NCLEX questions cognitive analysis 81 to 150

The nurse is caring for a client who has just been admitted to the nursing unit after receiving flame burns to the face and chest. The nurse notes a hoarse cough, and the client is expectorating sputum with black flecks. The client suddenly becomes restless, and his color is becoming dusky. The nurse should interpret this data as indicating which?

The client exhibits several warning signs of an inhalation injury: a history of a flame burn to the face, hoarseness, cough, carbonaceous sputum, singed facial hair, facial edema, and color change. Additionally, one of the cardinal signs of hypoxia is restlessness

Rifabutin (Mycobutin) is prescribed for a client with active Mycobacterium avium complex (MAC) disease and tuberculosis. The nurse should monitor for which side/adverse effects of the medication? Select all that apply

Rifabutin (Mycobutin) may be prescribed for a client with active MAC disease and tuberculosis. It inhibits mycobacterial DNA-dependent RNA polymerase and suppresses protein synthesis. Side effects include rash, gastrointestinal disturbances, neutropenia (low neutrophil count), red-orange body secretions, uveitis (blurred vision and eye pain), myositis, arthralgia, hepatitis, chest pain with dyspnea, and flu-like syndrome. Vitamin B6 deficiency and numbness and tingling in the extremities are associated with the use of isoniazid. Ethambutol (Myambutol) also causes peripheral neuritis.

The nurse is reinforcing instructions to a group of high school males in a health class about how to perform a testicular self-examination (TSE). The nurse should make which statement?

TSE is recommended monthly after a warm bath or shower when the scrotal skin is relaxed. It also could be done near the end of the shower. The client should be standing to examine the testicles. The client should use both hands, placing fingers under the scrotum and thumbs on top, and should gently roll the testicles, feeling for any lumps.

The nurse is assigned to care for a child after a spinal fusion for the treatment of scoliosis. The child complains of abdominal discomfort and begins to have episodes of vomiting. On data collection, the nurse notes abdominal distention. Which action should the nurse take?

A complication after the surgical treatment of scoliosis is superior mesenteric artery syndrome. This disorder is caused by mechanical changes in the position of the child's abdominal contents that result from the lengthening of the child's body. It results in a syndrome of emesis and abdominal distention that is similar to that which occurs with intestinal obstruction or paralytic ileus. Postoperative vomiting among children with body casts or among those who have undergone spinal fusion warrants attention because of the possibility of superior mesenteric artery syndrome. Therefore, the remaining options are incorrect

Which home care instructions should the nurse plan to reinforce to the mother of a child with acquired immunodeficiency syndrome (AIDS)? Select all that apply.

AIDS is a disorder that is caused by the human immunodeficiency virus (HIV) and is characterized by a generalized dysfunction of the immune system. Both cellular and humoral immunity are compromised. The horizontal transmission of HIV occurs through intimate sexual contact or parenteral exposure to blood or body fluids that contain visible blood. Vertical (perinatal) transmission occurs when an HIV-infected pregnant woman passes the infection to her infant. Home care instructions include the following: frequent hand washing; monitoring for fever, malaise, fatigue, weight loss, vomiting, diarrhea, altered activity level, and oral lesions and notifying the health care provider if these occur; monitoring for signs and symptoms of opportunistic infections; administering antiretroviral medications, as prescribed; avoiding exposure to other illnesses; keeping immunizations up to date; avoiding kissing the child on the mouth; monitoring the weight and providing a high-calorie, high-protein diet; washing eating utensils in the dishwasher; and avoiding the sharing of eating utensils. Gloves are worn for care, especially when in contact with body fluids or changing diapers. Diapers are changed frequently and away from food areas, and soiled disposable diapers are folded inward, closed with their tabs, and disposed of in a tightly covered plastic-lined container. Any body fluid spills are cleaned with a bleach solution made up of a 10:1 ratio of water to bleach.

Treatment measures have been implemented for a client with bleeding esophageal varices and have been unsuccessful. The health care provider states that a Sengstaken-Blakemore tube will be used to control the resulting hemorrhage. The nurse prepares for insertion via which route?

A Sengstaken-Blakemore tube is inserted via the nose into the esophagus and stomach. The other options are incorrect because this tube is not inserted in those manners.

An adult client was burned as a result of an explosion. The burn initially affected the client's entire face (the anterior half of the head) and the upper half of the anterior torso, and there were circumferential burns to the lower half of both of the arms. The client's clothes caught on fire, and the client ran, which caused subsequent burn injuries of the posterior surface of the head and the upper half of the posterior torso. According to the rule of nines, what is the extent of this client's burn injury? Fill in the blank.

According to the rule of nines, with the initial burn, the anterior half of the head equals 4.5%, the upper half of the anterior torso equals 9%, and the lower halves of both arms equal 9%. The subsequent burn included the posterior half of the head, which equals 4.5%, and the upper half of the posterior torso, which equals 9%. This totals 36%.

The nurse is monitoring a client who is receiving oxytocin (Pitocin) to augment labor. The nurse determines that the dosage should be decreased and notifies the registered nurse if which is noted?

Acute hypoxia is a common cause of fetal tachycardia. The dosage of oxytocin should be decreased in the presence of fetal tachycardia because of excessive uterine activity. The nurse should also ensure that the uterus maintains an adequate resting tone between contractions. Options 2, 3, and 4 are not indications of a problem.

The nurse is caring for a client after a mastectomy. Which finding would indicate that the client is experiencing a complication related to the surgery?

Arm edema on the operative side (lymphedema) is a complication after mastectomy that can occur immediately, months, or even years after surgery. Options 1, 3, and 4 are expected occurrences after mastectomy and are not indicative of a complication.

The nurse is reviewing the history and physical examination of a client who will be receiving asparaginase (Elspar), an antineoplastic agent. The nurse consults with the registered nurse regarding the administration of the medication if which is documented in the client's history?

Asparaginase (Elspar) is contraindicated if hypersensitivity exists, in pancreatitis, or if the client has a history of pancreatitis. The medication impairs pancreatic function, and pancreatic function tests should be performed before therapy begins and when a week or more has elapsed between administration of the doses. The client needs to be monitored for signs of pancreatitis, which include nausea, vomiting, and abdominal pain. The conditions noted in options 2, 3, and 4 are not contraindicated with this medication.

The clinic nurse is collecting data on a client being admitted. The nurse notes that the client is taking azelaic acid (Azelex). Because of the medication prescription the nurse should suspect that the client is being treated for which condition?

Azelaic acid is a topical medication used to treat mild to moderate acne. The acid appears to work by suppressing the growth of Propionibacterium acnes and decreasing the proliferation of keratinocytes. Options 2, 3, and 4 are incorrect.

Efavirenz (Sustiva), an antiviral medication, is prescribed for a client with human immunodeficiency virus (HIV) infection. Which time should the nurse tell the client is best to take this medication?

