Which items can the nurse delegate to the UAP? Select all that apply.

Ensure that oxygen is flowing at 5 liters per minute by nasal cannula. Check the client's pulse oximetry reading every 1 hour. An experienced UAP would be able to make sure the oxygen is flowing, the setting is correct, and the cannula is correctly positioned; the UAP would also know how to measure oxygen saturation rate by pulse oximetry. Assessments, auscultation of lungs, and client teaching require additional education, training, and skill and are appropriate for the RN scope of practice.

A nurse is teaching a client who has HIV about the adverse effects of aquinavir. What information is important to include?

thrombocytopenia Saquinavir is an antiretroviral-protease inhibitor used in combination with other antiretroviral medications to help manage HIV. Adverse effects include hyperglycemia, bone loss, hypersensitivity reaction, hyperlipidemia, thrombocytopenia, and leukopenia.

A breastfeeding primiparous client asks the nurse how breast milk differs from cow's milk. The nurse responds by saying that breast milk is higher in which nutrient?

Fat A breastfeeding primiparous client asks the nurse how breast milk differs from cow's milk. The nurse responds by saying that breast milk is higher in which nutrient?

When teaching parents about fifth disease (erythema infectiosum) and its transmission, the nurse should provide which information?

Fifth disease is transmitted by respiratory secretions. Fifth disease is transmitted by respiratory secretions. The transmission mode for roseola is unknown. Rubella is transmitted by respiratory secretions, stool, and urine. Intestinal parasitic conditions, such as giardiasis and pinworm infection, are transmitted by stool.

The nurse has completed an admission assessment on a retired military service member who has served two tours in Iraq. The nurse notes that the client continually fidgets, makes no eye contact, and responds to questions with "yes" and "no" answers. What is the priority nursing intervention?

Explore what experiences cause the client distress.

A nurse is caring for a newborn who has developed sepsis. The healthcare provider has given the following orders. Which order will the nurse implement first?

Obtain blood cultures. All of the orders that the healthcare provider initiated are important but the nurse should obtain the blood culture before starting any other interventions—especially before starting the ampicillin. If the culture is obtained after a dose of ampicillin has been given, the results of the culture could be altered and unreliable.

A woman at 22 weeks' gestation has right upper quadrant pain radiating to her back. She rates the pain as 9 on a scale of 1 to 10 and says that it has occurred 2 times in the last week for about 4 hours at a time. She does not associate the pain with food. Which nursing measure is the highest priority for this client?

Refer the client to her health care provider for evaluation and treatment of the pain.

When given by rapid I.V. infusion, cimetidine may cause profound hypotension and other cardiotoxic effects. Tetany and bronchospasms aren't associated with cimetidine. Although the drug may cause hallucinations, this adverse reaction doesn't result simply from rapid administration.

Provide a bed that is low to the floor. Providing a bed that is low to the floor complies with the least restraint policy and prevents falls from the bed. Raising all side rails on the bed would be considered excessive restraint and could contribute to greater risk of injury if the client tried to climb out of bed. The other options do not fully ensure the safety of the client.

As the nurse arrives to visit a family 2 days after release from the hospital, she hears shouting and swearing between the mother and father and several loud crashes, just as she is going to knock on the door. What action by the nurse is the most appropriate?

Return to the car and call the police. The nurse needs to consider his/her own personal safety in this situation and how he/she will be the most help to this family. The nurse needs to get some back-up support before entering the house due to the potential for violence. The nurse should not go into the home if his/her safety is in danger.

The client is a 17-year-old single mother who has given birth. On her first postpartum day, the client seems overwhelmed with her new baby and asks the nurse how she is supposed to interact with her baby when all the baby does is eat and sleep. Which of the following actions would be most effective for the nurse to use to facilitate mother-infant attachment?

Show the client how the baby initiates interaction with her and attends to her. Teaching the client how her baby comes prepared to interact with her will help her see that they are in a reciprocal relationship. This will help the client identify in the future other cues the baby is using to communicate with her and will increase the opportunities for attachment. Encouraging the client to pay attention to her baby may imply that the nurse does not believe the client is appropriately responding to her baby. Encouraging the client to watch a video may imply that the nurse is not interested in communication or spending time with her. Demonstrating different positions for holding the baby may be part of the teaching to facilitate mother-infant attachment, but this is only a small portion of attachment measures and it is more appropriate to teach the client about her newborn's interaction cues.

A client with appendicitis is experiencing excruciating abdominal pain. An abdominal X-ray film reveals intraperitoneal air. What should the nurse prepare the client for?

Surgery The client should be prepared for surgery because the signs and symptoms indicate bowel perforation. Appendicitis is a common cause of bowel perforation. Because perforation can lead to peritonitis and sepsis, surgery would not be delayed to perform other interventions, such as colonoscopy, NG tube insertion, or a barium enema. These procedures are not necessary at this point.

The nurse unit manager is making rounds on a team of clients and notices a client with a color-coded armband that indicates the client is at risk for falling walking down the hall unassisted. The client is at the end of the hallway farthest from the client's room, but is not tired. What should the nurse do first?

Walk with the client back to the room, and assist the client to get in bed or a chair. The client is identified as being at risk for falling, and a staff member or family member should accompany the client when walking. The nurse should first accompany the client back the room. Because the client is not fatigued, the client does not need a wheel chair, but must have assistance. The nurse can delegate the task of ambulating the client to the UAP, but it may take a while to locate one that it available at this time. Walking only in the room will not provide an opportunity for the client to gain strength and improve ambulation, but the nurse should remind the client to have assistance.

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

During morning assessment, a nurse assesses four clients. Which client is the priority for follow up?

a 73-year-old client who has pneumonia with coarse crackles, is receiving 2 L/minute of oxygen, and has an I.V. line The 73-year-old client with pneumonia should be the nurse's priority because of the oxygenation complications and the audible crackles that may result from fluid overload from the I.V. line. The 42-year-old client is younger and more mobile than the others. The 84-year-old client doesn't have pressing needs at this time. The nurse should evaluate the 48-year-old client if the client goes into atrial fibrillation, but this client isn't a priority at this time.

A client comes to a community mental health clinic for a psychiatric evaluation at the family's request. During the initial interview, the client tells the nurse about painting the streets to beautify the city, lecturing subway riders about germ control, and banning smoking in order to clean up the environment. The client is irritable and easily distracted by the slightest sound. Which stage of mania is the client exhibiting?

acute mania The client is demonstrating an expansive mood, high energy level, racing thoughts, and disjointed thinking. Any type of stimulation will distract the client from the current conversation. This behavior is indicative of the acute manic phase of mania. Hypomania is a mania phase characterized by an abnormally elevated mood, signs of inflated self-esteem, decreased sleep, flight of ideas, and pleasure-seeking behaviors. This phase lasts for 4 days or less. The delirious mania phase is when the client exhibits signs and symptoms of mania and delirium. Dementia mania isn't a phase of mania.

The nurse is caring for a client with juvenile idiopathic arthritis. What will the nurse include in the client's plan of care? Select all that apply.

administer ibuprofen for pain encourage a well-balanced diet measure growth and development assess joints for swelling and deformity Juvenile idiopathic arthritis affects the joints. Ibuprofen is a drug of choice, and eating a well-balanced diet helps in weight management. The joints can become deformed and swollen. Growth and development can be affected due to the changes in the joints.

Which intervention would be least appropriate for a client who is in a double hip spica cast?

advising the client to eat large amounts of cheese Explanation: The client in a double hip spica cast should avoid eating foods that can be constipating, such as cheese. Rather, fresh fruits and vegetables should be encouraged, and the client should be encouraged to drink at least 2,500 mL/day. Drinking cranberry juice, which helps keep urine acidic, thereby avoiding the development of renal calculi, is encouraged. The client should be encouraged to establish regular times for elimination to promote regularity in bowel and bladder habits. The client will develop orthostatic hypotension unless the circulatory system is reconditioned slowly through dangling and standing exercises.

