NCLEX - PassPoint PN 2020
The third stage of labor ends after the birth of the placenta. Which action should the nurse take immediately following the birth of the placenta? Discard the placenta. Store the placenta for the client. Examine the placenta for completeness. Milk the umbilical cord.
Examine the placenta for completeness. Explanation: The nurse should examine the placenta for completeness by checking that the membranes are intact and all lobes are complete to prevent postpartum hemorrhage. The placenta is not stored or immediately discarded until it is examined fully. Milking the umbilical cord at this time is not necessary.
The third stage of labor ends after the birth of the placenta. Which action should the nurse take immediately following the birth of the placenta? Store the placenta for the client. Discard the placenta. Examine the placenta for completeness. Milk the umbilical cord.
Examine the placenta for completeness. Explanation: The nurse should examine the placenta for completeness by checking that the membranes are intact and all lobes are complete to prevent postpartum hemorrhage. The placenta is not stored or immediately discarded until it is examined fully. Milking the umbilical cord at this time is not necessary.
A middle-age female complains of anxiety, insomnia, weight loss, the inability to concentrate, and her eyes feeling "gritty." Thyroid function tests reveal the following: a thyroid-stimulating hormone (TSH) level of 0.02 units/ml, a thyroxine level of 20 g/dl, and a triiodothyronine level of 253 ng/dl. A 6-hour radioactive iodine uptake test showed a diffuse uptake of 85%. Based on these findings, the nurse would suspect: Graves' disease. Hashimoto's thyroiditis. thyroiditis. multinodular goiter.
Graves' disease. Explanation: Graves' disease, an autoimmune disease causing hyperthyroidism, is most prevalent in middle-age females. In Hashimoto's thyroiditis, the most common form of hypothyroidism, TSH levels would be high and thyroid hormone levels low. In thyroiditis, radioactive iodine uptake is low (≤ 2%). A multinodular goiter will show an uptake in the high-normal range (3% to 10%).
Which of the following techniques is most effective in preventing nosocomial infection transmission when caring for a preschooler? Standard precautions Needleless syringe system Hand washing Client isolation
Hand washing Explanation: Hand washing is the single most important measure for preventing infection transmission. Isolating the child and using infection control precautions are required for certain diseases, such as varicella, diphtheria, mumps, pertussis, measles, and meningitis. Standard precautions, which include hand washing, are guidelines for treating all clients as potentially infectious. A needleless syringe system will prevent transmission through needle sticks but not from body fluid contact.
A geriatric client is admitted to the facility after fainting while gardening on a hot summer day. Which nursing diagnosis takes highest priority for this client? Impaired physical mobility Hyperthermia Activity intolerance Disturbed thought processes
Hyperthermia Explanation: With age, the ability to regulate temperature diminishes and the number of sebaceous and sweat glands decreases. This puts the geriatric client at risk for Hyperthermia. Because hyperthermia can be life-threatening, this nursing diagnosis takes highest priority. If the other options are relevant, the nurse should assign them lower priority when planning this client's care.
A client is admitted with a cervical spine injury sustained during a diving accident. When planning this client's care, the nurse should assign highest priority to which nursing diagnosis? Dressing or grooming self-care deficit Impaired physical mobility Disturbed sensory perception (tactile) Ineffective breathing pattern
Ineffective breathing pattern Explanation: Because a cervical spine injury can cause respiratory distress, the nurse should take immediate action to maintain a patent airway and provide adequate oxygenation. The other options may be appropriate for a client with a spinal cord injury — particularly during the course of recovery — but they don't take precedence over a diagnosis of Ineffective breathing pattern.
A client is admitted with a cervical spine injury sustained during a diving accident. When planning this client's care, the nurse should assign highest priority to which nursing diagnosis? Ineffective breathing pattern Dressing or grooming self-care deficit Impaired physical mobility Disturbed sensory perception (tactile)
Ineffective breathing pattern Explanation: Because a cervical spine injury can cause respiratory distress, the nurse should take immediate action to maintain a patent airway and provide adequate oxygenation. The other options may be appropriate for a client with a spinal cord injury — particularly during the course of recovery — but they don't take precedence over a diagnosis of Ineffective breathing pattern.
A 9-year-old child is being discharged from the hospital after severe urticaria caused by an allergy to nuts. Which instructions would be included in discharge education for the child's parents? Instruct parents and child on how to use an epinephrine administration kit. Use emollient lotions and baths. Apply over-the-counter products such as diphenhydramine. Apply topical steroids to the lesions as needed.
Instruct parents and child on how to use an epinephrine administration kit. Explanation: Children who have urticaria in response to nuts, seafood, or bee stings should be warned about the possibility of anaphylactic reactions to future exposure. The use of epinephrine pens should be taught to the parents and to older children. Other treatment choices, such as emollients, topical steroids, and diphenhydramine, are for the treatment of mild urticaria.
A woman who has just given birth to her infant tells the nurse that she is putting the baby up for adoption. The nurse must serve as an advocate for this mother. What would the nurse do to assist the client in placing the child for adoption? Keep the client informed of her rights and options and support her decision. Urge the client to explore the possibility of keeping the child. Provide the client with personal opinions on adoption. Share a personal belief system.
Keep the client informed of her rights and options and support her decision.
On a client's first postpartum day, nursing assessment reveals vital signs within normal limits, a boggy uterus, and saturation of the perineal pad with lochia rubra. Which of the following actions by the nurse is the most appropriate? Administer oxytocin as prescribed. Reassess the client in 2 hours. Massage the uterine fundus gently. Notify the physician or nurse-midwife.
Massage the uterine fundus gently. Explanation: If a postpartum client has a boggy (relaxed) uterus, the nurse should first massage her uterus gently to stimulate contraction (involution). The nurse should reassess the client 15 minutes later to ensure that massage was effective. If the uterus doesn't respond to massage, the nurse should administer oxytocin as prescribed. The nurse should notify the physician or nurse-midwife if the client's uterus remains boggy after massage and oxytocin administration or if assessment reveals a rapid, thready pulse or decreased blood pressure.
A licensed practical nurse (LPN) is coassigned with a registered nurse (RN) for the care of a client with hemophilia. The physician prescribes a blood transfusion for this client. Which task associated with blood transfusion is the responsibility of the LPN? Monitoring the client during the transfusion Ensuring that a 20-gauge I.V. catheter is in place before obtaining the blood product Obtaining informed consent Making sure that the RN signs the transfusion form
Monitoring the client during the transfusion Explanation: After the transfusion is initiated, the LPN should monitor the client under the guidance of the RN. The LPN should notify the RN immediately if complications arise. The physician is responsible for obtaining informed consent from the client. Before the RN administers the transfusion, she must make sure that the consent form was signed. She should then make sure that the transfusion order is complete and that an appropriate size (20-gauge or larger), functioning I.V. catheter is in place. The blood product should then be obtained from the blood bank, and the client's identity should be verified using two client identifiers before beginning the transfusion. The RN who begins the transfusion must sign the transfusion form.