Because the medication causes temporary nervous system side effects during the first 2 to 4 weeks of therapy, the client is instructed to take the medication at bedtime. Because of the nervous system effects, options 2, 3, and 4 are not recommended administration times.

The client with squamous cell carcinoma of the larynx is receiving bleomycin intravenously. The nurse caring for the client anticipates that which diagnostic study will be prescribed?

Bleomycin is an antineoplastic medication that can cause interstitial pneumonitis, which can progress to pulmonary fibrosis. Pulmonary function studies along with hematological, hepatic, and renal function tests need to be monitored. The nurse needs to monitor lung sounds for dyspnea and adventitious sounds, which could indicate pulmonary toxicity. The medication needs to be discontinued immediately if pulmonary toxicity occurs. Options 1, 2, and 3 are unrelated to the specific use of this medication.

A client with osteoarthritis is receiving diclofenac sodium (Voltaren). The licensed practical nurse (LPN) reviewing the client's medication prescription sheet should verify the prescription with the registered nurse (RN) if which other medication is listed?

Diclofenac sodium is a nonsteroidal anti-inflammatory (NSAID) medication. Interactions may occur with anticoagulants such as warfarin, resulting in increased risk for bleeding. The LPN should consult with the RN regarding a potential medication interaction. The other medications do not interact with diclofenac sodium. Mysoline is an anticonvulsant, calcium carbonate is an antacid, and vitamin C is a nutritional supplement. These medications are not contraindicated when diclofenac sodium is administered.

The nurse is planning care for a child with hemolytic-uremic syndrome (HUS). The child has been anuric and will be receiving peritoneal dialysis treatment. The nurse should plan to include which intervention in the care of the child?

HUS is thought to be associated with bacterial toxins, chemicals, and viruses that cause acute renal failure in children. Clinical features of the disease include acquired hemolytic anemia, thrombocytopenia, renal injury, and central nervous system symptoms. A child with HUS who is undergoing peritoneal dialysis for the treatment of anuria will be on fluid restrictions. Pain is not associated with HUS, and potassium would be restricted rather than encouraged if the child was anuric. Peritoneal dialysis does not require an AV fistula (only hemodialysis does).

The nurse assisting with monitoring a client in labor is told that the client's cervix is 3 cm dilated with contractions occurring every 2 to 3 minutes. When monitoring the client's psychological status, the nurse anticipates the client will reflect which attitude?

Home History Help Calculator Review Mode Question 19 of 75 Previous ▲ ▼ Go Next Stop Bookmark Rationale Strategy Reference Submit The nurse assisting with monitoring a client in labor is told that the client's cervix is 3 cm dilated with contractions occurring every 2 to 3 minutes. When monitoring the client's psychological status, the nurse anticipates the client will reflect which attitude? Rationale: In early labor, contractions are usually mild. The woman feels able to cope with the discomfort and may be relieved that labor has begun. Excitement is high about the impending birth. Options 1, 3, and 4 represent psychological states often noted late in labor when discomfort and fatigue are greater and coping ability may be reduced.

The nurse is caring for an older Appalachian client recovering from open heart surgery. In order to provide culturally appropriate care, the nurse should be aware that which aspects of reporting pain may be impacted by the Appalachian culture? Select all that apply.

In the Appalachian culture, clients often appear stoic and do not want to complain. Clients may not want to appear to be a complainer or a bother to someone, so often they do not report their pain. Addiction tendencies may be a concern to clients from many different backgrounds.. It is a common myth that all Appalachian clients are illiterate. The nurse must not assume that all Appalachian clients are illiterate.

The nurse is monitoring a client receiving levothyroxine sodium (Synthroid) for hypothyroidism. Which findings indicate the presence of a side effect associated with this medication? Select all that apply.

Insomnia, weight loss, and mild heat intolerance are side effects of levothyroxine sodium. Bradycardia and constipation are not side effects associated with this medication, but rather are associated with hypothyroidism, which is the disorder that this medication is prescribed to treat.

The burn client is receiving treatments of topical mafenide acetate (Sulfamylon) to the site of injury. The nurse monitors the client knowing that which indicates a systemic effect has occurred?

Mafenide acetate is a carbonic anhydrase inhibitor and can suppress renal excretion of acid, thereby causing acidosis. Clients receiving this treatment should be monitored for signs of an acid-base imbalance (hyperventilation). If this occurs, the medication should be discontinued for 1 to 2 days. Options 3 and 4 describe local rather than systemic effects. An elevated blood pressure may be expected from the pain that occurs with a burn injury.

A postoperative client has received a dose of naloxone hydrochloride (Narcan) for respiratory depression shortly after transfer to the nursing unit from the postanesthesia care unit. After administration of the medication, the nurse should check the client for which sign/symptom?

Naloxone hydrochloride is an antidote to opioids and may also be given to the postoperative client to treat respiratory depression. When given to the postoperative client for respiratory depression, it may also reverse the effects of analgesics. Therefore, the nurse must check the client for a sudden increase in the level of pain experienced. Options 1, 2, and 4 are not associated with this medication.

A child is diagnosed with scarlet fever. The nurse collects data regarding the child. Which is characteristic of scarlet fever?

Pastia's sign is a rash seen among children with scarlet fever that will blanch with pressure, except in areas of deep creases and in the folds of joints. The tongue is initially coated with a white furry covering with red projecting papillae (white strawberry tongue). By the fourth to fifth day, the white strawberry tongue sloughs off and leaves a red, swollen tongue (strawberry tongue). The pharynx is edematous and beefy red in color. Option 2 is associated with poliomyelitis. Abdominal pain and flaccid paralysis. Options 3 and 4 are characteristics of diphtheria. Dense pseudoformation membrane in the throat.Foul-smelling and mucopurulent nasal drainage

The nurse is repositioning the client who has returned to the nursing unit following internal fixation of a fractured right hip. How should the nurse plan to position the client?

Pillow to keep the right leg abducted during turning. Following internal fixation of a hip fracture, the client is turned to the affected side or the unaffected side, as prescribed by the surgeon. Before moving the client, the nurse places a pillow between the client's legs to keep the affected leg in abduction. The client is then repositioned while proper alignment and abduction are maintained. A trochanter roll is useful in preventing external rotation, but it is used once the client has been repositioned. It is not used while repositioning the client.

The nurse is told that a child with rheumatic fever (RF) will be arriving to the nursing unit for admission. Which question should the nurse ask the family to elicit information specific to the development of RF?

Rheumatic fever (RF) characteristically presents 2 to 6 weeks after an untreated or partially treated group A β-hemolytic streptococcal infection of the upper respiratory tract. Initially, the nurse determines if the child has had a sore throat or an unexplained fever within the past 2 months. Options 1, 2, and 3 are unrelated to RF.

A client arrives at the emergency department and has experienced frostbite to the right hand. Which should the nurse expect to find when inspecting the client's hand

The findings related to frostbite include a white or blue skin color and skin that is hard, cold, and insensitive to touch. As thawing occurs, so does flushing of the skin, the development of blisters or blebs, or tissue edema. Gangrene can develop in 9 to 15 days.