A client with renal insufficiency is admitted to the hospital with pneumonia. The client is being treated with gentamicin. Which laboratory value should be closely monitored?

blood urea nitrogen (BUN) BUN and creatinine levels should be closely monitored to detect elevations caused by nephrotoxicity. Sodium level should be routinely monitored in all hospitalized clients. Alkaline phosphatase helps evaluate liver function. The WBC count should be monitored to evaluate the effectiveness of the antibiotic; it doesn't help evaluate kidney function.

A client with acute osteomyelitis is to receive parenteral penicillin for 4 to 6 weeks. Before administering the first dose, the nurse asks the client about known drug allergies. An allergy to which antibiotic or antibiotic class necessitates cautious use of penicillin?

cephalosporins

Four clients are assigned to a nurse. Which client should the nurse identify who would benefit the most from hyperbaric oxygen therapy?

client with a compromised skin graft A client with a compromised skin graft could benefit from hyperbaric oxygen therapy because increasing oxygenation at the wound site promotes wound healing. Hyperbaric oxygen therapy is not used to improve the oxgyenation status of a client with chronic obstructive pulmonary disease or pneumonia. This type of treatment would not encourage bone healing after a fracture.

A client being treated for complications of chronic obstructive pulmonary disease needs to be intubated. The client has previously discussed their wish to not be intubated with the client's partner of 5 years, whom the client has designated as healthcare power of attorney. The client's children want their parent to be intubated. A nurse caring for this client knows that

clients commonly confer healthcare power of attorney on someone who shares their personal values and beliefs. The healthcare 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 healthcare 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 healthcare power of attorney in regards to healthcare decisions supersede those of family members. The law designates the healthcare power of attorney as the person to make decision; violating this designation could result in a lawsuit.

The client is admitted to the hospital for alcohol detoxification. Which intervention should the nurse use? Select all that apply.

monitoring intake and output reinforcing reality if the client is disoriented or hallucinating explaining to the client that the symptoms of withdrawal are temporary taking vital signs 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.

Which assessment finding would advise the nurse of a need to change from the prescribed intranasal route to an injection of desmopressin acetate for a child with diabetes insipidus?

mucous membrane irritation Mucous membrane irritation, caused by a cold or allergy, can render the intranasal route unreliable. Severe coughing, pneumonia, and nosebleeds shouldn't interfere with the intranasal route.

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

myxedema coma 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 is caused by severe hyperthyroidism. Systolic hypertension is associated with thyroid storm. A cerebrovascular accident is not typically associated with hypothyroidism.

The nurse is reviewing sterile procedures with a student nurse. The nurse understands that the student requires additional teaching when the student identifies which procedure as requiring sterile technique?

nasogastric (NG) tube placement The GI system isn't a sterile system; therefore, NG tube placement doesn't require sterile technique. I.V. insertion requires sterile technique because intentional penetration of the skin occurs. The urinary system is sterile, so the nurse must maintain sterility during catheter placement. Burns have a high risk for infection; the nurse must maintain sterile technique to decrease this risk.

While assessing a neonate at 4 hours after birth, the nurse observes an indentation with a small tuft of hair at the base of the neonate's spine. The nurse should document this finding as what finding?

spina bifida occulta A small tuft of hair and an indentation at the base of the neonate's spine is termed spina bifida occulta. This condition usually occurs between the L5 and S1 vertebrae with failure of the vertebrae to completely fuse. There are usually no sensory or motor deficits with this condition. Spina bifida cystica includes meningocele, myelomeningocele, and lipomeningocele. Meningocele is characterized by a saclike protrusion filled with spinal fluid and meninges. Usually, this condition is associated with sensory and motor deficits. Myelomeningocele is characterized by a saclike protrusion filled with spinal fluid, meninges, nerve roots, and spinal cord. With myelomeningocele, there are usually sensory and motor deficits.

A client with atrial fibrillation is prescribed warfarin. How should the nurse explain the purpose of this medication to the client?

"Warfarin is prescribed to people with atrial fibrillation to reduce the risk of having a stroke." Warfarin prevents vitamin K from synthesizing certain clotting factors and is used to reduce thrombus formation in the atria of people with atrial fibrillation. This reduces the risk of stroke. Warfarin and other anticoagulants do not alter the viscosity of the blood despite being commonly referred to as "blood thinners." Warfarin does not alter the rhythm associated with atrial fibrillation. Warfarin does increase the client's risk for bleeding, but this is a side effect, not the purpose of the medication.

A client ingested a large amount of acetaminophen at 1:00 am. Two hours later, the client comes to the emergency department, and is diagnosed with acetaminophen poisoning. What is the priority intervention for this client?

Administer acetylcysteine. If the client is seen within 1 hour of ingestion, activated charcoal can be given to prevent absorption, or gastric lavage can be used. Blood work would be obtained but wouldn't be the first priority. Intravenous fluids would also be administered, but administering ?-acetylcysteine, the specific antidote for acetaminophen poisoning, is the priority.

The hospital accreditation visitors are present on the nursing unit. What nursing actions will protect client privacy during the visit? Select all that apply.

Keep the client's curtains closed when providing direct care. Log off the computer screen when not in use. Secure client's medical records in a locked cabinet. Keeping client's curtains closed when providing direct care, logging off the computer screen when not in use, and securing client's medical records in a locked cabinet are actions to protect clients' privacy. Posting a computerized list of clients and allowing a client to use the nurses' desk do not provide client privacy.

A female client who has diagnosis of borderline personality disorder is manipulative and very disruptive on the hospital unit. She is not dangerous to herself or others, but is clearly not making any therapeutic progress. She consistently refuses any medications. The nurse realizes that legally this client has which option?

Refuse treatment. A client who has not been deemed a danger to self or others or who has not been declared incompetent retains the right to refuse treatment. Legal protocols need to be followed to initiate treatment against an adult client's wishes, even if the family wishes treatment to occur. Punitive threats of retaliation or loss of privileges are ethically unacceptable in administering treatment.

A client with toxoplasmosis and cytomegalovirus is confused and has been dislodging the I.V. access device. The client's scheduled to receive amphotericin B I.V. Which action would be most appropriate for the nurse to take?

Tell a nursing assistant to stay with the client during the infusion. The client needs the medication to combat the protozoal infection. Because the client has been dislodging the I.V. access devices, a staff member should remain with with the client during the infusion. Bilateral wrist restraints are a poor choice for managing this situation, and using them doesn't ensure that the client will receive the medication. Giving sedation to a confused client is risky, and it's a poor alternative to having a staff member remain with the client. Administering the drug shouldn't be delayed; appropriate nursing action allows for the drug's administration.

A client presents to a physician's office complaining of dyspnea with exertion, weakness, and coughing up blood. Further examination reveals peripheral edema, crackles, and jugular vein distention. The nurse anticipates the physician will make which diagnosis?

pulmonary hypertension Dyspnea, weakness, hemoptysis, and right-sided heart failure are all signs of pulmonary hypertension. Clients with COPD present with chronic cough, dyspnea on exertion, and sputum production. Those with empyema are acutely ill and have signs of acute respiratory infection or pneumonia. Clients with pulmonary tuberculosis usually present with low-grade fever, night sweats, fatigue, cough, and weight loss.

What should the nurse do when a hospitalized client is observed to have a ritualistic pattern of behavior?

Allow the client to continue so that he will not become more anxious. It is best to accept compulsive behavior in a comparatively permissive manner. The client may become increasingly anxious if he is denied the ritualistic activity. Isolating the client is inappropriate because it will have no effect on the behavior and will decrease the client's self-esteem. Observing for marked changes in behavior is unwarranted as this is unlikely. Reminding the client that he can control his behavior if he wishes is inappropriate in this situation because the action is needed to control anxiety. The nurse works with the client to find alternative anxiety-management methods that will result in a decrease in ritualistic behavior. Interrupting the behavior will increase anxiety.

