Pass point pt 1
A client was hospitalized and treated for acute diverticulitis. The nurse has reinforced discharge education. Which statement by the client indicates that the client understands the discharge instructions? "I'll decrease the fiber in my diet." "I'll reduce my fluid intake." "I'll exercise to increase my intra-abdominal pressure." "I'll take all of my antibiotics."
"I'll take all of my antibiotics." Explanation:Antibiotics are used to reduce inflammation. The client with acute diverticulitis typically isn't allowed anything orally until the acute episode subsides. Parenteral fluids are given until the client feels better; then it's recommended that the client drink eight 8-oz (237-ml) glasses of water per day and gradually increase fiber in the diet to improve intestinal motility. During the acute phase, activities that increase intra-abdominal pressure should be avoided to decrease pain and the chance of intestinal obstruction.
Which statement made by a parent of a child with short stature would indicate to the nurse the need for further education? "X-rays should be included in my child's diagnostic procedures." "A history of my child's growth patterns should be discussed." "A family history is important information for me to share with my health care provider." "Obtaining blood studies won't aid in proper diagnosis."
"Obtaining blood studies won't aid in proper diagnosis." A complete diagnostic evaluation should include a family history, a history of the child's growth patterns and previous health status, physical examination, physical evaluation, radiographic survey, and endocrine studies that may involve blood samples.
When explaining the hypoxic drive to the client, which statement by the nurse is best? "This is when you do not notice you need to breathe." "This is when you only breathe when your oxygen levels climb above a certain point." "This is when you only breathe when your oxygen levels dip below a certain point." "This is when you only breathe when your carbon dioxide level dips below a certain point."
"This is when you only breathe when your oxygen levels dip below a certain point." Clients with emphysema breathe when their oxygen levels drop to a certain level; this is known as the hypoxic drive. Clients with emphysema and chronic obstructive pulmonary disease take a breath when they've reached this low oxygen level. They don't take a breath when their levels of carbon dioxide are higher than normal, as do those with healthy respiratory physiology. If too much oxygen is given, the client has little stimulus to take another breath. His carbon dioxide levels climb, he loses consciousness, and respiratory arrest occurs.
The nurse notes that the blood glucose level of a client has increased and is planning to notify the healthcare provider by telephone. Which of the following techniques would be most appropriate for the nurse to use when communicating with the healthcare provider? a.) SOAP b.) SBAR c.) CBE d.) EMAR
Answer: B The nurse should use SBAR to communicate verbally to the healthcare provider. Situation, Background, Assessment, and Recommendation (SBAR) is the communication tool to provide critical client information to the healthcare provider.
The licensed practical nurse discovers a client with a pulse rate of 40 beats/minute. His blood pressure is 80/50 mm Hg and he reports dizziness. Which medication would the registered nurse use to treat the client's bradycardia? Atropine Dobutamine Amiodarone Lidocaine
Atropine Explanation: I.V. push atropine is used to treat symptomatic bradycardia. Dobutamine is used to treat heart failure and low cardiac output. Amiodarone is used to treat ventricular fibrillation and unstable ventricular tachycardia. Lidocaine is used to treat ventricular ectopy, ventricular tachycardia, and ventricular fibrillation.
Which trait is the most important for ensuring that a nurse-manager is effective? Communication skills Clinical abilities Health care experience Time management skills
Communication skills Communication skills are a necessity for a successful nurse-manager. The manager must be able to communicate with the staff, clients, and family members. Clinical abilities, experience, and time management are also important to the manager's success, but without communication skills the manager won't be effective.
The nurse is caring for a client who is postoperative after abdominal surgery and reporting "gas pains." What action by the nurse can assist the client with alleviating the discomfort associated with gas? Encourage the client to ambulate. Administer opioid analgesics. Encourage the client to drink iced liquids. Have the client turn to the right side.
Encourage the client to ambulate.