A client is admitted to the emergency department, and a diagnosis of myxedema coma is made. Which action should the nurse prepare to carry out initially?

The initial nursing action would be to maintain a patent airway. Oxygen would be administered, followed by fluid replacement. The nurse would also keep the client warm, monitor intravenous fluids, and administer thyroid hormones.

The nurse is preparing a list of home care instructions for the client who has been hospitalized and treated for tuberculosis. Which instructions should the nurse reinforce? Select all that apply

The nurse should provide the client and family with information about tuberculosis and allay concerns about the contagious aspect of the infection. The client is reassured that after 2 to 3 weeks of medication therapy, it is unlikely that the client will infect anyone. The client is also informed that activities should be resumed gradually. The client and family are informed that respiratory isolation is not necessary, because family members have already been exposed. The client is instructed about thorough hand washing and to cover the mouth and nose when coughing or sneezing and confine used tissues to plastic bags. The client is informed that a sputum culture is needed every 2 to 4 weeks once medication therapy is initiated and that when the results of three sputum cultures are negative, the client is no longer considered infectious and can usually return to his or her former employment.

A client has a terminal illness, and her spouse is distraught about the unrelenting pain she experiences. Which should the nurse implement as the most effective measure to alleviate the spouse's distress?

The most effective method of alleviating the spouse's distress is to provide comfort for both individuals. By helping the spouse comfort the client, the spouse helps alleviate the client's discomfort and thus helps attenuate his own distress. This is because providing comfort to the client gives the spouse a sense of purpose, control, and value. The remaining options are reasonable nursing interventions in palliative care; however, conveying respect (option 1) helps maintain dignity and self-esteem, promoting therapeutic communication (option 3) is important in establishing a caring relationship, and maintaining a presence (option 4) helps prevent feelings of abandonment and isolation.

The nurse is explaining the universal protocol for preventing wrong site, wrong procedure, and wrong person surgery to a group of nursing students. Which action does site marking involve?

The surgeon is responsible for verifying the operative site and must mark the operative site before the client is brought into the operating room suite. The client will be asked to verify the site requiring surgery. The client may refuse to have the site marked and is asked about marking the site. Although the nurse may also verify the site, this procedure is a primary health care provider responsibility. Verification of site should be done before the time-out period in addition to during the time-out period. Verification of the surgical site is not done at the completion of the procedure.

The nurse is applying a topical corticosteroid to a client with eczema. The nurse should monitor for the potential for increased systemic absorption of the medication if the medication is being applied to which body area?

Topical corticosteroids can be absorbed into the systemic circulation. Absorption is higher from regions where the skin is especially permeable (scalp, axilla, face, eyelids, neck, perineum, genitalia) and lower from regions in which permeability is poor (back, palms, soles).

The nurse is assigned to care for a child admitted to the hospital with a diagnosis of suspected bacterial endocarditis. The nurse prepares the child for which diagnostic test that will confirm the diagnosis?

When endocarditis is suspected, a definitive diagnosis is achieved through blood cultures. A negative blood culture does not rule out the existence of endocarditis; it just indicates a lesser likelihood of its exist.

A client is receiving a continuous heparin infusion for venous thromboembolism treatment. Which laboratory monitoring should the nurse plan to check during a continuous heparin infusion? Select all that apply.

A continuous heparin infusion requires monitoring the platelet count for heparin-induced thrombocytopenia and activated partial thromboplastin time to monitor blood clotting time. Warfarin (Coumadin) is monitored using the International Normalized Ratio (INR). The INR is a standardized system of reporting prothrombin time (PT). Recombinant factor VIIa is used to reverse the anticoagulant effect of fondaparinux (Arixtra).

Which laboratory result would verify the diagnosis of bacterial meningitis?

A diagnosis of meningitis is made by testing the cerebrospinal fluid (CSF) obtained by lumbar puncture. In the case of bacterial meningitis, findings usually include increased pressure, cloudy cerebrospinal fluid, a high protein level, and a low glucose level.

A client newly diagnosed with gout has been prescribed allopurinol (Zyloprim). The nurse should question the health care provider if the dose for which medication already prescribed has not changed?

Allopurinol is an antigout medication that may increase the effect of oral anticoagulants. Warfarin sodium is an anticoagulant, and if this medication was prescribed for the client, the nurse should verify the prescription. The dose of warfarin sodium may need to be decreased. Adenosine is an antidysrhythmic. Digoxin is a cardiac glycoside. Ergonovine maleate is an antimigraine medication

The client with acute myelocytic leukemia is being treated with busulfan (Myleran). Which laboratory value should the nurse specifically monitor during treatment with this medication?

Busulfan (Myleran) can cause an increase in the uric acid level. Hyperuricemia can produce uric acid nephropathy, renal stones, and acute kidney injury. Options 1, 3, and 4 are not specifically related to this medication.

The client with carcinoma of the lung develops the syndrome of inappropriate antidiuretic hormone (SIADH) as a complication of the cancer. The nurse anticipates that which may be prescribed to treat this complication? Select all that apply.

Cancer is a common cause of SIADH. In clients with SIADH, excessive amounts of water are reabsorbed by the kidney and put into the systemic circulation. The increased water causes hyponatremia (decreased serum sodium levels) and some degree of fluid retention. SIADH is managed by treating the condition and its cause, and treatment usually includes fluid restriction, increased sodium intake, and a medication with a mechanism of action that is antagonistic to ADH. Sodium levels are monitored closely because hypernatremia can suddenly develop as a result of treatment. The immediate institution of appropriate cancer therapy (usually either radiation or chemotherapy) can cause tumor regression so that ADH synthesis and release processes return to normal.

The nurse is reviewing the record of a child with increased intracranial pressure and notes that the child has exhibited signs of decerebrate posturing. On data collection of the child, the nurse expects to note which characteristic of this type of posturing?

Decerebrate (extension) posturing is characterized by the rigid extension and pronation of the arms and legs. Option 1 is incorrect. Options 2 and 4 describe decorticate (flexion) posturing.

A client is taking large doses of acetylsalicylic acid (aspirin) for rheumatoid arthritis. The nurse tells the client to report which signs and symptoms of ototoxicity?

Ototoxicity is damage to the eighth cranial nerve, which is responsible for hearing and balance. Purpura and ecchymosis are caused by prolonged bleeding, but not ototoxicity. GI bleeding and upset may be caused by acetylsalicylic acid (aspirin) irritation but are not symptoms of ototoxicity.