For a primigravid client with the fetal presenting part at -1 station, what would be the nurse's priority immediately after a spontaneous rupture of the membranes?

Check the fetal heart rate. Immediately after a spontaneous rupture of the membranes, the nurse should listen to the fetal heart rate to detect bradycardia. With the fetus at -1 station, the cord may prolapse as amniotic fluid rushes out. Fetal heart rate should be monitored because it will indicate if cord prolapse or cord compression has occurred. The color, amount, and odor of the amniotic fluid should be noted. Although the optimal position for the client is side lying, this is not a priority at this time. The client is not having a precipitous birth with the fetal head at ?1 station. Therefore, preparing the client for a cesarean birth is unnecessary. Although maternal blood pressure should be monitored throughout labor, this is not a priority at this time.

Which information would the nurse include in the teaching plan for a 32-year-old female client requesting information about using a diaphragm for family planning?

Diaphragms should not be used if the client develops acute cervicitis. The teaching plan should include a caution that a diaphragm should not be used if the client develops acute cervicitis, possibly aggravated by contact with the rubber of the diaphragm. Some studies have also associated diaphragm use with increased incidence of urinary tract infections. Douching after use of a diaphragm and intercourse is not recommended because pregnancy could occur. The diaphragm should be inspected and washed with mild soap and water after each use. A diaphragm should be left in place for at least 6 hours but no longer than 24 hours after intercourse. More spermicidal jelly or cream should be used if intercourse is repeated during this period.

The charge nurse is assessing assignments for staffing on a medical-surgical floor. Which client(s) will the nurse place in droplet precautions? Select all that apply.

a client with bacterial meningitis an older adult client with influenza Droplet precautions are used for clients with bacterial meningitis and influenza. The client with a positive staphylococcus wound culture needs contact precautions. The client receiving antibiotics for a fever after surgery will not require precautions. The client with the low white blood cell count will need neutropenic precautions.

A healthcare provider diagnoses leukemia in a 4-year-old child who complains of being tired and sleeps most of the day. Which nursing diagnosis should the nurse use to best reflect this physiologic effect of leukemia?

activity intolerance related to lack of normal blood cell production. A nursing diagnosis of activity intolerance related to abnormal blood cell production reflects the nurse's understanding of leukemia's physiologic effects; a child with leukemia may experience weakness and hypoxia as a result of the anemia commonly associated with the disease. The nurse's findings don't support the other diagnoses of ineffective airway clearance related to the inability to have an effective cough, imbalanced nutrition: less than body requirements related to decreased appetite, or ineffective cerebral tissue perfusion related to central nervous system infiltration by leukemic cells.

A nurse prepares to perform postural drainage. How should the nurse ascertain the best position to facilitate clearing the lungs?

auscultation The nurse should assess breath sounds before doing postural drainage to determine the areas that need draining. Inspection, chest X-rays, and ABG levels are all assessment parameters that give good information about respiratory function but aren't necessary to determine lung areas requiring postural drainage.

A client has given birth to a preterm neonate. The client tells the nurse that she wants to breast-feed her neonate. The nurse should explain to the mother that

breast milk contains antibodies that help protect her neonate. Studies have proven that breast milk provides preterm neonates with better protection from infections such as necrotizing enterocolitis because of the antibodies contained in the milk. Commercial formula doesn't provide any better nutrition than breast milk. Breast milk feedings can be started as soon as the neonate is stable. The neonate is more likely to develop infections when fed formula rather than breast milk.

On initial assessment of a 7-year-old child with rheumatic fever, which finding would require contacting the primary care provider immediately?

heart rate of 150 bpm A heart rate of 150 bpm is very high for a 7-year-old child and may indicate carditis. For this age group, the normal heart rate while awake is 70 to 110 bpm. Swollen and painful joints (e.g., the knee), twitching in the extremities (chorea), and a red rash on the trunk are characteristic findings in the child with rheumatic fever and do not require immediate primary care provider notification.

Which nursing diagnosis takes the highest priority for a client with parkinsonian crisis?

ineffective airway clearance In parkinsonian crisis, dopamine-related symptoms are severely exacerbated, virtually immobilizing the client. A client confined to bed during such a crisis is at risk for aspiration and pneumonia. Also, excessive drooling increases the risk of airway obstruction. Because of these concerns, the nursing diagnosis of an ineffective airway clearance takes the highest priority. Although imbalanced nutrition: less than body requirements, impaired urinary elimination, and risk for injury are also appropriate nursing diagnoses, they are not immediately life-threatening.

A 10-month-old infant with tetralogy of Fallot (TOF) experiences an cyanotic episode. To improve oxygenation during such an episode, the nurse should place the infant in which position?

knee-to-chest. TOF involves four defects: pulmonary stenosis, right ventricular hypertrophy, ventricular-septal defect (VSD), and dextroposition of the aorta with overriding of the VSD. Pulmonary stenosis decreases pulmonary blood flow and right-to-left shunting via the VSD, causing desaturated blood to circulate. The nurse should place the child in the knee-to-chest position because this position reduces venous return from the legs and increases systemic vascular resistance, maximizing pulmonary blood flow and improving oxygenation status. Fowler's, Trendelenburg's, and the prone positions don't improve oxygenation.

The nurse is analyzing the arterial blood gas (AGB) results of a client diagnosed with severe pneumonia. What ABG results are most consistent with this diagnosis?

pH: 7.20, PaCO2: 65 mm Hg, HCO3-: 26 mEq/L Respiratory acidosis is a clinical disorder in which the pH is less than 7.35 and the PaCO2 is greater than 42 mm Hg and a compensatory increase in the plasma HCO3- occurs. It may be either acute or chronic. The ABG of pH: 7.32, PaCO2: 40 mm Hg, HCO3-: 18 mEq/L indicates metabolic acidosis. The ABGs of pH: 7.50, PaCO2: 30 mm Hg, and HCO3-: 24 mEq/L indicate respiratory alkalosis. The ABGs of pH 7.42, PaCO2: 45 mm Hg, and HCO3-: 22 mEq/L indicate a normal result/no imbalance.

A client is in the first stage of Alzheimer's disease. The nurse should plan to focus this client's care on:

providing emotional support and individual counseling. Clients in the first stage of Alzheimer's disease are aware that something is happening to them and may become overwhelmed and frightened. Therefore, nursing care typically focuses on providing emotional support and individual counseling. The other options are appropriate during the second stage of Alzheimer's disease, when the client needs continuous monitoring to prevent minor illnesses from progressing into major problems and when maintaining adequate nutrition may become a challenge. During this stage, offering nourishing finger foods helps clients to feed themselves and maintain adequate nutrition.

A client with nausea, vomiting, and abdominal cramps and distention is admitted to the healthcare facility. Which test result is most significant?

serum potassium level of [3 mEq/L (3.0 mmol/L)] A serum potassium level of 3 mEq/L is below normal, indicating hypokalemia. Because hypokalemia may cause cardiac arrhythmias and asystole, it's the most significant finding. In a client with a potential fluid volume imbalance, such as from vomiting, the other options are expected but none are as life-threatening as hypokalemia. A BUN level of 29 mg/dl indicates slight dehydration. A serum sodium level of 132 mEq/L is slightly below normal but not life-threatening. A urine specific gravity of 1.025 is normal.

A neonate born at 30 weeks' gestation and weighing 2,000 g is admitted to the neonatal intensive care unit. What nursing measure will decrease insensible water loss in a neonate?

use of humidity in the incubator Adding humidity to the incubator adds moisture to the ambient air, which helps to decrease the insensible water loss. Bathing and the use of eye patches has no impact on insensible water loss. The use of a radiant warmer will increase the insensible water loss by drawing moisture out of the skin.