The nurse observes small white nodules on the roof of an infant's mouth. Which term will the nurse use when describing this finding to the health care provider? Epstein pearls milia erythema toxicum melasma
Epstein pearls Epstein pearls are small white nodules that appear on the roof of a newborn's mouth. Melasma is a dark coloration of the skin seen in pregnant females. Milia are small white bumps that occur on the nose due to clogged sebaceous glands. Erythema toxicum is a maculopapular rash seen in newborns.
A client with human immunodeficiency virus (HIV) infection is preparing for discharge from the hospital when he reports to a nurse that he continually feels weak. How should the nurse intervene? Recommend that the client exercise for 30 minutes a day to increase his strength. Notify the physician and request that the client's discharge be postponed. Explain to the client that he should schedule periods of rest throughout the day. Make arrangements for a wheelchair to be available for him after discharge.
Explain to the client that he should schedule periods of rest throughout the day. The nurse should advise the client to schedule periods of rest throughout the day to prevent weakness and fatigue. The nurse shouldn't recommend an exercise routine without consulting with the physician. A client with HIV infection will most likely suffer from weakness and fatigue; neither are reasons to postpone discharge. The client should be encouraged to remain as independent as possible; there is no need to make arrangements for a wheelchair at this time.
A client who reportedly consumes 1 qt of vodka daily is admitted for alcohol detoxification. To try to prevent alcohol withdrawal symptoms, the nurse expects the health care practitioner to most likely prescribe which drug? Clozapine Thiothixene Lorazepam Lithium carbonate
Lorazepam Explanation: The best choice for preventing or treating alcohol withdrawal symptoms is lorazepam, a benzodiazepine. Clozapine and thiothixene are antipsychotic agents, and lithium carbonate is an antimanic agent; these drugs aren't used to manage alcohol withdrawal syndrome.
After a client enters the second stage of labor, the nurse notes that her amniotic fluid is port-wine colored. What should the nurse do next? Document this as normal finding Position the client on left side Insert a foley catheter Prepare for immediate delivery of the baby
Prepare for immediate delivery of the baby Port-wine-colored amniotic fluid isn't normal and may indicate abruptio placentae. Immediate delivery of the baby is needed. Positioning the client on the left side does not prevent abruptio placenta. Inserting a foley catheter helps decompress the bladder but does nothing for the safety of the baby and mother.
Which nursing intervention is the best way to help reduce the occurrence of poisoning in children? Place the number for poison control in the home. Provide education to those who care for children. Identify children who are at risk of poisoning. Teach parents to read toy labels.
Provide education to those who care for children. Educating those who care for children about poisoning is the best way to reduce the occurrence of poisoning. Identifying high-risk groups will help but won't reduce poisoning. Reading toy labels will help to identify toys that may contain lead and may help reduce lead exposure. Having the number to poison control is essential if poisoning has occurred but will not prevent poisoning.
The nurse is caring for a client with peripheral vascular disease who is scheduled for a venogram. The client reports allergy to several food items. The nurse should be most concerned about allergy to which food? Eggs Shellfish Peanuts Tomatoes
Shellfish Tomatoes, eggs, and peanuts have no cross-sensitivity to iodine. Shellfish allergy is an indicator of iodine allergy. Most radiologic procedures use iodine in the contrast.
The nurse is assisting the health care provider in applying a cast. Which intervention should be provided during immediate cast care? Support the cast with the palms of her hand. Wait until the cast dries before cleaning surrounding skin. Dispose of the plaster water in the sink. Rest the cast on the bedside table.
Support the cast with the palms of her hand. After a cast has been applied, it should be immediately supported with the palms of the nurse's hands. Later, the nurse should dispose of the plaster water in a sink with a plaster trap or in a garbage bag. Then the nurse should clean the surrounding skin before the cast dries, and make sure that the cast isn't resting on a hard or sharp surface.
A client is admitted to the inpatient adolescent unit after being arrested for attempting to sell cocaine to an undercover police officer. The nurse assists in writing a behavioral contract. Which action would the nurse incorporate to best promote compliance by this client? The contract should be written abstractly. The contract should be written by the client alone. The contract should be written jointly by the client and nurse. The contract should be written jointly by the physician and nurse.