The nurse is monitoring a client receiving spironolactone (Aldactone) by mouth daily. Which data would indicate to the nurse that the client is experiencing a side effect related to the medication

Spironolactone is a potassium-retaining diuretic. Side effects include hyperkalemia, dehydration, hyponatremia, and lethargy. Although the concern with most diuretics is hypokalemia, this medication is potassium-retaining, which means that the concern with the administration of this medication is hyperkalemia. The normal sodium level is 135 to 145 mEq/L, and the normal potassium level is 3.5 to 5.0 mEq/L. Additional side effects include nausea, vomiting, cramping, diarrhea, headache, ataxia, drowsiness, confusion,and fever. Dry skin is unrelated to the administration of this medication.

The nurse is assisting with caring for a client with cancer who is receiving cisplatin. Which adverse effects are associated with this medication? Select all that apply

Cisplatin is an alkylating medication. Alkylating medications are cell cycle phase-nonspecific medications that affect the synthesis of DNA by causing the cross-linking of DNA to inhibit cell reproduction. Cisplatin may cause ototoxicity, tinnitus, hypokalemia, hypocalcemia, hypomagnesemia, and nephrotoxicity. Amifostine (Ethyol) may be administered before cisplatin to reduce the potential for renal toxicity.

The nurse is asked to assist another health care member in providing care to a client who is placed in a modified Trendelenburg's position. The nurse interprets that the client is likely being treated for which condition?

A client in shock is placed in a modified Trendelenburg's position that includes elevating the legs, leaving the trunk flat and slightly elevating the head and shoulders. This position promotes increased venous return from the lower extremities without compressing the abdominal organs against the diaphragm, which is vital to the treatment of shock. The remaining conditions would not benefit from and, in some cases, would worsen because of this position.

A client has been taking isoniazid for 2 months. The client complains to the nurse about numbness, paresthesias, and tingling in the extremities. The nurse interprets that the client is experiencing which problem?

A common adverse effect of isoniazid is peripheral neuritis. This is manifested by numbness, tingling, and paresthesias in the extremities. This adverse effect can be minimized by pyridoxine (vitamin B6) intake. Options 1, 3, and 4 are incorrect.

The nurse is assisting with data collection from an infant who has been diagnosed with hydrocephalus. If the infant's level of consciousness diminishes, which is a priority intervention?

A full or bulging anterior fontanel indicates an increase in cerebrospinal fluid collection in the cerebral ventricle. Apical pulse and blood pressure changes and proteinuria are not specifically associated with increasing cerebrospinal fluid in the brain tissue in an infant.

The nurse is monitoring for stoma prolapse in a client with a colostomy. Which stoma observation should indicate that a prolapse has occurred?

A prolapsed stoma is one in which bowel protrudes through the stoma, with an elongated and swollen appearance. A stoma retraction is characterized by sinking of the stoma. Ischemia of the stoma would be associated with dusky or bluish color. A stoma with a narrowed opening, either at the level of the skin or fascia, is said to be stenosed.

The client with small cell lung cancer is being treated with etoposide (Toposar). The nurse assisting in caring for the client during its administration should understand that which side/adverse effect is specifically associated with this medication?

A side effect specific to etoposide (Toposar) is orthostatic hypotension. The client's blood pressure is monitored during the infusion. Hair loss occurs with nearly all the antineoplastic medications. Chest pain and pulmonary fibrosis are unrelated to this medication.

The nurse is caring for a client with a multilumen catheter and is monitoring for signs of an air embolism. Which signs and symptoms would be noted in this complication? Select all that apply.

All clients with intravenous lines are at risk for air embolism. Because an air embolism can be life threatening, it is essential that the nurse monitor for the presence of chest pain, coughing, hypotension, cyanosis, and hypoxia. In addition, if the client does have an air embolism, auscultation over the right ventricle may reveal a churning "windmill" sound.

The client with ovarian cancer is being treated with vincristine (Vincasar). The nurse monitors the client, knowing that which adverse effect is specific to this medication?

An adverse effect specific to vincristine is peripheral neuropathy. Peripheral neuropathy can be manifested as numbness and tingling in the fingers and toes. Depression of the Achilles tendon reflex may be the first clinical sign indicating peripheral neuropathy. Constipation, rather than diarrhea, is most likely to occur with this medication, although diarrhea may occur occasionally. Hair loss occurs with nearly all the antineoplastic medications. Chest pain is unrelated to this medication.

The nurse suspects that a co-worker is substance impaired and is self-administering opioid medications rather than administering them to clients as prescribed. Which action should the nurse take?

An impaired nurse is one who is unable to function effectively because of some type of substance abuse. Nurse practice acts require reporting the suspicion of impaired nurses. The board of nursing has jurisdiction over the practice of nursing and may develop plans for treatment and supervision. This suspicion needs to be reported to the nursing supervisor who will then report to the board of nursing. Options 1, 3, and 4 are incorrect. Confronting the nurse may cause a conflict. The supervisor will report the substance abuse situation as necessary.

The nurse reviews the results of a tuberculin skin test performed on a 3-year-old child. The results indicate an area of induration that measures 10 mm. How should the nurse interpret this result?

An induration that measures 10 mm or more is considered to be a positive result for children who are younger than 4 years old and for those with chronic illness or with a high risk for environmental exposure to tuberculosis. A reaction of 5 mm or more is considered to be a positive result for those in the highest-risk groups.

A client has had a partial gastrectomy and the nurse is reinforcing discharge instructions. The nurse should tell the client about the need for which? Select all that apply

Gastric surgery can have serious effects on the client's nutritional status. The absorption of vitamin B12, folic acid, iron, calcium, and vitamin D may be impaired, so supplements will be needed. Insufficient intrinsic factor results in the inability to absorb vitamin B12, which must then be supplemented by the parenteral route. Antibiotic therapy and antacid use would not help treat the lack of intrinsic factor or absorption of vitamins.

An older client recently has been taking cimetidine (Tagamet). The nurse should monitor the client for which most frequent central nervous system side effect of this medication?

Cimetidine is a histamine 2 (H2)-receptor antagonist. Older clients are especially susceptible to the central nervous system side effects of cimetidine. The most frequent of these is confusion. Less common central nervous system side effects include headache, dizziness, drowsiness, and hallucinations.

The nurse is working in the emergency department and is caring for a child who has been diagnosed with epiglottitis. Which is an indication that the child may be experiencing airway obstruction

Clinical manifestations that are suggestive of airway obstruction include tripod positioning (leaning forward supported by the hands and arms with the chin thrust out and the mouth open), nasal flaring, tachycardia, a high fever, and a sore throat.

A client has been started on cyclobenzaprine (Flexeril) for the management of muscle spasms in the cervical spine. The client is experiencing drowsiness, dizziness, and dry mouth. The nurse interprets these signs/symptoms as which response?

Drowsiness, dizziness, and dry mouth are the most common side effects of cyclobenzaprine. This medication is a centrally acting skeletal muscle relaxant used in the management of muscle spasm that accompanies a variety of conditions. Options 2, 3, and 4 are incorrect.

The nurse is monitoring a client for the early signs and symptoms of dumping syndrome. Which indicates this occurrence?