A nursing student is assigned to care for a client with HIV. The student asks the staff nurse what precautions are necessary when measuring this client's blood pressure. What is the best information to give the student?

wash hands Because measuring blood pressure doesn't involve contact with the client's blood or secretions, the nursing student should wash the hands before proceeding.

A nurse is preparing a dose of amoxicillin for a 3-year-old with acute otitis media. The child weighs 33 lb (15 kg). The dosage prescribed is 50 mg/kg/day in divided doses for every 8 hours. The concentration of the drug is 250 mg/5 ml. How many milliliters would the nurse administer? Record your answer using a whole number.

5 mL The nurse should calculate the daily dosage for the child: 50 mg/kg/day × 15 kg = 750 mg/day. To determine divided daily dosage, the nurse would know that "every 8 hours" means three times per day. So, the nurse would perform that calculation in this way: Total daily dosage ÷ 3 times per day = Divided daily dosage 750 mg/day ÷ 3 = 250 mg The drug's concentration is 250 mg/5 ml, so nurse would administer 5 ml.

The nurse is planning care for a client with osteomyelitis. The client is taking an antibiotic, but the infection has not resolved. What should the nurse advise the client to do?

Eat a diet high in protein and vitamins C and D. The goal of care for this client is healing and tissue growth while the client continues on long-term antibiotic therapy to clear the infection. A diet high in protein and vitamins C and D promotes healing. Herbal supplements may potentiate bleeding (e.g., ginkgo, ginger, tumeric, chamomile, kelp, horse chestnut, garlic, and dong quai) and have not been proven through research to promote healing. Frequent passive motion will increase circulation but may also aggravate localized bone pain. It is not appropriate to advise the client to change antibiotics as treatment may take time.

A nurse is walking down the hall in the main corridor of a hospital when the infant security alert system sounds and a code for an infant abduction is announced. The first responsibility of the nurse when this situation occurs is to take which action?

Observe individuals in the area for large bags or oversized coats. The process for infant abduction in a hospital system focuses on utilizing all health care workers to observe for anyone who may possibly be concealing an infant in a large bag or under an oversized coat and is attempting to leave the building. Moving to the entrances and exits and checking each individual would be a responsibility of the doorman or security staff within the hospital system. Going to the obstetrics unit to determine if they need help would not be advised as the doors to the unit will be locked and access will not be available. Calling the nursery to ask about a missing baby wastes time, and the nursery staff should not reveal such information.

A nurse has an order to administer an I.M. injection of iron dextran to a client. Which action is correct for an I.M. injection?

Withdraw the needle and release the skin. I.M. iron dextran should should be given by intramuscular injection using a z-tract technique. When giving an I.M. injection using the z-track technique, the nurse pulls the skin laterally away from the injection site, inserts the needle at a 90-degree angle, waits 10 seconds after injecting the medication, and then withdraws the needle and releases the skin. No massage is used with a z-tract injection.

The nurse is caring for an infant diagnosed with a congenital heart disease. Which of the following concerns should be a priority for the nurse to address with the parents when discussing the child's condition?

congestive heart failure Parents of children with congenital heart disease need information about congestive heart failure because congestive heart failure is generally the first consequence seen in a child with congenital heart disease. In addition to often being the primary diagnosis, it can also remain an ongoing complication. Kidney failure, eating concerns, and intermittent elevated temperature may inevitably present as complications, but not initially.

After teaching a new mother about the care of her neonate after circumcision with a Gomco clamp, which statement by the mother indicates to the nurse that the mother needs additional instructions?

"I will remove any yellowish crusting gently with water." The mother needs further instruction when she says that a yellowish crust should be removed with water. The yellowish crust is normal and indicates scar formation at the site. It should not be removed because to do so might cause increased bleeding. The petroleum gauze prevents the diaper from sticking to the circumcision site, and it may fall off in the diaper. If this occurs, the mother should not attempt to replace it but should simply apply plain petroleum jelly to the site. The gauze should be left in place for 24 hours, and the mother should continue to apply petroleum jelly with each diaper change for 48 hours after the procedure. A few drops of oozing blood is normal, but if the amount is greater than a few drops the mother should apply pressure and contact the health care provider (HCP) . Any bleeding after the first day should be reported.

After being examined and fitted for a diaphragm, a 24-year-old client receives instructions about its use. Which client statement indicates a need for further teaching?

"If I gain or lose 20 lb (9 kg), I can still use the same diaphragm." The client would need additional instructions when she says that she can still use the same diaphragm if she gains or loses 20 lb (9 kg). Gaining or losing more than 15 lb (7 kg) can change the pelvic and vaginal contours to such a degree that the diaphragm will no longer protect the client against pregnancy. The diaphragm can be used for 2 to 3 years if it is cared for and well protected in its case. The client should be refitted for another diaphragm after pregnancy and childbirth because weight changes and physiologic changes of pregnancy can alter the pelvic and vaginal contours, thus affecting the effectiveness of the diaphragm. The client should use a spermicidal jelly or cream before inserting the diaphragm.

When developing the teaching plan for the mother and a child with insulin-dependent diabetes about sick-day management, which of the following instructions should the nurse include?

Adjust insulin based on more frequent testing of blood glucose levels. Sick-day management requires more frequent monitoring of the child's blood glucose to evaluate for changes associated with a decreased intake and absorption of food, commonly associated with illness. Based on the child's glucose levels, insulin adjustments may be needed. In this case, regular insulin is used. Adhering to the same schedule, type, and amount of insulin is inappropriate because the child's ability to take in food and absorb nutrients can change rapidly. Typically, the child and parents are provided with specific instructions about sick-day management rules. Commonly the physician will prescribe adjustments to insulin (e.g., on a sliding scale) based on the child's blood glucose levels. Therefore, calling the physician to report that the child is ill and ask what to do is inappropriate. However, the parents do need to notify the physician should any problems arise with management of the child's blood glucose levels. The child who can tolerate oral feedings of simple sugars can be kept at home as long as the parents monitor the child's blood glucose levels frequently for changes.

A nurse is caring for a client who underwent surgical repair of a detached retina in the right eye. Which nursing interventions would the nurse perform postoperatively? Select all that apply. A detached retina is repaired by surgical procedures such as a scleral buckle, pneumatic retinopexy or a vitrectomy, which places the retina back in its proper position. Postoperatively, the nurse would approach the client from the left side—the unaffected side—to avoid startling. The nurse would also discourage the client from bending down, deep breathing, hard coughing and sneezing, and other activities that can increase intraocular pressure during the postoperative period. The client would be oriented to the environment to reduce the risk of injury. Stool softeners would be administered to discourage straining during defecation. The client would lie on the back or on the unaffected side to reduce intraocular pressure in the affected eye. The client's feet would not be higher than the head, as in the Trendelenburg position.

Discourage the client from bending down. Approach the client from the left side. Orient the client to the environment. Administer a stool softener.

A 12-year-old with cystic fibrosis is being treated in the hospital for pneumonia. The health care provider (HCP) is calling in a telephone prescription for ampicillin. The nurse should take which actions? Select all that apply.

Repeat the prescription to the HCP. Ask the HCP to confirm that the prescription is correct as understood by the nurse. To ensure client safety in obtaining telephone prescriptions, the prescription must be received by a registered nurse (RN) . The nurse should write the prescription, read the prescription back to the HCP, and receive confirmation from the HCP that the prescription is correct. It is not necessary to ask the unit clerk to listen to the prescription, to require the HCP to come to the hospital to write the prescription on the medical record, or to have the nursing supervisor cosign the telephone prescription.

A nurse is developing a care plan for a client in her 34th week of gestation who's experiencing premature labor. What nonpharmacologic intervention should the plan include to halt premature labor?

promoting adequate hydration. Providing adequate hydration to the woman in premature labor may help halt contractions. The client should be placed on bed rest so that the fetus exerts less pressure on the cervix. A nutritious diet is important in pregnancy, but it won't halt premature labor. Nipple stimulation activates the release of oxytocin, which promotes uterine contractions.