A client with hypertension visits the health clinic for a routine checkup. The nurse measures the client's blood pressure at 164/92 mm Hg and notes a 5-lb (2.3-kg) weight gain over the past 6 months. Which nursing diagnosis reflects the most serious problem in managing a client with hypertension? Imbalanced nutrition: More than body requirements Noncompliance (nonadherence to therapeutic regimen) Excess fluid volume Deficient knowledge
Noncompliance (nonadherence to therapeutic regimen) Explanation: Noncompliance is the most serious problem in managing a client with hypertension. One authority estimates that 40% to 60% of hypertensive clients fail to comply with prescribed treatment. Reasons for noncompliance include a lack of symptoms, which makes the problem seem less serious; the difficulty of making required lifestyle changes, such as eating a low-sodium diet, stopping smoking, and losing or managing weight; adverse reactions to antihypertensive drugs; and the inconvenience and high cost of obtaining health care. The other options may promote or result from noncompliance. Deficient knowledge contributes to noncompliance; Excessive fluid volume, caused by excessive sodium intake, and Imbalanced nutrition: More than body requirementsmay result from noncompliance.
A client undergoes total gastrectomy. Several hours after surgery, the nurse notes that the client's nasogastric (NG) tube has stopped draining. How should the nurse respond? Notify the physician. Increase the suction level. Irrigate the tube. Reposition the tube.
Notify the physician. Explanation: An NG tube that fails to drain during the postoperative period should be reported to the physician immediately. It may be clogged, which could increase pressure on the suture site because fluid isn't draining adequately. Repositioning or irrigating an NG tube in a client who has undergone gastric surgery can disrupt the anastomosis. Increasing the level of suction may cause trauma to GI mucosa or the suture line.
A nurse is caring for a neonate whose mother was abusing drugs. The nurse anticipates that the neonate may experience drug withdrawal. Which intervention would be the priority? Dress the neonate in loose clothing so he won't feel restricted. Place the Isolette in a quiet area of the nursery. Withhold all medication to help the liver metabolize drugs. Place the Isolette near the nurses' station for frequent contact with health care workers.
Place the Isolette in a quiet area of the nursery. Explanation: Neonates experiencing drug withdrawal commonly have sleep disturbance. The neonate should be moved to a quiet area of the nursery to minimize environmental stimuli. Medications, such as phenobarbital, methadone, and diazepam should be given as needed. The neonate should be swaddled to prevent him from flailing and stimulating himself.
A client, 7 months pregnant, is admitted to the unit with abdominal pain and bright red vaginal bleeding. Which action should the nurse take? Administer I.V. oxytocin, as ordered, to stimulate uterine contractions and prevent further hemorrhage. Massage the client's fundus to help control the hemorrhage. Place the client on her left side and start supplemental oxygen, as ordered, to maximize fetal oxygenation. Ease the client's anxiety by assuring her that everything will be all right.
Place the client on her left side and start supplemental oxygen, as ordered, to maximize fetal oxygenation. Explanation: The client's signs and symptoms indicate abruptio placentae, which decreases fetal oxygenation. To maximize fetal oxygenation, the nurse should place the client on her left side to increase placental blood flow to the fetus and administer supplemental oxygen, as ordered, to increase the blood oxygen level. Administering oxytocin isn't appropriate because this drug stimulates contractions, which further reduce fetal oxygenation. The nurse can't assure the client that everything will be all right, only that everything possible will be done to help her and her fetus. Fundal massage is used only during the postpartum period to control hemorrhage.
A client comes to the emergency department diagnosed with a ruptured aortic aneurysm. What is the priority action for this client? Prepare the client for surgery. Administer beta-blocker. Transport the client for an aortogram. Administer antihypertensive medication.
Prepare the client for surgery. Explanation: When the vessel ruptures, surgery is the only intervention that can repair it. Administration of antihypertensive medications and beta-blockers can help control hypertension, reducing the risk of rupture. An aortogram is a diagnostic tool used to detect an aneurysm.
A client is admitted to the emergency department with a suspected overdose of an unknown drug. Arterial blood gas values indicate respiratory acidosis. What should the nurse do first? Obtain urine for drug screening. Monitor the client's heart rhythm. Prepare for gastric lavage. Prepare to assist with ventilation.
Prepare to assist with ventilation. Explanation: Respiratory acidosis is associated with hypoventilation; in this client, hypoventilation suggests intake of a drug that has suppressed the brain's respiratory center. Therefore, the nurse should realize that the client has respiratory depression, and she should prepare to assist with ventilation. After the client's respiratory function has been stabilized, the nurse can safely monitor the heart rhythm, prepare for gastric lavage, and obtain a urine sample for drug screening.
A neonate born 18 hours ago with myelomeningocele over the lumbosacral region is scheduled for corrective surgery. Preoperatively, what is the most important nursing goal? Preventing infection Providing adequate nutrition Ensuring adequate hydration Preventing contracture deformity
Preventing infection Explanation: Preventing infection is the nurse's primary preoperative goal for a neonate with myelomeningocele. Although the other options are relevant for this neonate, they're secondary to preventing infection.
A client's gestational diabetes is poorly controlled throughout her pregnancy. She goes into labor at 38 weeks and gives birth. Which priority intervention should be included in the plan of care for the neonate during the first 24 hours? Administer a bolus of dextrose IV. Administer insulin subcutaneously. Avoid oral feedings. Provide frequent early feedings with formula.
Provide frequent early feedings with formula. Explanation: The neonate of a mother with gestational diabetes may be slightly hyperglycemic immediately after birth because of the high glucose levels that cross the placenta from mother to fetus. During pregnancy, the fetal pancreas secretes increased levels of insulin in response to this increased glucose amount that crosses the placenta from the mother. However, during the first 24 hours of life, this combination of high insulin production in the neonate coupled with the loss of maternal glucose can cause severe hypoglycemia. Frequent, early feedings of formula given orally can prevent hypoglycemia. Insulin shouldn't be administered because the neonate of a mother with gestational diabetes is at risk for hypoglycemia. A bolus of dextrose given IV may cause rebound hypoglycemia. If dextrose is given IV, it should be administered as a continuous infusion.
A nurse is caring for a client who has a brain tumor and increased intracranial pressure (ICP). Which nursing intervention should be included in the client's care? Encourage coughing and deep breathing. Position the client's head toward the side of the tumor. Provide sensory stimulation to improve neural activity. Provide rest periods between nursing interventions.
Provide rest periods between nursing interventions. Explanation: Nursing interventions for a client with increased ICP should be spaced throughout the day to prevent further increase in ICP, which can occur with any type of stimulation. Coughing increases ICP by increasing intrathoracic pressure and reducing venous return. Keeping the head in midline and avoiding extreme neck flexion prevents obstruction of venous outflow from the brain. Both sensory stimulation and noxious stimuli can increase ICP.