Early manifestations occur 5 to 30 minutes after eating. Symptoms include vertigo, tachycardia, syncope, sweating, pallor, palpitations, and the desire to lie down.

The nurse collects a urine specimen preoperatively from a child with epispadias who is scheduled for surgical repair. The nurse reviews the child's record for the laboratory results of the urine test and would most likely expect to note which finding?

Epispadias is a congenital defect that involves the abnormal placement of the urethral orifice of the penis. In clients with this condition, the urethral opening is located anywhere on the dorsum of the penis. This anatomical characteristic leads to the easy access of bacterial entry into the urine. Options 1, 3, and 4 are not characteristically noted with this condition.

The nurse is collecting data about a child who has been admitted to the hospital with a diagnosis of seizures. Which action would best assist in determining the causes of the seizure?

Fever and infections increase the body's metabolic rate. This can cause seizure activity among children who are less than 5 years old. Dehydration and electrolyte imbalance can also contribute to the occurrence of a seizure. Falls can cause head injuries, which would increase intracranial pressure or cerebral edema. Some medications could cause seizures. Specific gravity would not be a reliable test because it varies, depending on the existing condition. Psychiatric illness has no impact on seizure occurrence or cause. Children do not remember what happened during the seizure itself.

A client is being transferred to the nursing unit from the postanesthesia care unit following spinal fusion with rod insertion. How should the nurse transfer the client from the stretcher to the bed?

Following spinal fusion, with or without instrumentation, the client is transferred from the stretcher to the bed using a slider board and the assistance of three to four people. This permits optimal stabilization and support of the spine while allowing the client to be moved smoothly and gently. A bath blanket is not used because it does not provide spinal support for the client.

The nurse has reinforced instructions to a postpartum client who is hepatitis B positive how to safely bottle-feed her newborn to prevent the transmission of the infection. Which action by the client indicates an understanding of this procedure?

Hepatitis B virus (HBV) is highly contagious by direct contact with blood and body fluids of infected persons. Strict hand washing before contact with the newborn will assist in prevention of the transmission of infection. Option 2 will not affect disease transmission. Options 3 and 4 are appropriate feeding techniques for bottle-feeding but do not minimize disease transmission for hepatitis B.

The nurse is caring for a client after a thyroidectomy and notes that calcium gluconate is prescribed for the client. The nurse determines that this medication has been prescribed for which reason?

Hypocalcemia can develop after thyroidectomy if the parathyroid glands are accidentally removed or injured during surgery. Manifestations develop 1 to 7 days after surgery. If the client develops numbness and tingling around the mouth, fingertips, or toes, or muscle spasms or twitching, the health care provider is notified immediately. Calcium gluconate should be accessible for the client who underwent thyroidectomy.

Which nursing interventions are appropriate for a hospitalized client with mania who is exhibiting manipulative behavior? Select all that apply.

Interventions for dealing with the client exhibiting manipulative behavior include setting clear, consistent, and enforceable limits on manipulative behaviors; being clear with the client regarding the consequences of exceeding limits set; following through with the consequences in a nonpunitive manner; and assisting the client in developing means of setting limits on personal behaviors. Enforcing rules and informing the client that he or she will not be allowed to attend therapy groups are violations of a client's rights. Ensuring that the client knows that he or she is not in charge of the nursing unit is inappropriate; power struggles need to be avoided.

The nurse enters a client's room and notes that the client's lawyer is present and that the client is preparing a living will. The living will requires that the client's signature be witnessed, and the client asks the nurse to witness the signature. Which is the appropriate nursing action?

Living wills are required to be in writing and signed by the client. The client's signature either must be witnessed by specified individuals or notarized. Many states prohibit any employee from being a witness, including the nurse in a facility in which the client is receiving care.

A child has a basilar skull fracture. Which health care provider's prescription should the nurse question?

Nasotracheal suctioning is contraindicated in a child with a basilar skull fracture. Because of the location of the injury, the suction catheter may be introduced into the brain. Fluids are restricted to prevent fluid overload. The child may require a urinary catheter for the accurate monitoring of intake and output. An IV line is maintained to administer fluids or medications, if necessary.

The nurse is monitoring a client following cardioversion. Which observations should be of highest priority to the nurse?

Nursing responsibilities after cardioversion include maintenance of a patent airway, oxygen administration, assessment of vital signs and level of consciousness, and dysrhythmia detection. Airway is the priority.

6-month-old infant receives a diphtheria, tetanus, and acellular pertussis (DTap) immunization at the well-baby clinic. The mother returns home and calls the clinic to report that the infant has developed swelling and redness at the site of injection. Which instruction by the nurse is appropriate?

Occasionally tenderness, redness, or swelling may occur at the site of the injection. This can be relieved with cool packs for the first 24 hours and followed by warm or cool compresses if the inflammation persists. It is not necessary to bring the infant back to the clinic. Option 1 may be an appropriate intervention, but it is not specific to the subject of the question.

The client has been taking omeprazole (Prilosec) for 4 weeks. The nurse evaluates that the client is receiving an optimal intended effect of the medication if the client reports the absence of which symptom?

Omeprazole is a proton pump inhibitor classified as an antiulcer agent. The intended effect of the medication is relief of pain from gastric irritation, often called "heartburn" by clients. Omeprazole is not used to treat the conditions identified in options 1, 3, and 4.

A long-term care resident with a history of paranoid schizophrenia refuses to eat and tells the nurse that she believes that someone is poisoning the food. The nurse should make which appropriate response to the client

Option 3 validates the client's feelings. Option 1 may place the client on the defensive and is not a facilitative technique. Option 2 involves the nurse in the client's delusion. Option 4 is incorrect because the statement is defensive and therefore nontherapeutic

A client with diabetes mellitus visits a health care clinic. The client's diabetes mellitus previously had been well controlled with glyburide (DiaBeta) daily, but recently the fasting blood glucose level has been 180 to 200 mg/dL. Which medication, added to the client's regimen, may have contributed to the hyperglycemia?

Prednisone may decrease the effect of oral hypoglycemics, insulin, diuretics, and potassium supplements. Option 2, a monoamine oxidase inhibitor, and option 3, a β-blocker, have their own intrinsic hypoglycemic activity. Option 4 decreases urinary excretion of sulfonylurea agents, causing increased levels of the oral agents, which can lead to hypoglycemia.

A client is 3 days postoperative from gastric surgery and still has a nasogastric tube in place. The client is at risk to develop which electrolyte imbalances? Select all that apply.

Prolonged gastric suction or gastric surgery can result in electrolyte imbalances. There can be deficits of potassium, sodium, or magnesium blood levels.

A client diagnosed with thrombophlebitis 1 day ago suddenly complains of chest pain and shortness of breath, and the client is visibly anxious. The nurse understands that a life-threatening complication of this condition is which?

Pulmonary embolism is a life-threatening complication of deep vein thrombosis and thrombophlebitis. Chest pain is the most common symptom, which is sudden in onset and may be aggravated by breathing. Other signs and symptoms include dyspnea, cough, diaphoresis, and apprehension.