The contract should be written jointly by the client and nurse. A contract written jointly by the client and nurse most successfully promotes cooperation and consistent behavior. The most effective contract — and the type least likely to allow for manipulation and misinterpretation — states the behavioral terms as concretely as possible. A contract written solely by the client may not be agreeable to staff members; one written by the physician and nurse may not be agreeable to the client.
A client underwent an open cholecystectomy. For which complication should the nurse monitor this client over the next 24 hours? atelectasis bronchitis pneumonia pneumothorax
atelectasis Explanation: Atelectasis develops when there's interference with the normal negative pressure that promotes lung expansion. Clients in the postoperative phase typically guard their breathing because of pain and positioning, which causes hypoxia. It's uncommon for any of the other respiratory disorders to develop after surgery.
The nurse auscultates inspiratory and expiratory wheezes with a decreased forced expiratory volume in a client with asthma. Which class of medication would the nurse expect to administer immediately? beta blockers bronchodilators inhaled steroids oral steroids
bronchodilators Bronchodilators are the first line of treatment for asthma because bronchoconstriction is the cause of reduced airflow. Inhaled or oral steroids may be given to reduce the inflammation but aren't used for emergency relief. Beta blockers aren't used to treat asthma and can cause bronchoconstriction.
A nurse is caring for a client who was admitted to the burn unit after suffering burns from a house fire. During the acute phase of a burn, the nurse should collect data on which topic? circulatory status tobacco use alcohol use lifestyle
circulatory status During the acute phase of a burn, the nurse should assess the client's circulatory and respiratory status, vital signs, fluid intake and output, ability to move, bowel sounds, wounds, and mental status. Information about the client's lifestyle and alcohol and tobacco use may be obtained later when the client's condition has stabilized.
For a client who must undergo colon surgery, the physician orders preoperative cleansing enemas. The nurse anticipates administration of neomycin to this client to: control postoperative nausea and vomiting. decrease the intestinal bacteria count. increase the intestinal bacteria count. prevent the development of megacolon.
decrease the intestinal bacteria count. The antibiotic neomycin sulfate is prescribed to decrease the bacterial count and reduce the risk of fecal contamination during surgery. After surgery, the physician may prescribe an antiemetic — not an antibiotic — to control postoperative nausea and vomiting. Antibiotics have no relation to megacolon development. To prevent this complication, the client should avoid opioid analgesics, such as morphine, which can decrease intestinal motility and contribute to megacolon.
A client with herpes zoster is prescribed acyclovir, 200 mg by mouth every 4 hours while awake. The nurse should inform the client that this drug may cause: palpitations. dizziness. diarrhea. metallic taste.
diarrhea. Oral acyclovir may cause such adverse GI effects as diarrhea, nausea, and vomiting. It isn't associated with palpitations, dizziness, or a metallic taste.
A nurse obtaining data from a client observes jugular vein distention (JVD). Which condition does the nurse suspect this client to have? abdominal aortic aneurysm heart failure myocardial infarction (MI) deep vein thrombosis
heart failure Elevated venous pressure, exhibited as JVD, indicates the heart's failure to pump. JVD is not a sign of abdominal aortic aneurysm or deep vein thrombosis. An MI, if severe enough, can progress to heart failure; however, in and of itself, an MI does not cause JVD.
The nurse is caring for a neonate whose mother is infected with hepatitis B. The nurse would inform the mother that her child will receive which treatment? hepatitis B immune globulin within 12 hours of birth, and hepatitis B vaccine at birth, age 1 month, and age 6 months hepatitis B immune globulin within 48 hours of birth, and hepatitis B vaccine at age 1 month hepatitis B immune globulin at birth; no hepatitis B vaccine hepatitis B vaccine at birth and age 1 month
hepatitis B immune globulin within 12 hours of birth, and hepatitis B vaccine at birth, age 1 month, and age 6 months Hepatitis B immune globulin should be given as soon as possible after birth but within 12 hours. Neonates should also receive hepatitis B vaccine at regularly scheduled intervals. This sequence of care is considered superior to the other treatment options.