A nurse is caring for a client with a chest tube connected to a three-chamber drainage system without suction. In which chamber will the nurse observe to record the current drainage level? (Left or Right Side)
Right Explanation: A chest tube drains blood, fluid, and air from around the lungs. The drainage system, which the nurse measures each shift, is on the right. It has three calibrated chambers that show the amount of drainage collected. When the first chamber fills, drainage empties into the second; when the second chamber fills, drainage flows into the third. The water seal chamber is located in the center. The suction control chamber is on the left.
The nurse is caring for a wheelchair-bound client. Which piece of equipment impedes circulation to the area it's meant to protect? Gel flotation pad Air-fluidized bed Ring or donut Water bed
Ring or donut Explanation: Rings or donuts aren't to be used because they restrict circulation. An air- fluidized bed contains beads that move under an airflow to support the client, thus reducing shearing force and friction. Gel pads redistribute with the client's weight. The water bed also distributes pressure over the entire surface.
A new mother is holding her infant after a feeding. Which behavior by the mother would be concerning to the nurse related to malattachment? She changes the infant's diaper. She rocks the infant when the infant begins to cry. She refers to the infant as "it" instead of saying the infant's name. She looks into the infant's face.
She refers to the infant as "it" instead of saying the infant's name.
When assisting with the education of the family of a client with C4 quadriplegia on how to perform tracheostomy suctioning, which instruction should the nurse be sure to include? Regulate the suction machine to 300 cm suction. Pass the suction catheter into the opening of the tracheostomy tube 2 to 3 cm. Suction for 10 to 15 seconds at a time. Apply suction to the catheter during insertion only.
Suction for 10 to 15 seconds at a time. Explanation: Suction should be applied for 10 to 15 seconds at a time. When suctioning the trachea, the catheter is inserted 4 to 6 inches (10 to 15 cm) or until resistance is felt. Suction should be applied only during withdrawal of the catheter. Suction is regulated to 80 to 120 cm.
When assisting with the education of the family of a client with C4 quadriplegia on how to perform tracheostomy suctioning, which instruction should the nurse be sure to include? Suction for 10 to 15 seconds at a time. Regulate the suction machine to 300 cm suction. Apply suction to the catheter during insertion only. Pass the suction catheter into the opening of the tracheostomy tube 2 to 3 cm.
Suction for 10 to 15 seconds at a time. Explanation: Suction should be applied for 10 to 15 seconds at a time. When suctioning the trachea, the catheter is inserted 4 to 6 inches (10 to 15 cm) or until resistance is felt. Suction should be applied only during withdrawal of the catheter. Suction is regulated to 80 to 120 cm.
A client who comes to the labor and delivery area tells the nurse she believes her membranes have ruptured. When obtaining her history, what should the nurse ask about first? The time of membrane rupture The frequency of contractions The presence of back pain The presence of bloody show
The time of membrane rupture Explanation: First, the nurse should ask the client when her membranes ruptured because the risk of perinatal infection increases with the time elapsed between membrane rupture and the onset of contractions. After determining the time of membrane rupture, the nurse should ask about the frequency of contractions and find out whether the client has back pain or bloody show.
A woman gave birth to a healthy baby girl 2 days ago. Which observation by the nurse indicates the need for additional assessment and follow up? The woman reports that she will be happy to get home because she does not like hospital food. The woman actively participates in the care of her baby. The woman tells a friend, referring to her baby, "It just cries all the time." The woman comments that her baby has red hair like her grandmother.
The woman tells a friend, referring to her baby, "It just cries all the time."
Based on the nurse's knowledge about the postpartum period and an increase in blood coagulability during the first 48 hours, the nurse closely assesses the client for which condition? varicose veins calcium depletion thromboembolism hyperglycemia
Thromboembolism
A client is scheduled for a laminectomy to repair a herniated intervertebral disk. When developing the postoperative plan of care, the nurse should include which action? Turning the client from side to side, using the logroll technique Placing the client in semi-Fowler's position Maintaining bed rest for 72 hours after the laminectomy Keeping a pillow under the client's knees at all times
Turning the client from side to side, using the logroll technique Explanation: To avoid twisting the spine or hips when turning a client onto the side, the nurse should use the logroll technique. (Twisting after a laminectomy could injure the spine.) After surgery, the nurse shouldn't put anything under the client's knees or place the client in semi-Fowler's position because these actions increase the risk of deep vein thrombosis. Typically, the client is allowed out of bed by the first or second day after a laminectomy.
During pregnancy a woman's cardiovascular system expands to care for the growing fetus. After birth, during the early postpartum period, the woman eliminates the additional fluid volume she has been carrying. What is one way she does this? Elimination of solid wastes Breathing off fluid vapor Urinary elimination Being too tired to eat
Urinary elimination In the early postpartum period, the woman eliminates the additional fluid volume that is present during the pregnancy via the skin and urinary tract and through blood loss.
A client with an indwelling urinary catheter is suspected of having a urinary tract infection. Which technique should the nurse use to collect a urine specimen for culture and sensitivity? Clamp the tubing for 60 minutes, and insert a sterile needle into the tubing above the clamp to aspirate urine. Wipe the self-sealing aspiration port with antiseptic solution, and aspirate urine with a sterile needle. Open the drain on the urine collection bag, and allow it to drain into a sterile container. Disconnect the tubing from the urinary catheter, and let the urine flow into a sterile container.
Wipe the self-sealing aspiration port with antiseptic solution, and aspirate urine with a sterile needle. Explanation: Most catheters have a self-sealing port for obtaining a urine specimen. Antiseptic solution is used to reduce the risk of introducing microorganisms into the catheter. Tubing should not be disconnected from the urinary catheter. Any break in the closed urine drainage system can allow the entry of microorganisms. Urine in urine drainage bags may not be fresh and may contain bacteria, giving false positive test results. When there is no urine in the tubing, the catheter may be clamped for no more than 30 minutes to allow urine to collect.
A client is admitted to the facility with a suspected ectopic pregnancy. When reviewing the client's health history for risk factors for this abnormal condition, the nurse expects to find: grand multiparity (five or more births). use of an intrauterine device for 1 year. use of a hormonal contraceptive for 5 years. a history of pelvic inflammatory disease.
a history of pelvic inflammatory disease. Explanation: Pelvic inflammatory disease with accompanying salpingitis is commonly implicated in cases of tubal obstruction, the primary cause of ectopic pregnancy. Ectopic pregnancy isn't associated with grand multiparity or hormonal contraceptive use. Ectopic pregnancy is associated with use of an intrauterine device for 2 years or more.
An infant is diagnosed with a congenital hip dislocation. The nurse should expect to note: increased hip abduction. femoral lengthening. symmetrical thigh and gluteal folds. asymmetrical thigh and gluteal folds.
asymmetrical thigh and gluteal folds. Explanation: Asymmetrical thigh and gluteal folds, limited hip abduction, unequal leg length, and a positive Ortolani's sign (a click or popping sensation that's felt or heard when a neonate's hip is flexed 90 degrees and abducted) are present with congenital hip dislocation.