A client diagnosed with thyroid cancer signed a living will that states the client doesn't want ventilatory support if the condition deteriorates. As the client's condition worsens, the client states, "I changed my mind. I want everything done for me." Which response by the nurse is best?

"What exactly do you mean by wanting 'everything' done for you?" Asking the client what they mean is the best response. The nurse should clarify the client's request and get as much information as possible before notifying the physician of the client's wishes. Asking the physician to revoke the client's do-not-resuscitate (DNR) order makes an assumption about the client's wishes without obtaining clarification of their statement. The client might want aggressive treatment without reversing the DNR order. Asking the client if they understand that they'll be placed on a ventilator places the client on the defensive. Telling the client to talk with family is an inappropriate response; the client has the right to change their treatment plan without input from their family.

Preoperatively, the nurse develops a plan to prepare a 7-month-old infant psychologically for a scheduled herniorrhaphy the next day. Which intervention should the nurse expect to implement to accomplish this goal?

having the mother stay with the infant The best way to prepare a 7-month-old infant psychologically for surgery is to have the primary caretaker stay with the child. Infants in the second 6 months of life commonly develop separation anxiety. Therefore, the priority in this case is to support the child by having the parent present. Teaching the mother what to expect may decrease her anxiety; this is important because infants sense anxiety and distress in parents, but the priority in this case is to have the parent present. Actual play and acting out life experiences are appropriate for preschool-age children. Allowing an infant to play with surgical equipment would be inappropriate and dangerous.

The nurse providing health promotion education to the parents of a 6-year-old child should include which statements about 6-year-old children in the education?

"They are very sensitive to criticism." A nurse should explain that a 6-year-old child has a precarious sense of self that can cause overreaction to criticism and a sense of inferiority. By age 6, most children no longer depend on the parents for daily tasks and actually love the routine of a schedule. Tattling is more common at age 4 or 5; by age 6, the child wants to make friends and be a friend.

A client has been taking intravenous furosemide for congestive heart failure. The client is ordered to start intravenous gentamicin. What intervention is the priority for the nurse?

monitor serum BUN and creatinine levels Concurrent furosemide and gentamicin administration have a potential to increase both drugs' toxicity. This increases the risk of ototoxicity and nephrotoxicity. The nurse should monitor renal labs including BUN and creatinine, tinnitus, and balance/gait. Urine output should be monitored, however, the BUN and creatinine will be impacted before there is a change in urine output. The I.V. site should be assessed regularly as part of routine nursing care, not as a priority for the administration of these drugs. A serum furosemide is not a routine lab during the administration of these medications.

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. 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.

A client is being treated for deep vein thrombosis (DVT) in the left femoral artery. The health care provider (HCP) has prescribed 60 mg of enoxaparin subcutaneously. Before administering the drug, the nurse checks the client's laboratory results. (See image.) Based on these results, what should the nurse do?

Withhold the dose of the medication and contact the health care provider (HCP). Based on the laboratory findings, prothrombin time and INR are at acceptable anticoagulation levels for the treatment of DVT. However, the platelets are below the acceptable level. Clients taking enoxaparin are at risk for thrombocytopenia. Because of the low platelet level, the nurse should withhold the enoxaparin and contact the HCP. The nurse should not administer the drug until the HCP has been contacted. The HCP, not the pharmacist, will make the decision about the dose of the enoxaparin. The decision about administering the drug will be based on laboratory results, not evidence of bruising or bleeding.

A nurse is assigned to care for a client with a tracheostomy tube. How can the nurse communicate with this client?

by supplying a magic slate or similar device. The nurse should use a nonverbal communication method, such as a magic slate, note pad and pencil, and picture boards (if the client can't write or speak English). The physician orders a tracheostomy plug when a client is being weaned off a tracheostomy; it doesn't enable the client to communicate. The call button, which should be within reach at all times for all clients, can summon attention but doesn't communicate additional information. Suctioning clears the airway but doesn't enable the client to communicate.

A nurse is teaching child care classes for adolescent parents. To enhance the adolescents' understanding of infant safety, the nurse would suggest that the parent:

crawl around on the floor looking for potential hazards from the viewpoint of an infant. Crawling on the floor is a participative activity that can help promote understanding of infant safety in relation to the infant's perspective. The nurse doesn't need to instruct adolescents to discuss infant safety with the pediatrician because the nurse can provide such information in the class environment. Presenting a lecture or video doesn't directly focus on the infant's perspective regarding items that may be a safety threat.

Which is the priority intervention for a preschool child with epiglottiditis and a deteriorating respiratory status?

assisting with intubation. The most important intervention for a child with epiglottiditis is airway management because children are at high risk for developing abrupt airway obstruction. Therefore, intubation should be performed as soon as possible in a controlled environment. Children need supplemental oxygen, but most are so anxious that they will never allow a mask to stay in place. Provide humidified "blow-by" oxygen administered by the parent if possible. The child does need parenteral antibiotics; however, the priority is airway management. The most common rhythm in this client is sinus tachycardia related to compensation. However, monitoring for arrhythmias isn't a priority over airway management.

A multiparous client and her small-for-gestational-age neonate, who has been cared for in the intensive care nursery for the past 3 days, are to be discharged. Before their release, the mother tells the nurse, "I have been living in my car for the past 2 weeks." What should the nurse do next?

Contact the hospital's social worker. When a client is being released from the hospital with her neonate and the nurse learns that the client is homeless, the nurse should contact the hospital's or unit's social worker. Social workers have access to resources to assist the client to find temporary shelter in emergencies. The director of the birthing unit does not need to be notified. The director's responsibilities are primarily administrative. The client's HCP can be notified once the social worker has offered assistance to the client. The HCP may cancel the release of the neonate until temporary housing is located. Notifying any of the client's family members is inappropriate. The client may not have any immediate family members, or there may be some stress between the client and family members.

A client has been placed in an isolation room and family members have stated that access to the client seems restricted. WhicH actions would be appropriate for the nurse to take to address this situation? Select all that apply.

a thorough explanation of the isolation procedures acknowledgement of the family's concerns a communication plan for the family and client To ensure that everyone complies with the isolation procedures, the nurse should develop a communication plan with the family and client, provide thorough explanations about the importance of complying with the isolation procedures, and address family and client concerns. Allowing free access or discontinuing isolation procedures at the family's request would be a safety violation.

When providing client teaching about continuous bladder irrigation following prostate surgery, what should the nurse tell the client?

"The purpose of the irrigation is to keep bladder drainage clear and to prevent the formation of blood clots in the bladder." Continuous bladder irrigation (CBI) is performed when urinary surgery (typically prostate surgery) results in hematuria. It is accomplished using an indwelling Foley catheter with three lumens. One port is for the balloon, a second port allows irrigant inflow, and a third port enables outflow. The purpose of the irrigation is to achieve and maintain clear outflow and to prevent clot formation within the bladder. Manual irrigation is used as an intermittent type of bladder irrigation and is not the same as CBI. CBI involves irrigation of the bladder; it is not an intravascular infusion. The rate is often initially fast to achieve a clear outflow. Stopping and clamping the irrigant inflow is done only under a health care provider's (HCP's) direction and is typically not expected until at least 1 day following the procedure.

An older adult client is admitted to the unit after being examined in the emergency department (ED) and diagnosed with delirium. After the admission interviews with the client and her grandson, the nurse explains that there will be more laboratory tests and X-rays done that day. The grandson says, "She's already been stuck several times and had a brain scan or something. Just give her some medicine and let her rest." What should the nurse tell the grandson? Select all that apply.