The nurse is assisting in caring for a client admitted to the emergency department with diabetic ketoacidosis. The nurse anticipates that the health care provider will prescribe which type of insulin for intravenous administration to treat this disorder?

Regular insulin is a short-acting insulin and can be administered by the intravenous route. Lantus is a long-acting insulin. Humulin N and Isophane insulin NPH injection are intermediate-acting insulin.

A client is receiving baclofen (Lioresal) for muscle spasms caused by a spinal cord injury. The nurse monitors the client, knowing that which is a side effect of this medication?

Side effects of baclofen include drowsiness, dizziness, weakness, and nausea. Occasional side effects include headache, paresthesia of the hands and feet, constipation or diarrhea, anorexia, hypotension, confusion, and nasal congestion. Paradoxical central nervous system excitement and restlessness can occur, along with slurred speech, tremor, dry mouth, nocturia, and impotence. Options 1, 2, and 4 are not side effects of this medication.

The client with metastatic breast cancer is receiving tamoxifen (Soltamox). The nurse specifically monitors which laboratory value while the client is taking this medication?

Tamoxifen may increase calcium, cholesterol, and triglyceride levels. Before the initiation of therapy, a complete blood count, platelet count, and serum calcium levels should be assessed. These blood levels, along with cholesterol and triglyceride levels, should be monitored periodically during therapy. The nurse should assess for hypercalcemia while the client is taking this medication. Signs of hypercalcemia include increased urine volume, excessive thirst, nausea, vomiting, constipation, hypotonicity of muscles, and deep bone and flank pain.

A child is scheduled to receive a measles, mumps, and rubella (MMR) vaccine. The nurse, preparing to administer the vaccine, reviews the child's record. Which finding should make the nurse question the health care provider's prescription?

The MMR vaccine contains minute amounts of neomycin. A history of an anaphylactic reaction to neomycin is considered a contraindication to the MMR vaccine. The general contraindication to all immunizations is a severe febrile illness. The presence of a minor illness such as the common cold is not a contraindication. In addition, a history of frequent respiratory infections is not a contraindication to receiving a vaccine. A local reaction to an immunization is treated with cool packs for the first 24 hours after injection, and this is followed by warm or cool compresses if the inflammation persists.

The nurse is reviewing the prescriptions of a client admitted to the hospital with a diagnosis of acute pancreatitis. Which interventions should the nurse expect to note? Select all that apply.

The client with acute pancreatitis is normally placed on an NPO status to rest the pancreas and suppress gastrointestinal (GI) secretions. Because abdominal pain is a prominent symptom of pancreatitis, pain medication will be prescribed. Some clients experience lessened pain by assuming positions that flex the trunk and draw the knees up to the chest. A side-lying position with the head elevated 45 degrees decreases tension on the abdomen and may also help ease the pain. The client is susceptible to respiratoryinfections because the retroperitoneal fluid raises the diaphragm, which causes the client to take shallow, guarded abdominal breaths. Therefore, measures such as turning, coughing, and deep breathing are instituted. Antacids and anticholinergics may be prescribed to suppress GI secretions.

The evening nurse reviews the nursing documentation in the client's chart and notes that the day nurse has documented that the client has a stage 2 pressure ulcer in the sacral area. Which should the nurse expect to find when checking the client's sacral area?

With a stage 2 pressure ulcer, the skin is not intact. There is partial-thickness skin loss of the epidermis or dermis. The ulcer is superficial, and it may look like an abrasion, blister, or shallow crater. The skin is intact with a stage 1 pressure ulcer. A deep, crater-like appearance occurs during stage 3, and tunneling develops during stage 4.

A client with tuberculosis is being started on antituberculosis therapy with isoniazid. Before giving the client the first dose, the nurse ensures that which baseline study has been completed?

Isoniazid therapy can cause an elevation of hepatic enzyme levels and hepatitis. Therefore, liver enzyme levels are monitored when therapy is initiated and during the first 3 months of therapy. They may be monitored longer in the client who is greater than age 50 or abuses alcohol.

The nurse is assisting to develop a plan of care for a child who is at risk for seizures. Which interventions apply if the child has a seizure? Select all that apply.

During a seizure, the child is placed on his or her side in a lateral position. This type of positioning will prevent aspiration because saliva will drain out of the corner of the child's mouth. The child is not restrained because this could cause injury. The nurse would loosen clothing around the child's neck and ensure a patent airway. Nothing is placed into the child's mouth during a seizure because this action may cause injury to the child's mouth, gums, or teeth. The nurse would stay with the child to reduce the risk of injury and allow for the observation and timing of the seizure.

The nurse is caring for a client after a Billroth II (gastrojejunostomy) procedure. On review of the postoperative prescriptions, which should the nurse clarify?

In a Billroth II resection, the proximal remnant of the stomach is anastomosed to the proximal jejunum. Patency of the NG tube is critical for preventing the retention of gastric secretions. The nurse, however, should never irrigate or reposition the gastric tube after gastric surgery unless specifically prescribed by the health care provider. In this situation, the nurse should clarify the prescription. Options 1, 2, and 4 are appropriate postoperative interventions.

Isotretinoin (Amnesteem, Clavaris) is prescribed for a client with severe acne. Before the administration of this medication, the nurse anticipates that which laboratory test will be prescribed?

Isotretinoin can elevate triglyceride levels. Blood triglyceride levels should be measured before treatment and periodically thereafter until the effect on the triglycerides has been evaluated. Options 1, 3, and 4 do not need to be monitored specifically during this treatment.

The nurse is caring for an infant with a diagnosis of tetralogy of Fallot. The infant suddenly becomes cyanotic and the oxygen saturation reading drops to 60%. Which interventions should the nurse perform?

The child who is cyanotic with oxygen saturations dropping to 60% is having a hypercyanotic episode. Hypercyanotic episodes often occur among infants with tetralogy of Fallot, and they may occur among infants whose heart defect includes the obstruction of pulmonary blood flow and communication between the ventricles. If a hypercyanotic episode occurs, the infant is placed in a knee-chest position immediately. The registered nurse is notified, who will then contact the health care provider. The knee-chest position improves systemic arterial oxygen saturation by decreasing venous return so that smaller amounts of highly saturated blood reach the heart. Toddlers and children squat to get into this position and relieve chronic hypoxia. There is no reason to call a code blue unless respirations cease. Additional interventions include administering 100% oxygen by face mask, morphine sulfate, and intravenous fluids, as prescribed.

The nurse is reviewing the health care provider's prescriptions written for a client admitted with acute pancreatitis. Which health care provider prescription should the nurse verify if noted in the client's chart?