A nurse collects data on a client who is postoperative thyroid surgery. The client has a positive Chvostek's sign. Which laboratory finding supports the presence of this finding? potassium 4.5 mEq/L (4.5 mmol/L) calcium 7.1 mg/dL (1.77 mmol/L) sodium 130 mg/dL (130 mmol/L) magnesium 2.4mg/dL (0.99 mmol/L)
calcium 7.1 mg/dL (1.77 mmol/L) Explanation: The presence of Chvostek's sign indicates hypocalcemia (serum calcium levels below 8.2 mg/dL or 2.05 mmol/L). Chvostek's sign is elicited by lightly tapping the client's face over the facial nerve, just below the temple causing the client's facial muscles to twitch. Because the parathyroid glands (regulates calcium balance) are in close proximity to the thyroid gland, they are sometimes removed accidentally, resulting in hypocalcemia. Signs and symptoms of hyponatremia (serum sodium level below 135 mg/dl or 135 mmol/L) include weight loss, abdominal cramping, muscle weakness, headache, and orthostatic hypotension. Hypokalemia (serum potassium level below 3.5 mEq/L or 4.5 mmol/L) causes paralytic ileus, muscle weakness, fatigue, and cardiac conduction disturbances. Clients with hypermagnesemia (above normal serum magnesium levels 2.1 mg/dL or 1.05 mmol/L) may exhibit loss of deep tendon reflexes, coma, and cardiac arrest.
A client is sitting in a chair and begins having a tonic-clonic seizure. The most appropriate nursing response is to: allow him to remain in the chair but move all objects out of his way. place an oral airway in his mouth to maintain an open airway. hold the client's arm still to keep him from hitting anything. carefully move him to a flat surface and turn him on his side.
carefully move him to a flat surface and turn him on his side. Explanation: When caring for a client experiencing a tonic-clonic seizure, the nurse should take steps to ensure that the client can breathe and to protect the client from injury. In this situation, the nurse should help the client to a flat nonelevated surface and then position him on his side. These steps help reduce the risk of injury from falling or hitting surrounding objects. They also help establish an open airway. The client shouldn't be restrained during the seizure. Also, nothing should be placed in his mouth; anything in the mouth could impair ventilation and damage the inside of his mouth.
A client in the short-procedure unit is recovering from renal angiography in which a femoral puncture site was used. When providing postprocedure care, the nurse should: keep the client's knee on the affected side bent for 6 hours. remove the dressing on the puncture site after vital signs stabilize. check the client's pedal pulses frequently. apply pressure to the puncture site for 30 minutes.
check the client's pedal pulses frequently. Explanation: After renal angiography involving a femoral puncture site, the nurse should check the client's pedal pulses frequently to detect reduced circulation to the feet caused by vascular injury. The nurse also should monitor vital signs for evidence of internal hemorrhage and should observe the puncture site frequently for fresh bleeding. The client should be kept on bed rest for several hours so the puncture site can seal completely. Keeping the client's knee bent is unnecessary. By the time the client returns to the short- procedure unit, manual pressure over the puncture site is no longer needed because a pressure dressing is in place. The nurse shouldn't remove this dressing for several hours — and only if instructed to do so.
A client on bedrest with an indwelling urinary catheter informs the nurse of having discomfort in the lower abdomen. What is the first action by the nurse? irrigate the catheter obtain a urine specimen to see if the client has a urinary tract infection remove the catheter and reinsert another check to see if the catheter is kinked
check to see if the catheter is kinked Explanation: The urinary catheter should be checked for kinks. There is no indication that the catheter should be removed and reinserted; this also increases the client's risk of infection. Irrigation of the catheter is not routine care and is not indicated. There is not enough data to indicate that the client is having a urinary tract infection.
The nurse is caring for the four clients. Which client should the nurse see first? client who needs pain medication for a pain level of 9 of 10 client who needs a stool specimen and wants to go to the bathroom client scheduled for surgery in 2 hours client scheduled for magnetic resonance imaging in a few hours
client who needs pain medication for a pain level of 9 of 10 Explanation: The client with pain should be seen first (according to Maslow's hierarchy of needs). A client for a magnetic resonance imaging and surgery can be prepared in 2 hours after giving pain medication. The client that needs a stool specimen can be taught to obtain the stool specimen or the nurse may be able to obtain it later.
While providing care to a client receiving antipsychotic therapy, the nurse suspects that the client is experiencing tardive dyskinesia based on which finding? restlessness blurred vision sudden fever involuntary movements
involuntary movements Explanation: Symptoms of tardive dyskinesia include tongue protrusion, lip smacking, chewing, blinking, grimacing, choreiform movements of limbs and trunk, and foot tapping. Blurred vision is a common adverse reaction of antipsychotic drugs and usually disappears after a few weeks of therapy. Restlessness is associated with akathisia. Sudden fever may be a symptom of a malignant neurologic disorder.
A nurse is caring for a client at 30 weeks' gestation who has tested positive for the human immunodeficiency virus (HIV). Which information would be most appropriate for the nurse to emphasize when reinforcing instruction about prenatal care? Select all that apply. maintaining breast skin integrity to help with breastfeeding maintaining compliance with medication therapy ensuring periodic rest periods throughout the day limiting her intake of protein-rich foods increasing fluid intake to 2 liters per day
maintaining compliance with medication therapy increasing fluid intake to 2 liters per day ensuring periodic rest periods throughout the day Explanation: For a pregnant client who is HIV positive, important information should include the need to adhere to medication therapy because this therapy greatly reduces the risk of HIV transmission to the neonate. In addition, the client should be reminded to increase her fluid intake to 2 liters/day or more, consume adequate amounts of protein, and take frequent rest periods throughout the day to prevent fatigue. Transmission of HIV can occur through breast milk, so breastfeeding should be discouraged in a client who has tested positive for HIV.
A client scheduled for a colonoscopy has received nothing by mouth since midnight. The procedure is scheduled for 8 a.m. At 6:30 a.m. the nurse collects a fingerstick glucose sample that registers 40 mg/dl on the glucose monitor. The client is alert, has clear speech, and states, "I don't feel like my sugar is too low." Initially, the nurse should: document the finding and withhold the client's morning insulin. give the client an oral simple sugar. notify the registered nurse immediately so she can administer 50 g of dextrose I.V. repeat the fingerstick glucose test.
repeat the fingerstick glucose test. Explanation: Because the client is showing no signs of hypoglycemia, yet the glucose level is abnormally low, an error may have occurred in obtaining the result. Therefore, the nurse should repeat the test. Responding to the low results takes precedence over documenting the findings. Because of the inconsistency between the 40 mg/dl reading and the absence of symptoms, the value should be rechecked before any glucose is administered.