"I agree she needs to rest, but there's no one specific medicine for your grandmother's condition." "The health care provider will look at the results of those tests in the ED and decide what other tests are needed." "Delirium commonly results from underlying medical causes that we need to identify and correct."

The nurse is instructing a client with vulvovaginal candidiasis on the use of the prescribed nystatin vaginal tablets. Which statement indicates that the client requires additional teaching?

"I can get up to do other activities after inserting the medicine." The client will need to lay down for at least 30 minutes after insertion of the vaginal tablets. Refrigerating nystatin tablets, finishing all the tablets, and reporting increased skin irritation to the healthcare provider are all important interventions concerning this medication.

The nurse is caring for a senior citizen who lives alone. When evaluating the effectiveness of adding fluticasone propionate and salmeterol to the chronic obstructive airway disease (COPD) client's medication regimen, which client statements would support symptom improvement? Select all that apply.

"I have begun walking upstairs to use the bathroom." "I can now push my granddaughter on the swings when she visits." "The nurse aide no longer comes to the house to help me bathe." Fluticasone propionate and salmeterol is a combination of steroid and bronchodilator used in the treatment of chronic asthma and chronic obstructive airway disease. The medication is intended to be used daily. It is not a rescue inhaler, and additional doses do not improve respiratory function. Evaluation of effectiveness includes improvement in respiratory status and ability to perform activities of daily living/quality of life activities such as walking and playing. Side effects of the medication include an increase in cough and sputum production. Nervous system side effects include tremors and nervousness.

In an outpatient addiction group, a recovering client said that before her treatment, her husband drank on social occasions. "Now he drinks at home, from the time he comes home from work and drinks until he goes to bed. He says that he doesn't like me anymore and that I expect him to do more work on the house and yard. I used to ignore that stuff. I don't know what to do." In which order of priority from first to last would the nurse make the comments? All options must be used.

"I hear how confused and frustrated you are." "It can happen that as one person sobers up, the spouse deteriorates." "What have you tried to do about your husband's behaviors?" "What do you think you could do to have your husband come in for an evaluation?" The client's feelings and concerns need to be validated so she will open up more. She also should know that the changes in her husband are not unusual. It helps to know the client has tried with her husband to determine if they are appropriate or not. Then there can be a discussion about getting help for her husband so that her efforts to stay sober are not compromised.

A client is admitted to the health care facility with acute chest pain. When obtaining the client's health history, which question would be most helpful for the nurse to ask?

"What were you doing when the pain started?" Subjective data (data from the client) about the chest pain helps the nurse determine the specific health problem. For example, asking about the setting in which the pain developed can provide helpful information about its cause. Asking about the history and medications will yield helpful information, but would not be the most helpful.

A client that works as a pilot tells the nurse that they use illegal drugs for recreational purposes every weekend. Using the ethical principle of nonmaleficence to guide the nurse's interaction with the client, which is the nurse's best response?

"You could easily have an error in judgement and cause a serious accident." Because the nurse's statement refers to those who could be harmed as a result of the pilot's drug use, the nurse's suggestion that the client should consider how an error in judgment could result in a serious accident reflects the principle of nonmaleficence (the obligation to do no harm). Telling the client that recreational drug use jeopardizes the client's health and decision-making ability addresses the personal danger of drug use, not the principle of nonmaleficence. Commenting that the pilot could test positive in a random drug test does not address any of the four basic ethical principles (autonomy, beneficence, nonmaleficence, and justice). Telling the client that there is a problem with their use of drugs to cope with stress reflects the principle of autonomy by addressing how the client's actions influence the rights of others.

A client with deep vein thrombosis has an I.V. infusion of heparin infusing at 1,500 units/hour. The concentration in the bag is 25,000 units/500 ml. How many milliliters of solution should the nurse document as intake from this infusion for an 8-hour shift? Record your answer using a whole number.

240 First, calculate how many units are in each milliliter of the medication: 25,000 units/500 ml = 50 units/ml Next, calculate how many milliliters the client receives each hour: 1 ml/50 units × 1,500 units/hour = 30 ml/hour Lastly, multiply by 8 hours: 30 ml/hour × 8 hours = 240 ml

A charge nurse is making client care assignments for the day. Which client would be most appropriate to assign a licensed practical nurse (LPN)?

6-year-old child 2-day post-op appendectomy with a surgical drain The 6-year-old child who is post-appendectomy would be the most stable child to assign to the LVN/LPN. The skill set of an LVN/LPN includes care of surgical drains. A 6-month-old infant with pneumonia requiring oxygen might be the next choice, depending on the infant's vital signs. Being that the child is very young, the condition could change rapidly. This infant will require frequent respiratory assessments.The infant with a respiratory rate of 60 is not stable and is in respiratory distress. The child with nephrotic syndrome and 4+ protein is very ill and needs many nursing interventions and assessments best done by the registered nurse.

A client is hospitalized for depression. The client calmly tells the nurse that they cut their foot and need a bandage. The client reveals a 2 cm by 6 cm (1 in by 2.5 in) bloody triangle on the right insole that appeared to be a self-inflicted wound with a sharp instrument. Which action would be the priority for the nurse to take?

Assess the injury and assess for any other self-inflicted wounds in a matter-of-fact manner. The nurse would first assess the client and treat the injury in a matter-of-fact manner before reporting to the physician. Asking the client about their feelings is correct; however, this would not be the first step. Removing all dangerous items from the environment would be the next step after assessing the extent of the client's injury.

The telemetry unit nurse is caring for a client who was just transferred from the coronary care unit (CCU). The client reports anxiety because of receiving less monitoring than in the CCU. How can the nurse allay the client's fears?

Assign the same nurse to the client when possible.

While caring for the neonate of a human immunodeficiency virus-positive mother, the nurse prepares to administer a prescribed vitamin K intramuscular injection at 1 hour after birth. Which action should the nurse do first?

Bathe the neonate. Newborns are typically bathed 2 to 4 hours after birth when their temperatures have had time to stabilize, but early/immediate bathing is recommended for the infants of HIV-positive mothers to decrease blood exposure. Placing the neonate under the radiant warmer for the vitamin K injection is not necessary unless the neonate's temperature is subnormal. Washing the injection site with povidone-iodine is not recommended and may increase the risk for possible allergy to iodine preparations. The first dose of zidovudine is given when the newborn is 6 to 12 hours old, but vitamin K is recommended to be given within an hour of birth to be most effective. Therefore the vitamin K should not be delayed.

A neonate must receive an eye preparation to prevent ophthalmia neonatorum. How should the nurse administer this preparation?

By positioning the neonate so that the head remains still After positioning the neonate securely so that the head remains still, the nurse should hold the eyelid open and instill the medication into the conjunctival sac. Holding the neonate in the football position doesn't secure the head.

A nurse and a nursing student drive to the home of a client with postpartum depression and discover the client and her baby completely naked in the backyard. The client is unable to communicate in an effective manner. What is the nurse's most appropriate response to resolve this situation?

Contact the nursing supervisor to clarify the appropriate actions in this acute mental health situation. The nurse should contact the immediate nursing supervisor to clarify or guide the correct nursing actions in this acute mental health situation. Community mental health services may be available that could visit the home and assess and intervene in this situation. The nurse should help the mother and baby inside and stay with them until the supervisor advises how best to manage the situation. It is inappropriate to call the client's partner and have them come home because the nurse first needs to assess and address any immediate safety concerns for the mother and baby. Asking the nursing student to remain with this client while the nurse leaves is inappropriate because this may jeopardize the safety of the nursing student. In addition, given the context, the care required may be beyond the nursing student's scope of practice.

A client has radiation seeds implanted into the prostate gland. Which action should the nurse take to safely provide care to this client? Select all that apply.