The pain associated with acute pancreatitis is aggravated when the client lies in a supine and flat position. Therefore, the nurse would verify this prescription. Options 1, 2, and 4 are appropriate interventions for the client with acute pancreatitis

The nurse is reviewing the health care record of a client with a lesion that has been diagnosed as malignant melanoma. The nurse should expect which characteristic of this type of lesion to be documented in the client's record?

A melanoma is an irregularly shaped pigmented papule or plaque with a red, white, or blue color. Basal cell carcinoma appears as a pearly papule with a central crater and a rolled, waxy border. Squamous cell carcinoma is a firm nodular lesion that is topped with a crust or a central area of ulceration. Actinic keratosis, which is a premalignant lesion, appears as a small macule or papule with a dry, rough, adherent yellow or brown scale.

The nurse is monitoring the daily weight of an infant with heart failure (HF). Which finding alerts the nurse to suspect fluid accumulation and thus the need to notify the registered nurse?

A weight gain of 0.5 kg (1 lb) in 1 day is a result of the accumulation of fluid. The nurse should monitor the urine output, monitor for evidence of facial or peripheral edema, check the lung sounds, and report the weight gain. Tachypnea and an increased BP would occur with fluid accumulation. Diaphoresis is a sign of HF, but it is not specific to fluid accumulation, and it usually occurs with exertional activities.

The nurse is caring for a postoperative parathyroidectomy client. Which would require the nurse's immediate attention?

During the postoperative period, the nurse carefully observes the client for signs of hemorrhage, which causes swelling and the compression of adjacent tissue. Laryngeal stridor is a harsh, high-pitched sound heard on inspiration and expiration that is caused by the compression of the trachea and that leads to respiratory distress. It is an acute emergency situation that requires immediate attention to avoid the complete obstruction of the airway.

The client arrives at the emergency department after a burn injury that occurred in the basement at home, and an inhalation injury is suspected. Which should the nurse anticipate as being prescribed for the client?

If an inhalation injury is suspected, the administration of 100% oxygen via a tight-fitting, nonrebreather face mask is prescribed until the carboxyhemoglobin level falls below 15%. With inhalation injuries, the oropharynx is inspected for evidence of erythema, blisters, or ulcerations. The need for endotracheal intubation is also determined. Options 1, 2, and 3 are incorrect

The nurse is preparing to care for a client with acquired immunodeficiency syndrome (AIDS) who has Pneumocystis jiroveci pneumonia. In planning infection control for this client which should be the appropriate form of isolation to use to prevent the spread of infection to others?

The acquired immunodeficiency syndrome (AIDS) virus is transmitted through anal, vaginal, or oral sexual contact with infected semen or vaginal secretions; contact with infected blood or blood products; from mother to fetus during childbirth; or during breast-feeding. P. jiroveci pneumonia is an opportunistic infection seen in clients with compromised immune function. Blood and body fluid precautions will prevent contact with infectious matter from P. jiroveci pneumonia.Strict isolation is not needed and may contribute to feelings of isolation in the client. Enteric or contact precautions alone are insufficient to prevent transmission of the AIDS virus.

The nurse is aware that criminal offenses would have which characteristics as opposed to civil offenses? Select all that apply.

The characteristics of a criminal law involve conduct that is offensive to society in general; is detrimental to society as a whole; involves public offenses such as robbery, murder, and assault; and its purpose is to punish a person for the crime and deter and prevent further crimes. Characteristics of civil law involve conduct that violates a person's rights, is detrimental to that individual, involves an offense that is against an individual, and the law's purpose is to make the aggrieved person whole again and to restore the person to where he or she was.

A postcardiac surgery client with a blood urea nitrogen (BUN) level of 45 mg/dL and a serum creatinine level of 2.2 mg/dL has a total 2-hour urine output of 25 mL. The nurse understands that the client is at risk for which?

The client who undergoes cardiac surgery is at risk for acute kidney injury from poor perfusion, hemolysis, low cardiac output, or vasopressor medication therapy. Kidney injury is signaled by a decreased urine output and increased BUN and creatinine levels. The client may need medications to increase renal perfusion and could need peritoneal dialysis or hemodialysis.

The nurse caring for an infant with congenital heart disease is monitoring the infant closely for signs of heart failure (HF). The nurse should observe for which early sign of HF?

The early signs of HF include tachycardia, tachypnea, profuse scalp sweating, fatigue, irritability, sudden weight gain, and respiratory distress. A cough may occur with HF as a result of mucosal swelling and irritation, but it is not an early sign. Pallor may be noted in the infant with HF, but it is also not an early sign.

To use an external cardiac defibrillator on a client, which action should be performed to check the cardiac rhythm?

The nurse or rescuer puts two large adhesive patch electrodes on the client's chest in the usual defibrillator position. The nurse stops cardiopulmonary resuscitation and orders anyone near the client to move away and not touch the client. The defibrillator then analyzes the rhythm, which may take up to 30 seconds. The machine then indicates if it is necessary to defibrillate. Although automatic external defibrillation can be done transtelephonically, it is done through the use of patch electrodes (not standard electrocardiographic electrodes) that interact via telephone lines to a base station that controls any actual defibrillation. It is not necessary to hold defibrillator paddles against the client's chest with this device.

The nurse is assessing a client with suspected acute kidney injury. Which finding would support a diagnosis of acute intrarenal failure?

Acute tubular necrosis is responsible for 90% of acute intrarenal failure cases, and in these cases, the tubular epithelium is destroyed. The debris from the destruction of the epithelial cells can be detected in the urinalysis of a client with acute intrarenal failure. The BUN-to-creatinine ratio is normally 10:1. When the BUN-to-creatinine ratio is greater than 20:1, it generally indicates acute prerenal failure. Option 4 has a BUN-to-creatinine ratio of 40:1, indicating acute prerenal failure. However, if the client were to have elevated BUN and creatinine levels, but the ratio remains 10:1, this generally indicates intrarenal failure. A urine output of 30 mL/hr is an adequate urine output, and this does not indicate that the client has acute kidney injury. Ureteral calculi place the client at risk for postrenal failure.

A child with rubeola (measles) is being admitted to the hospital. When preparing for the admission of the child, which precautions should be implemented?

Rubeola is transmitted via airborne particles or direct contact with infectious droplets. Respiratory precautions are required, and a mask is worn by those who come in contact with the child. Gowns and gloves are not indicated. Articles that are contaminated should be bagged and labeled. Options 1, 2, and 3 are not indicated for rubeola.

The nurse is assigned to care for a child who is suspected of having glomerulonephritis. The nurse reviews the child's record and notes that which finding is associated with the diagnosis of glomerulonephritis?

Gross hematuria resulting in dark, smoky, cola-colored or red-brown urine is a classic symptom of glomerulonephritis, and hypertension is also common. A mid- to high urinary specific gravity is associated with glomerulonephritis. BUN levels may be elevated.

A client with severe acne is seen in the clinic, and the health care provider (HCP) prescribes isotretinoin (Amnesteem, Clavaris). The nurse reviews the client's medication record and should contact the HCP if the client is taking which medication?