The clinic nurse is reinforcing teaching about symptoms of cardiovascular disease (CVD) with the client. What are common symptoms associated with cardiovascular disease? mood swings, vomiting, fainting fatigue, weight changes, edema shortness of breath, chest discomfort/pain, palpitations dyspnea, headache, sputum production
shortness of breath, chest discomfort/pain, palpitations Explanation: Clinical manifestations of CVD are shortness of breath, chest discomfort/pain, dyspnea, palpitations, fainting, and peripheral skin changes such as edema.
On discharge, a client who underwent a left mastectomy expresses relief that "the cancer" has been treated. When discussing this issue with the client, the nurse should stress that she: is lucky that the cancer was caught in time. should schedule a follow-up appointment in 6 months. should continue to perform breast self-examination on her right breast. may expect her menstrual periods to be irregular.
should continue to perform breast self-examination on her right breast. Explanation: Having breast cancer on her left side increases the client's risk for developing cancer on the contralateral side and chest wall. Therefore, the nurse should stress the importance of monthly breast self-examinations and annual mammograms. Follow-up appointments should be monthly for the first few months and then at the direction of her physician. A mastectomy shouldn't affect the menstrual cycle.
A client is admitted to the hospital with a diagnosis of respiratory failure. The client is intubated, placed on 100% FiO2, and is coughing up copious secretions. Which intervention has priority? suctioning the client restraining the client getting an x-ray obtaining an arterial blood gas (ABG) analysis
suctioning the client Explanation: Suctioning the client is the priority because secretions can cut off the oxygen supply to the client and result in hypoxia. X-rays are the next priority; check placement of the endotracheal tube. Restraints are warranted only if the client is a threat to his safety. After the client has acclimated to his ventilator settings, ABG levels can be drawn.
A nurse is monitoring laboratory results for a client admitted with a possible myocardial infarction (MI). Which laboratory result would be used to rule out an MI? total red blood cell (RBC) count of 4.7 million/mm³ mean corpuscular hemoglobin of 27 pg/cell troponin level of less than 0.2 ng/mL (0.2 µg/L) total white blood cell (WBC) count of 15,000/mm³
troponin level of less than 0.2 ng/mL (0.2 µg/L) Explanation: Cardiac troponins are proteins that exist in cardiac muscle and are released with cardiac muscle injury. A troponin level of less than 0.2 ng/mL (0.2 µg/L) is considered normal. An elevated WBC count (15,000/mm³) is seen in many disease processes and with severe necrosis, but doesn't specifically indicate MI. A total RBC count of 4.7 million/mm³ is within normal limits for males and females, but isn't used to rule out an MI. Mean corpuscular hemoglobin is an RBC index providing information about the hemoglobin concentration of RBCs, but it isn't used to rule out an MI.
A school-age child has a fever, joint inflammation, and a nonpruritic rash. Knowing that these are signs of rheumatic fever, the nurse should ask the parents: "Has your child recently been exposed to other children with rheumatic fever?" "Is your child's Haemophilus influenzae vaccine up to date?" "Has your child had strep throat recently?" "Does your child have a congenital heart defect?"
"Has your child had strep throat recently?" Explanation: Group A beta-hemolytic streptococcal infection typically precedes rheumatic fever. An inflammatory disease, rheumatic fever affects the heart, joints, and central nervous system. It isn't infectious and can't be transmitted from one person to another. Congenital heart defects don't play a role in the development of rheumatic fever. H. influenzae vaccine doesn't prevent streptococcal infection or rheumatic fever.
An older child has received diet instruction as part of the treatment plan for type 1 diabetes. Which statement by the older child indicates to the nurse the need for additional instruction? "I can have an occasional low-calorie drink as long as I include it in my meal plan." "I can eat whatever I want as long as I cover the calories with sufficient insulin." "I will need a bedtime snack because I take an evening dose of NPH insulin." "I should eat meals as scheduled, even if I'm not hungry, to prevent hypoglycemia."
"I can eat whatever I want as long as I cover the calories with sufficient insulin." Explanation: The goal of diet therapy in diabetes is to attain and maintain ideal body weight. Each child with diabetes will be prescribed a specific caloric intake and insulin regimen to help accomplish this goal.
x An older child has received diet instruction as part of the treatment plan for type 1 diabetes. Which statement by the older child indicates to the nurse the need for additional instruction? "I will need a bedtime snack because I take an evening dose of NPH insulin." "I can eat whatever I want as long as I cover the calories with sufficient insulin." "I can have an occasional low-calorie drink as long as I include it in my meal plan." "I should eat meals as scheduled, even if I'm not hungry, to prevent hypoglycemia."
"I can eat whatever I want as long as I cover the calories with sufficient insulin." Explanation: The goal of diet therapy in diabetes is to attain and maintain ideal body weight. Each child with diabetes will be prescribed a specific caloric intake and insulin regimen to help accomplish this goal.
A nurse is reinforcing education to a client diagnosed with renal calculi. Which statement made by the client suggests further instruction is indicated? "I do not need to limit my intake of tea or cola." "I should avoid foods that are high in calcium." "I should contact my health care provider if I see blood in my urine." "I should contact my health care provider if I develop flank pain again."
"I do not need to limit my intake of tea or cola." Explanation: A client with a history of kidney stones should notify the health care provider if he develops flank pain or blood in the urine. Foods high in calcium can cause calcium stones. Cola and teas can cause oxalate stones and should be avoided.
The nurse and a client have just discussed the client's recent diagnosis of hypothyroidism and its causes and effects. Which statement indicates that the client needs further instruction? "Now I see. My clumsiness is caused by a hormone problem." "I'm not cold all the time because I'm getting older. I'm cold because of a metabolic problem." "I just eat too much. That's why I'm depressed and overweight." "No wonder I'm constipated. I'm predisposed to it no matter what I eat."
"I just eat too much. That's why I'm depressed and overweight." Explanation: Hypothyroidism causes inadequate secretion of thyroid hormones, which slows all metabolic processes and can cause depression and weight gain. Hypothyroidism can also cause clumsiness, constipation, and a feeling of coldness. A client with hypothyroidism requires further instruction about the effects of the disease if the client insists that overeating has caused obesity and depression or claims that being hot or predisposed to diarrhea is caused by the disease.
A client diagnosed with hyperosmolar hyperglycemic nonketotic syndrome (HHNS) is stabilized and prepared for discharge. When preparing the client for discharge and home management, which statement indicates that the client understands her condition and how to control it? "If I begin to feel especially hungry and thirsty, I'll eat a snack high in carbohydrates." "If I experience trembling, weakness, and headache, I should drink a glass of soda that contains sugar." "I will have to monitor my blood glucose level closely for hypoglycemia." "I should avoid becoming dehydrated and pay attention to my need to urinate, drink, or eat more than usual."