Learn the safe distance from the client. Identify the safest amount of time to be at the bedside. Obtain the necessary shielding when providing care. Clients receiving internal radiation emit radiation while the implant is in place. Because of this, actions should be taken to prevent accidental exposure. The principles of time, distance, and shielding should be implemented to minimize the risk of radiation exposure. The safe distance should be identified. The safest amount of time that the nurse can be at the bedside should be identified. The type of shielding that care staff should wear must be identified and obtained. Expelling the seeds through the urine would not protect the nurse when providing care. The client with implantable radiation should always be in a private, not a semi-private, room.

The nurse is asked to develop an in-service to explain documents guiding professional nursing practice on the obstetrical unit. One of the documents included is the Code of Ethics. The nurse correctly explains that the Code of Ethics asks nurses to demonstrate which behaviors? Select all that apply.

Maintain integrity and shape social policy. Develop, maintain, and improve health care environments. Be responsible and accountable for individual practice. Increase professional competence and personal growth.

A nurse working in the emergency department enters the room of a client who is agitated and swears at the nurse. The client stands up and moves toward the nurse in an aggressive fashion. What is the most appropriate action by the nurse to address this situation?

Move toward the door and leave to call the crisis response team. The nurse assesses and identifies that the nurse's safety is at risk because the client is agitated and moving aggressively toward the nurse. The nurse needs to leave and obtain help in the form of a crisis response team. The other options are incorrect because they do not provide for the safety of the nurse or the client.

An adolescent client is hospitalized with bacterial meningitis. At 1730, the client's mother reports her child is "burning up." The nurse is reviewing the client's medication administration records in the medical record. The health care provider (HCP) has prescribed ibuprofen 325 mg every 3 to 4 hours for temperature over 99°F (37.2°C). The child's temperature at 1730 is 102.5°F (39.1°C). What should the nurse do first?

Notify the HCP. Because the client's temperature continues to rise in spite of recently administering ibuprofen, the nurse notifies the HCP. After notifying the HCP, the nurse can bathe the client with tepid water. If the temperature cannot be lowered shortly, the client is also at risk for seizures; the nurse pads side rails and observes for seizure activity. The nurse cannot administer another dose of ibuprofen without the HCP's orders.

A client arrives to the emergency department with suspected appendicitis. The admitting nurse performs an assessment. Order the following steps according to the sequence in which they are performed. All options must be used.

Obtain a health history. Inspect the abdomen, noting the shape, contours, and any visible peristalsis or pulsations. Auscultate bowel sounds in all four quadrants. Percuss all four abdominal quadrants. Gently palpate all four quadrants, saving the painful area for last.

The nurse finds a confused client with soft wrist restraints in place (see figure). What should the nurse do first?

Untie the restraint and resecure to the bed frame using a quick-release knot. To ensure the client's safety when using restraints, the restraint must be secured to the bedframe (not the side rail) using a quick-release slip knot (not a square knot). Assessing and documenting skin should be done regularly when restraints are in use, but safety is first priority. Regularly releasing restraints and performing range of motion is essential but not priority in this case. Providing for the client's basic needs while in restraints (i.e., toileting) is important but not first priority.

A client develops atrial fibrillation following an acute myocardial infarction. The physician orders digoxin, 0.125 mg I.M. daily. The nurse clarifies the order with the physician because I.M. administration of digoxin leads to

an increased serum creatine kinase (CK) level. I.M. administration of digoxin isn't recommended because it causes severe pain at the injection site and increases serum CK, which complicates interpretation of enzyme levels. Regardless of the route of administration, digoxin doesn't increase the serum creatinine level. When digoxin is administered, the serum digoxin level will rise from zero, not decrease.

The nurse should teach the client with erectile dysfunction (ED) to alter his lifestyle by doing which?

avoiding alcohol Avoidance of alcohol can improve the outcome of therapy. Alcohol and smoking can affect a man's ability to have and maintain an erection. The client should be encouraged to follow a healthy diet, but no specific diet is associated with improvement of sexual function. The client should cease smoking, not just decrease smoking. Increasing attempts at intercourse without treatment will not facilitate improvement. The client should be reassured that ED is a common problem and that help is available.

What is the best way for the nurse to position a chest tube for a client to prevent dislocation?

coiled flat on the bed and secured without putting tension on the tube Tubing that is coiled flat on the bed and secured without putting tension of the tube maintains a patent, free draining system. This prevents fluid accumulation and decreases the risk of infection, atelectasis, and tension pneumothorax. The other choices all have risks associated with becoming disconnected.

The nurse is assigning a room for a client admitted with hepatitis A. Which diagnosis would be an appropriate roommate for this client?

congestive heart failure The nurse needs to determine the need for specific standard and transmission-based precautions. It would be appropriate for a hepatitis A and congestive heart failure client to share a room, as neither requires isolation. The varicella is airborne isolation and must be in a private negative airflow room. Postoperative clients should not be in a room with a medical client with a communicable infection.

A client undergoing long-term peritoneal dialysis at home is currently experiencing a reduced outflow from the dialysis catheter. To determine if the catheter is obstructed, what should the nurse ask the client about experiencing recently?

constipation Constipation may contribute to reduced urine outflow in part because peristalsis facilitates drainage outflow. For this reason, bisacodyl suppositories can be used prophylactically, even without a history of constipation. Diarrhea, vomiting, and flatulence typically do not cause decreased outflow in a peritoneal dialysis catheter.

A client has an elective hemorrhoidectomy. Immediately after surgery, the priority goal of nursing care is to:

control pain. Rectal surgery is accompanied by severe pain resulting from spasms of sphincters and muscles. Therefore, controlling pain is a priority goal of nursing care. Preventing venous stasis, promoting ambulation, and preventing infection are appropriate goals, but controlling the severe pain that can accompany a hemorrhoidectomy is a priority in the immediate postoperative period.

A client who speaks little English has emergency gallbladder surgery. During discharge preparation, which nursing action would best help this client understand wound care instructions?

demonstrating the procedure and having the client return the demonstration Demonstration by the nurse with a return demonstration by the client ensures that the client can perform wound care correctly. Asking whether the client understands the instructions isn't appropriate because clients may claim to understand discharge instructions when they don't. An interpreter or family member may communicate verbal or written instructions inaccurately.

A 19-year-old unmarried college student who is approximately 8 weeks pregnant asks the nurse, "If I have an abortion in the next 2 or 3 weeks, how will it be done?" The nurse instructs the client that at this gestational age, an abortion is usually performed by which technique?

dilatation and curettage When the gestation is less than 13 weeks, an elective abortion is usually performed by the dilatation and curettage method. Menstrual extraction, or suction evacuation, is the easiest method, but it is used only when the client is between 5 and 7 weeks' gestation. Dilatation and vacuum extraction is used when clients are between 12 and 16 weeks' gestation. Saline induction, used for clients between 16 and 24 weeks' gestation, involves instillation of a hypertonic saline solution into the amniotic sac to initiate expulsion. Oxytocin infusion may also be used with saline induction.

A nurse caring for a client who has just received chemotherapy infusion is wearing a disposable gown, gloves, and goggles for protection. The nurse knows that accidental exposure to chemotherapy agents can occur through

inhalation of aerosols. Aerosol inhalation or absorption through the skin can cause accidental chemotherapy exposure. A nurse must wear a disposable gown and gloves when preparing and administering chemotherapy. The nurse won't absorb chemicals through an intact gown, protective gloves, or goggles.

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.

inspection auscultation percussion palpation 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.

The nurse asks a school-age child with Guillain-Barré syndrome to cough and also assesses the child's speech for decreased volume and clarity. The underlying rationale for these assessments is to determine which finding?

involvement of facial and cranial nerves In a child with Guillain-Barré syndrome, decreased volume and clarity of speech and decreased ability to cough voluntarily indicate ascending progression of neural inflammation, specifically affecting the cranial nerves. Inflammation of the larynx and epiglottis is manifested by hoarseness, stridor, and dyspnea. A child with laryngeal inflammation still retains the ability to cough. Irritability, behavior changes, headache, and vomiting are common signs of increased intracranial pressure in a school-age child. Regression would be manifested by being more dependent and less able to care for self.