Isotretinoin is a metabolite of vitamin A and can produce generalized intensification of isotretinoin toxicity. Because of the potential for increased toxicity, vitamin A supplements should be discontinued before isotretinoin therapy. Options 2, 3, and 4 are not contraindicated with the use of isotretinoin.

Salicylic acid is prescribed for a client with a diagnosis of psoriasis. The nurse monitors the client knowing that which would indicate the presence of systemic toxicity from this medication?

Salicylic acid is absorbed readily through the skin, and systemic toxicity (salicylism) can result. Symptoms include tinnitus, dizziness, hyperpnea, and psychological disturbances. Constipation and diarrhea are not associated with salicylism

The nurse, reinforcing home care instructions, prepares a list for the parents of a child who has a plaster cast applied to the left forearm. Which instructions should be included on the list? Select all that apply.

While the cast is drying, the palms of the hands are used to lift the cast. If the fingertips are used, indentations in the cast could occur and cause constant pressure on the underlying skin. Small toys and sharp objects are kept away from the cast, and no objects (including padded objects) are placed inside of the cast because of the risk of altered skin integrity. A heating pad is not applied to the cast or fingers. Cold fingers could indicate neurovascular impairment, and the HCP should be notified. The extremity is elevated to prevent swelling, and the HCP is notified immediately if any signs of neurovascular impairment develop.

The home care nurse is visiting a client who was recently diagnosed with type 2 diabetes mellitus. The client is prescribed repaglinide (Prandin) and metformin (Glucophage) and asks the nurse to explain these medications. The nurse should reinforce which instructions to the client? Select all that apply.

Repaglinide is a rapid-acting oral hypoglycemic agent that stimulates pancreatic insulin secretion that should be taken before meals and that should be withheld if the client does not eat. Hypoglycemia is a side effect of repaglinide, and the client should always be prepared by carrying a simple sugar with her or him at all times. Metformin is an oral hypoglycemic given in combination with repaglinide and works by decreasing hepatic glucose production. A common side effect of metformin is diarrhea. Muscle pain may occur as an adverse effect from metformin but it might signify a more serious condition that warrants health care provider notification, not the use of acetaminophen.

The nurse is reviewing the health record of a 14-year-old child who is suspected of having Hodgkin's disease. Which is the primary characteristic of this disease?

Signs and symptoms specifically associated with Hodgkin's disease include painless, firm, and movable adenopathy in the cervical and supraclavicular areas. Hepatosplenomegaly is also noted. Although anorexia, weight loss, fever, and malaise are associated with Hodgkin's disease, these manifestations are not the primary characteristics and are seen with many disorders.

The nurse assists with admitting a child with a diagnosis of acute-stage Kawasaki disease. When obtaining the child's medical history, which manifestation is likely to be noted?

During the acute stage of Kawasaki disease, the child presents with fever, conjunctival hyperemia, a red throat, swollen hands, a rash, and enlargement of the cervical lymph nodes. During the subacute stage, cracking lips and fissures, desquamation of the skin on the tips of the fingers and toes, joint pain, cardiac manifestations, and thrombocytosis occur. During the convalescent stage, the child appears normal, but signs of inflammation may be present.

The nurse in a medical unit is caring for a client with heart failure. The client suddenly develops extreme dyspnea, tachycardia, and lung crackles, and the nurse suspects pulmonary edema. The nurse immediately notifies the registered nurse and expects which interventions to be prescribed? Select all that apply.

Pulmonary edema is a life-threatening event that can result from severe heart failure. In pulmonary edema the left ventricle fails to eject sufficient blood, and pressure increases in the lungs because of the accumulated blood. Oxygen is always prescribed, and the client is placed in a high-Fowler's position to ease the work of breathing. Furosemide, a rapid-acting diuretic, will eliminate accumulated fluid. A Foley catheter is inserted to accurately measure output. Intravenously administered morphine sulfate reduces venous return (preload), decreases anxiety, and reduces the work of breathing. Transporting the client to the coronary care unit is not a priority intervention. In fact, this may not be necessary at all if the client's response to treatment is successful.

The nurse is preparing for the admission of an infant with a diagnosis of bronchiolitis caused by the respiratory syncytial virus (RSV). Which interventions should be included in the plan of care? Select all that apply.

Rationale: The infant with RSV should be isolated in a private room or in a room with another child with RSV. The infant should be placed in a room near the nurses' station for close observation. The infant should be positioned with the head and chest at a 30- to 40-degree angle and the neck slightly extended to maintain an open airway and to decrease pressure on the diaphragm. Cool, humidified oxygen is delivered to relieve dyspnea, hypoxemia, and insensible water loss from tachypnea. Contact precautions (wearing glovesand a gown) reduce the nosocomial transmission of RSV.Recalling the mode of transmission of RSV will assist you with determining that the infant needs to be placed in a private room or in a room with another child with RSV and that contact precautions need to be maintained. Recalling the reasons to maintain a patent airway (edema and the accumulation of mucus obstruct the bronchioles) will assist you with determining that the infant needs to be observed closely, that the infant's head should be elevated, and that the infant should receive cool, humidified oxygen.

The nurse reviews the record of a child who was just seen by a health care provider (HCP). The HCP has documented a diagnosis of suspected aortic stenosis. Which specific sign/symptom of aortic stenosis should the nurse anticipate?

The child with aortic stenosis shows signs of exercise intolerance, chest pain, and dizziness when standing for long periods. Pallor may be noted, but it is not specific to this type of disorder alone. Options 2 and 4 are not related to this disorder.

The nurse is reviewing the laboratory results of a client who is receiving chemotherapy and notes that the platelet count is 10,000 cells/mm3. On the basis of this laboratory value, the nurse should collect which data as a priority?

A high risk of hemorrhage exists when the platelet count drops below 20,000/mm3. Fatal central nervous system hemorrhage or massive gastrointestinal hemorrhage can occur when the platelet count is less than 10,000 cells/mm3. The client should be monitored for changes in the level of consciousness, which may be an early indication of an intracranial hemorrhage. Option 2 is a priority when the white blood cell count is low and the client is at risk for an infection. Although options 1 and 3 are important, they are not the priority in this situation.

A child is admitted to the hospital with a probable diagnosis of nephrotic syndrome. Which findings should the nurse expect to observe? Select all that apply.

Nephrotic syndrome is a kidney disorder that is characterized by massive proteinuria, hypoalbuminemia, edema, elevated serum lipids, anorexia, and pallor. The urine volume is decreased, and the urine is dark and frothy in appearance. The child with this condition gains weight.

The nurse notes that a client is being treated with nesiritide (Natrecor). The nurse should expect this client to be experiencing which disorder?

Nesiritide is a synthetic form of human B-type natriuretic peptide (BNP) indicated only for short-term, intravenous therapy of hospitalized clients with acutely decompensated heart failure. It is not used for the disorders noted in options 2, 3, or 4.