"I should avoid becoming dehydrated and pay attention to my need to urinate, drink, or eat more than usual." Explanation: Inadequate fluid intake during hyperglycemic episodes commonly leads to HHNS. By recognizing the signs of hyperglycemia (polyuria, polydipsia, and polyphagia) and increasing fluid intake, the client may prevent HHNS. Drinking a glass of nondiet soda would be appropriate for hypoglycemia. The client needs to monitor for hyperglycemia, not hypoglycemia. A high-carbohydrate diet would exacerbate the client's condition, particularly if fluid intake is low.
The nurse is teaching circumcision care to a mother before discharge. Which statement by the mother indicates that teaching was successful? "I should wash the penis with warm soap and water." "I should reapply fresh petrolatum gauze after each diaper change." "I must change my son's diaper at least every 2 hours." "I can use premoistened towelettes to clean the penis."
"I should reapply fresh petrolatum gauze after each diaper change." Explanation: The mother's verbalization of understanding that fresh petrolatum gauze should be applied after each diaper change indicates that teaching was successful. The mother should change the diaper at least every 4 hours and clean the penis with warm water, not soap and water, until the circumcision is healed. Soap can be used after the circumcision has healed. The mother should avoid using premoistened towelettes to clean the penis because they contain alcohol, which can cause discomfort and delay healing.
A nurse is assisting a primary health care provider perform a lumbar puncture. The client appears worried and anxious. After the procedure, which statement is most appropriate for the nurse to make? "I'll put the head of the bed up so you can watch your favorite television programs. There's a good baseball game on now." "Just relax. There are no bad aftereffects, and the worst is over." "I want you to lie flat for a while. I'll close the curtain, and perhaps you can rest. I'll be quiet when I check on you in a few minutes." "I'll fluff your pillows so you can sit and drink some juice. Call me if you need me."
"I want you to lie flat for a while. I'll close the curtain, and perhaps you can rest. I'll be quiet when I check on you in a few minutes." Explanation: Headaches are common after a lumbar puncture. Laying the client flat in a darkened room may help relieve or prevent discomfort. Checking on the client frequently helps the client feel secure. Watching television and sitting up may promote a headache. Telling the client to relax and stating that there are no bad aftereffects from lumbar puncture is unprofessional and shows disregard for the client's anxious state.
A nurse is caring for a client who was admitted to the intensive care unit with a diagnosis of respiratory failure. Arterial blood gases are as follows: pH 7.28, PCO2 54 mm Hg, and HCO3- 25 mEq/L, PO2 55, O 2 saturation 89%. What does the nurse determine the results indicate? metabolic acidosis metabolic alkalosis respiratory acidosis respiratory alkalosis
A pH of 7.28 is less than 7.35 (normal is 7.35 to 7.45) and indicates acidosis. The CO2 of 54 (normal is 35 to 45) also indicates acidosis. The CO2 matches the pH because they are both acidotic. The high PCO2 and normal HCO3- of 25 (normal is 22 to 26) indicates the lungs are the cause of the acidosis—respiratory acidosis.
A school-age child has a fever, joint inflammation, and a nonpruritic rash. Knowing that these are signs of rheumatic fever, the nurse should ask the parents: "Has your child recently been exposed to other children with rheumatic fever?" "Has your child had strep throat recently?" "Does your child have a congenital heart defect?" "Is your child's Haemophilus influenzae vaccine up to date?"
"Has your child had strep throat recently?" Explanation: Group A beta-hemolytic streptococcal infection typically precedes rheumatic fever. An inflammatory disease, rheumatic fever affects the heart, joints, and central nervous system. It isn't infectious and can't be transmitted from one person to another. Congenital heart defects don't play a role in the development of rheumatic fever. H. influenzae vaccine doesn't prevent streptococcal infection or rheumatic fever.
The nurse is reinforcing education provided for the client and spouse regarding electroconvulsive therapy (ECT). What statement made by the client would indicate that further education is required? "I will have no further episodes of depression after I have the procedure." "The anesthesiologist will be there to assist with my breathing during the procedure." "I will still take my antidepressant medication after the procedure." "I may have some short-term memory loss briefly after the procedure."
"I will have no further episodes of depression after I have the procedure." Explanation: The client should understand that although ECT is used for relapse prevention in depression, the treatments, such as one per month, are used to maintain mood improvement. The client may not see any long-term improvement after one treatment. The other options are correct statements by the client.
A client with pernicious anemia is receiving parenteral vitamin B12 therapy. Which client statement indicates effective teaching about this therapy? "I will receive parenteral vitamin B12 therapy monthly for 6 months to a year." "I will receive parenteral vitamin B12 therapy until my signs and symptoms disappear." "I will receive parenteral vitamin B12 therapy until my vitamin B12 level returns to normal." "I will receive parenteral vitamin B12 therapy for the rest of my life."
"I will receive parenteral vitamin B12 therapy for the rest of my life." Explanation: Because a client with pernicious anemia lacks intrinsic factor, oral vitamin B12 can't be absorbed. Therefore, parenteral vitamin B12 therapy is recommended and required for life.
A child has been brought to the ED with a bite to the arm from a dog. What action by the nurse will assist in the prevention of infection? No action is necessary since bites from a dog has a low incidence of infection. Clean and irrigate the wounds. Give antibiotics immediately. Give the rabies vaccine.
Clean and irrigate the wounds. Explanation: Not every dog bite requires antibiotic therapy, but cleaning the wound is necessary for all injuries involving a break in the skin. Rabies vaccine is used if the dog is suspected of having rabies. The infection rate for dog bites has been reported to be as high as 50%.
The health care provider has prescribed oral diazepam 50 mg once daily. The drug is available as oral suspension with a strength of 25 mg/5 ml. How many milliliters should the nurse administer? Record your answer using a whole number.
10 Explanation: The correct formula to calculate a drug dose is:(Dose on hand)/(Quantity on hand) = (Dose desired)/XThe health care provider prescribes 50 mg, which is the dose desired. The drug available is 25 mg/5 ml, which is the dose on hand. 25 mg/5 ml = 50 mg/X. X = 10 ml.
An older adult client has experienced an episode of acute pulmonary edema. Fearful of a repeat episode, the client asks what precautions should be taken to prevent another episode. What instruction should the nurse give to this client? Limit calorie intake. Measure weight twice per day. Call the health care provider if he gains more than 3 lb (1.4 kg) in 1 day. Restrict carbohydrates.
Call the health care provider if he gains more than 3 lb (1.4 kg) in 1 day. Explanation: Gaining 3 lb (1.4 kg) in 1 day is indicative of fluid retention that would increase the heart's workload, thereby putting the client at risk for acute pulmonary edema. Restricting carbohydrates wouldn't affect fluid status. The body needs carbohydrates for energy and healing. Limiting calorie intake doesn't influence fluid status. The client must be weighed only in the morning after the first urination. If the client is weighed later in the day, the finding wouldn't be accurate because of fluid intake during the day.