A nurse is assessing a client with bipolar disorder. The client tells the nurse that the family health care provider prescribed lithium. Which symptom would indicate that the client is developing lithium toxicity?

lethargy Nausea, vomiting, diarrhea, thirst, polyuria, lethargy, slurred speech, hypotension, muscle weakness, and fine hand tremors are signs of lithium toxicity.

The nurse is preparing the prescribed medications for a client. Which medication will the nurse prioritize obtaining a witness for wasting a partial dose?

lorazepam 1 mg PO; dose available 2 mg tablet Federal law requires two nurses to witness and document the waste of any partial dose of a controlled substance. Lorazepam is a controlled substance, therefore the waste of 1 mg, or 1/2 of the 2 mg tablet, will require another nurse as witness. Hydromorphone is a controlled substance, but the prescription requires the full dose to be administered. Pregabalin and amiodarone are not controlled substances, therefore no special procedure is needed to waste a partial dose.

The nurse would expect a client with a hiatal hernia to report that the symptoms worsen when the client is:

lying down. Hiatal hernia produces symptoms of esophageal reflux as the sphincter slides up into the negative-pressure environment of the thorax. The symptoms typically occur when the client is in a recumbent position. Emotions and normal activity do not influence the incidence of reflux. Sitting upright helps prevent reflux.

A client with a history of chronic cystitis comes to an outpatient clinic with signs and symptoms of this disorder. To prevent cystitis from recurring, the nurse recommends maintaining an acid-ash diet to acidify the urine, thereby decreasing the rate of bacterial multiplication. On an acid-ash diet, the client must restrict which beverage?

milk A client on an acid-ash diet must avoid milk and milk products because these make the urine more alkaline, encouraging bacterial growth. Other foods to avoid on this diet include all vegetables except corn and lentils; all fruits except cranberries, plums, and prunes; and any food containing large amounts of potassium, sodium, calcium, or magnesium. Cranberry and prune juice are encouraged because they acidify the urine. Coffee and tea are considered neutral because they don't alter the urine pH.

Nurses should be aware of their own feelings about clients and the difficulty of maintaining effective relationships with depressed clients experiencing suicidal ideation because of which behaviors?

pessimism, which arouses frustration and anger in others Depressed clients are difficult to relate to because of their hopelessness, negativity, helplessness, and general apathy. The concomitant feelings of hopelessness and lack of success experienced by the nurse may lead the nurse to withdraw or to feel angry with the client. It is important for nurses to be aware of their feelings and how their feelings might affect nursing care. Poor personal grooming is typical of clients with depression and suicidal ideation. The nurse can intervene and help the client with grooming. Depressed clients are typically dependent on others. Depressed clients are not lazy but are fatigued and apathetic.

A group of visitors arrives to visit a client in radiation precautions. Which visitor(s) should the nurse prohibit from entering the client's room? Select all that apply.

pregnant adult preschool-age child Safety precautions used in caring for a client receiving radiation include prohibiting visits by pregnant adults or children. The middle-aged male, middle-aged female, and older male should not be prohibited from visiting the client.

A young child with a history of bronchial asthma is brought to the emergency department for the second time in a month with symptoms of audible expiratory wheezing and intercostal retractions. The parents voice frustration about repeated hospital visits. What information is most important for the nurse to address with the parents?

providing a variety of resources to help the parents quit smoking Smoking is a main allergen that can initiate the inflammatory response in children with bronchial asthma. Few children with bronchial asthma will remain asymptomatic for the remainder of their lives. As many as one in two children who had childhood asthma and who are asymptomatic at 18 years of age are likely to have recurrent, symptomatic disease by age 26 years. Asthma usually persists as a low-grade, subclinical condition. Asthmatic episodes may be life threatening in all age groups.

A client is ordered diazepam to treat severe skeletal muscle spasms. During this therapy, the nurse monitors the client closely for adverse reactions. Which adverse reaction is most likely to occur?

sedation Most adverse reactions to diazepam and other benzodiazepines involve the central nervous system; less than 1% involve other body systems. Therefore, the client is more likely to experience sedation than bradycardia, skin rash, or hypotension.

How does the nurse on the obstetrics unit assure client safety? Select all that apply.

staff training communication among staff reconciliation of medication prescriptions use of two unique identifiers Client care safety is enhanced by the process of reconciling all medication prescriptions at least one time each 24 hours of hospitalization. This can rule out duplication of prescriptions, missing medication prescriptions, or alerting the staff to medications that should have been terminated. Communication among all staff members enhances client safety and prevents errors in written or in verbal format. Culturally similar clients are appreciative of being with someone who can speak their language or share thoughts and ideas, but this does not increase the safety of the clients. The use of two identifiers should be consistently used to prevent wrong client and procedure errors. Staff training is an extremely valuable tool to educate and increase communication among staff members concerning existing or potential safety situations.

Which finding in a client diagnosed with heart failure would require a nurse to take immediate action?

stridor Stridor, even though unrelated to heart failure, indicates partial obstruction of the airway and is of primary concern. Fine crackles indicate fluid accumulation. Coarse crackles are typically caused by secretion accumulation in the airways. Friction rubs occur with pleural inflammation. Sonorous rhonchi are typically caused by secretions in the bronchi.

A nurse is assessing a client with heart failure. To assess hepatojugular reflux, the nurse should

tell the client specifically and concisely what needs to be done. The client must be informed of the activity and when it will occur. Giving choices isn't desirable because the client can be manipulative or refuse to do anything. Negotiation and preparation wouldn't be therapeutic because this type of client might not want to perform the activity.

The nurse judges correctly that a client is experiencing an adverse effect from amitriptyline hydrochloride when the client has which manifestation?

urine retention Urine retention is a result of the anticholinergic effects of amitriptyline and requires intervention. It can be a serious problem in the elderly and should be reported promptly. Elevated blood glucose level, insomnia, and hypertension are not associated with amitriptyline hydrochloride therapy.

When communicating with a client who has sensory (receptive) aphasia, the nurse should:

use short, simple sentences. Although sensory aphasia allows the client to hear words, it impairs the ability to comprehend their meaning. The nurse should use short, simple sentences to promote comprehension. Allowing time for the client to respond might be helpful but is less important than simplifying the communication. Because the client's hearing isn't affected, speaking loudly isn't necessary. A writing pad is helpful for clients with expressive, not receptive, aphasia.

The nurse is working in the intensive care unit with a client in shock. During hand-off the nurse reports the results of which assessment findings that signal early signs of the decompensation stage? Select all that apply.

vital signs peripheral pulses skin color urine output

To follow standard precautions, the nurse should carry out which measure?

wearing gloves when administering I.M. medication To follow standard precautions, caregivers must place used, uncapped needles and syringes in a puncture-resistant container; wear gloves when anticipating contact with a client's blood, body fluid, mucous membranes, or nonintact skin (such as when administering an I.M. injection); and wear a gown during procedures that are likely to generate splashes of blood or body fluids. Standard precautions don't call for caregivers to wear a gown or gloves when bathing a client because this activity isn't likely to cause contact with blood or body fluids.

The RN is administering intravenous chemotherapy to a client with cancer. Which precautions are necessary when administering chemotherapy? Select all that apply.

wearing gloves when handling the client's urine disposing of chemotherapy waste as hazardous material wearing a long-sleeved gown when administering chemotherapy Nurses preparing and administering chemotherapy wear gloves and a disposable, long-sleeved gown. Antineoplastic agents are disposed of as hazardous material and gloves are always worn when handling the excretions of clients who have received chemotherapy. It is not appropriate to tape IV tubing connections; antineoplastic agents are administered using Luer lock fittings on all intravenous tubing to minimize the risk of exposure from needle stick injury.