Parents bring their 13-month-old toddler to the clinic. The toddler has erythema and small vesicles that ooze on the buttocks. Which instruction should the nurse give the parents? Wash all bed linens and clothing with hot water. Apply permethrin cream, leave it on for 8 hours, and then bathe the child. Use cloth diapers and rubber pants until the rash heals. Change diapers frequently and air-dry when possible.
Change diapers frequently and air-dry when possible. Explanation: The child shows signs of diaper dermatitis. Therefore, the nurse should instruct the parent to change the child's diapers frequently, air-dry if possible, and avoid rubber pants. Permethrin cream and washing all bed linens and clothing with hot water are indicated for the treatment of scabies, not diaper dermatitis.
A client is admitted for right leg vein ligation and stripping for varicose veins. Which nursing intervention postoperatively should the nurse include? Apply knee-high stockings over the dressing. Ask the client to elevate the legs when sitting. Apply ice to dressings to decrease swelling. Ask the client to remain inactive until healing is complete.
Ask the client to elevate the legs when sitting. Explanation: Vein ligation and stripping postoperative nursing interventions should include educating the client to elevate the legs when sitting.
During the first 24 hours after a client is diagnosed with addisonian crisis, which task should the nurse perform frequently? Test urine for ketones. Assess vital signs. Administer oral hydrocortisone. Weigh the client.
Assess vital signs. Explanation: Because the client in addisonian crisis is unstable, the nurse should assess his vital signs and fluid and electrolyte balance every 30 minutes until he's stable. Daily weights are sufficient when assessing the client's condition. The client shouldn't have ketones in his urine, so there is no need to assess the urine for their presence. Oral hydrocortisone isn't administered during the first 24 hours in severe adrenal insufficiency.
The nurse is about to give a full-term neonate his first bath. Which of the following should the nurse do first? Bathe the neonate only after his vital signs have stabilized Scrub the neonate's skin to remove the vernix caseosa Clean the neonate with medicated soap Wash the neonate from feet to head
Bathe the neonate only after his vital signs have stabilized Explanation: To guard against heat loss, the nurse should bathe the neonate only after vital signs have stabilized. To avoid altering the skin pH, the nurse should use only mild soap and water. Scrubbing should be avoided because it may cause abrasions, through which microorganisms can enter. The nurse should wash the neonate from head to feet.
A client with a forceful, pounding heartbeat is diagnosed with mitral valve prolapse. This client should be instructed to avoid which of the following? High volumes of fluid intake Aerobic exercise programs Caffeine-containing products Foods rich in protein
Caffeine-containing products Explanation: Caffeine is a stimulant, which can exacerbate palpitations, and should be avoided by a client with symptomatic mitral valve prolapse. High-fluid intake helps maintain adequate preload and cardiac output. Aerobic exercise helps increase cardiac output and decrease heart rate. Protein-rich foods aren't restricted but high-calorie foods are.
The nurse is caring for a client in the postoperative period who had an open colon resection. The nurse attempts to change the dressing but observes the protrusion of intestine through the wound. What is the priority nursing action at this time? Call the health care provider to provide a description of the wound. Cover the wound with a sterile dressing moistened with normal saline. Put the dressing back over the wound until the health care provider arrives. Push the abdominal contents back into the wound and secure with a binder.
Cover the wound with a sterile dressing moistened with normal saline. Explanation: Evisceration is the protrusion of body organs from a wound. It may occur following surgery because of delayed wound healing or from forceful straining. When this event occurs, the first action by the nurse is to cover the wound with a sterile dressing moistened with normal saline to prevent drying out of abdominal contents. The next step would be to call the health care provider. The nurse should not push the contents back in the wound or replace with a wound dressing that is not sterile.
The nurse is caring for a 2-year-old child suspected of having bacterial meningitis. What is the nurse's priority action? Administer oxygen at 3 L/minute by nasal cannula. Review the child's history and physical examination report. Interview the child's parents about recent illnesses. Evaluate the child's neurologic status.
Evaluate the child's neurologic status. Explanation: Acute bacterial meningitis can be a pediatric emergency. A diagnosis based on accurate evaluation of neurologic status is a priority for correct treatment. A baseline neurologic evaluation is needed for later comparisons. Reading the child's history, reading the physical examination report, and interviewing the child's parents are not as crucial as evaluating neurologic status. No prescriptions or data exist to warrant the administration of oxygen.
A child, age 2, is brought to the emergency department after ingesting an unknown number of aspirin tablets about 30 minutes earlier. On entering the examination room, the child is crying and clinging to his mother. Which data should the nurse obtain first? Recent exposure to communicable diseases Heart rate, respiratory rate, and blood pressure Height and weight Number of immunizations received
Heart rate, respiratory rate, and blood pressure Explanation: The most important data to obtain on a child's arrival in the emergency department are vital sign measurements. The nurse should gather the other data later.
A geriatric client is admitted to the facility after fainting while gardening on a hot summer day. Which nursing diagnosis takes highest priority for this client? Hyperthermia Activity intolerance Disturbed thought processes Impaired physical mobility
Hyperthermia Explanation: With age, the ability to regulate temperature diminishes and the number of sebaceous and sweat glands decreases. This puts the geriatric client at risk for Hyperthermia. Because hyperthermia can be life-threatening, this nursing diagnosis takes highest priority. If the other options are relevant, the nurse should assign them lower priority when planning this client's care.
Which factor should the nurse be most concerned about when caring for a client taking an antianxiety medication? transient hypertension constipation abrupt withdrawal diarrhea
abrupt withdrawal Explanation: Abrupt discontinuation of an antianxiety drug can lead to withdrawal symptoms. Antianxiety medications are usually prescribed for short periods. If used over a prolonged period, such drugs may produce psychological or physical dependence. Transient hypertension, constipation, and diarrhea aren't associated with antianxiety drugs.
The nurse is instructing a client about the use of antiembolism stockings. Antiembolism stockings help prevent deep vein thrombosis (DVT) by: forcing blood into the deep venous system. elevating the extremity to prevent pooling of blood. encouraging ambulation to prevent pooling of blood. providing warmth to the extremity.
forcing blood into the deep venous system. Explanation: Antiembolism stockings prevent DVT by forcing blood into the deep venous system, instead of allowing blood to pool. Ambulation prevents blood from pooling and prevents DVT, but encouraging ambulation isn't a function of the stockings. Antiembolism stockings could possibly provide warmth, but this isn't how they prevent DVT. Elevating the extremity will decrease edema but won't prevent DVT.
Following a transsphenoidal hypophysectomy, the nurse should assess the client carefully for: hyperglycemia. hypocortisolism. hypoglycemia. hypercalcemia.
hypocortisolism. Explanation: The nurse should assess for hypocortisolism. Abrupt withdrawal of endogenous cortisol may lead to severe adrenal insufficiency. Steroids should be given during surgery to prevent hypocortisolism from occurring. Signs of hypocortisolism include vomiting, increased weakness, dehydration and hypotension. After the corticotropin- secreting tumor is removed, the client shouldn't be at risk for hyperglycemia. Calcium imbalance shouldn't occur in this situation.
Following a transsphenoidal hypophysectomy, the nurse should assess the client carefully for: hypocortisolism. hyperglycemia. hypoglycemia. hypercalcemia.
hypocortisolism. Explanation: The nurse should assess for hypocortisolism. Abrupt withdrawal of endogenous cortisol may lead to severe adrenal insufficiency. Steroids should be given during surgery to prevent hypocortisolism from occurring. Signs of hypocortisolism include vomiting, increased weakness, dehydration and hypotension. After the corticotropin- secreting tumor is removed, the client shouldn't be at risk for hyperglycemia. Calcium imbalance shouldn't occur in this situation.
A client recovering from an acute asthma attack experiences respiratory alkalosis. The nurse measures a respiratory rate of 46 breaths/minute, a heart rate of 110 beats/minute, a blood pressure of 162/90 mm Hg, and a temperature of 98.6° F (37° C). To help correct respiratory alkalosis, the nurse should: administer acetaminophen as prescribed. administer antibiotics as prescribed. instruct the client to breathe into a paper bag. insert a nasogastric tube (NG) as ordered.
instruct the client to breathe into a paper bag. Explanation: A client recovering from an acute asthma attack who experiences respiratory alkalosis should breathe into a paper bag to increase arterial carbon dioxide tension and ease anxiety (which may exacerbate the alkalosis). An NG tube would be indicated for a client with metabolic alkalosis secondary to ingestion of toxic substances; nothing indicates that this has occurred. Fever may cause metabolic (not respiratory) alkalosis and would be treated with acetaminophen. A client with sepsis also may have metabolic alkalosis and probably would receive antibiotics; however, this clinical situation doesn't suggest sepsis.
The nurse obtains laboratory results on assigned clients during morning report. Which results needs to be immediately reported to the health care provider? creatinine level 0.6 mg/dL hemoglobin 13.6 mg/dL glucose level 98 mg/dL potassium level 6.2 mg/dL
potassium level 6.2 mg/dL Explanation: Frequently, laboratory results are returned during the morning report. The nurse must review the labwork and decide a course of action. The potassium level is noted to be in the critical range. Often, there are no symptoms associated with elevated potassium levels, but it may be demonstrated in electrocardiogram readings. Renal impairment can create difficulty in removing potassium from the blood and create a dangerous buildup. These results should be reported to the health care provider immediately so that intervention may be provided.
A nurse is part of a team providing care to a neonate with a myelomeningocele. When implementing the neonate's plan of care, what is the priority action by the nurse? preventing infection ensuring adequate nutrition conserving body heat promoting neural tube sac drainage
preventing infection Explanation: The nurse needs to provide special care to the neural tube sac of a neonate born with a myelomeningocele to prevent infection. Allowing the sac to dry could result in cracks that allow microorganisms to enter. Pressure on the sac could cause it to rupture, creating a portal of entry for microorganisms. Promoting neural tube sac drainage may also place the neonate at risk for infection. Administering antibiotics and keeping the sac free from urine and stool are other measures to prevent infection. Adequate nutrition is a concern for all neonates, including those with a myelomeningocele. Like all neonates, a neonate with a myelomeningocele must be kept warm, but care must be taken to avoid drying out the neural tube sac with a radiant heater or exerting pressure on the sac by using a sheet or blanket.
A client has recently been diagnosed with hypertension. The client has an elevated blood pressure with no symptoms, and the cause is uncertain. Which term best describes this condition? malignant hypertension accelerated hypertension secondary hypertension primary hypertension
primary hypertension Explanation: Characterized by a progressive, usually asymptomatic blood pressure increase over several years, primary hypertension is the most common type. Malignant hypertension, also known as accelerated hypertension, is rapidly progressive and uncontrollable; it causes a rapid onset of complications. Secondary hypertension occurs secondary to a known, potentially correctable cause.
A client is diagnosed with disseminated intravascular coagulation (DIC) postpartum. The nurse recognizes that DIC may be related to which antepartum complication? urinary retention fetal decelerations severe pre-eclampsia Rhogam administration
severe pre-eclampsia Explanation: DIC is a life-threatening defect in coagulation that may occur in several complications of pregnancy (abruption placenta, pre-eclampsia, HELLP syndrome, sepsis). While anticoagulation is occurring, inappropriate coagulation also is occurring in the microcirculation. DIC can result in time clot formation in small blood vessels which block blood flow to organs and cause ischemia. Urinary retention, Rhogam administration, or fetal decelerations do not increase the risk of DIC.
The clinic nurse is reinforcing teaching about symptoms of cardiovascular disease (CVD) with the client. What are common symptoms associated with cardiovascular disease? mood swings, vomiting, fainting dyspnea, headache, sputum production fatigue, weight changes, edema shortness of breath, chest discomfort/pain, palpitations
shortness of breath, chest discomfort/pain, palpitations Explanation: Clinical manifestations of CVD are shortness of breath, chest discomfort/pain, dyspnea, palpitations, fainting, and peripheral skin changes such as edema.
A neonate was born at 36-weeks' gestation weighing 4 pounds (1,800 g). The neonate also has microcephaly and microphthalmia. The nurse is reviewing the maternal history in preparation for care. Which risk factor would the nurse most likely expect to find? positive group B streptococci use of marijuana gestational diabetes use of alcohol
use of alcohol Explanation: The most common sign of the effects of alcohol on fetal development is retarded growth in weight, length, and head circumference (microcephaly). Intrauterine growth retardation isn't characteristic of marijuana use. Gestational diabetes usually produces large-for-gestational-age neonates. Positive group B streptococci isn't a relevant risk factor.
A 3-day-old neonate needs phototherapy for hyperbilirubinemia. The nurse is reviewing the plan of care for this neonate. Which interventions would the nurse most likely find? use of eye patches to prevent retinal damage administration of tube feedings feeding the neonate while under phototherapy lights temperature monitoring every 6 hours during phototherapy
use of eye patches to prevent retinal damage Explanation: The neonate's eyes must be covered with eye patches to prevent damage. The neonate can be removed from the lights and held for feeding. Tube feedings are not necessary. The neonate's temperature should be monitored at least every 2 to 4 hours because of the risk of hyperthermia with phototherapy.
A nurse reviews the laboratory results for a client reporting right lower quadrant abdominal pain. Which laboratory finding should the nurse report to the health care provider immediately? red blood cell count of 5.4 million cells/mcL white blood cell (WBC) count of 22.8/mm serum potassium level of 4.2 mEq/L serum sodium level of 135 mEq/L
white blood cell (WBC) count of 22.8/mm Explanation: The nurse should report an elevated WBC count of 22.8/mm3 because it is a sign of infection, indicating that the client's appendix is inflamed or may have ruptured. The other laboratory values are within normal limits.