When assisting in discharge planning for a child with Duchenne muscular dystrophy, what should the nurse be sure to include regarding the diet? low calorie, high protein, and high fiber low calorie, high protein, and low fiber high calorie, high protein, and restricted fluids high calorie, high protein, and high fiber
low calorie, high protein, and high fiber A child with Duchenne muscular dystrophy is prone to constipation and obesity, so dietary intake should include a diet low in calories, high in protein, and high in fiber. Adequate fluid intake should also be encouraged.
The nurse is caring for a client with severe diarrhea. The nurse recognizes that the client is at risk for developing which of the following acid-base imbalances? metabolic acidosis respiratory acidosis metabolic alkalosis respiratory alkalosis
metabolic acidosis The client is at risk for developing metabolic acidosis. Metabolic acidosis is caused by diarrhea, lower intestinal fistulas, ureterostomies, and use of diuretics; early renal insufficiency; excessive administration of chloride; and the administration of parenteral nutrition without bicarbonate or bicarbonate-producing solutes (e.g., lactate).
An elderly client has been admitted to the medical-surgical unit from the postanesthesia care unit. While the nurse is off the floor, the client falls out of bed and fractures the right leg and right wrist. The nurse finding the client states, "The side rails were down and the bed was in the high position." The client's family files legal charges against the nurse and the hospital. Which charge most accurately reflects the nurse's actions? collective liability comparative negligence battery negligence
negligence The position of the client's bed indicates negligence, a general term that denotes conduct lacking in due care. Collective liability stems from cooperation by several manufacturers in a wrongful activity. Comparative negligence holds the injured parties accountable for their fault in the injury. Battery involves harmful or unwarranted contact with the client.
Which client requires immediate nursing intervention? The client who complains of epigastric pain after eating. complains of anorexia and periumbilical pain. presents with a rigid, boardlike abdomen. presents with ribbonlike stools.
presents with a rigid, boardlike abdomen. A rigid, boardlike abdomen is a sign of peritonitis, a possibly life-threatening condition. Epigastric pain occurring 90 minutes to 3 hours after eating may indicate a duodenal ulcer. Anorexia and periumbilical pain are characteristic of appendicitis. A client with a large-bowel obstruction may have ribbonlike stools.
A client is reporting severe pain in the right upper arm. Which x-ray finding would indicate to the nurse that further investigation is required? longitudinal fracture oblique fracture spiral fracture transverse fracture
spiral fracture Explanation: Spiral fractures are commonly seen in the upper extremities and are related to physical abuse. Oblique and longitudinal fractures generally occur with trauma. A transverse fracture commonly occurs with such bone diseases as osteomalacia and Paget disease.
The nurse is performing an electrocardiogram (ECG) for a client with chest pain. To achieve the best results, in which position will the nurse place the client? Fowler supine lateral prone
supine
An infant with hypothyroidism is receiving oral thyroid hormone. Which finding should alert a nurse to a potential overdose? tachycardia, cool extremities, and irritability bradycardia, irritability, and cool extremities bradycardia, excessive sleepiness, and dry, scaly skin tachycardia, irritability, and diaphoresis
tachycardia, irritability, and diaphoresis Clinical manifestations of thyroid hormone overdose in an infant include tachycardia, irritability, and diaphoresis. Bradycardia; excessive sleepiness; dry, scaly skin; and cool extremities are manifestations of hypothyroidism or inadequate hormone replacement (underdosage).
A parent of a 9-year-old child who is scheduled to have surgery expresses concern about the potential for a postoperative infection. Which information would be most important for the nurse to tell the parent? "All visitors should wash their hands before they leave or enter the room." "Cover your mouth and nose when you cough or sneeze in the room." "Do not bring fresh flowers or fruit to the room after surgery." "Wear an isolation gown when entering the room."
"All visitors should wash their hands before they leave or enter the room."
A pregnant client, who is originally from another country, is admitted to the hospital in labor. During the admission process, the spouse tells the nurse that the client will not receive any pain medication during the process. The spouse then waits in the waiting room. As the birthing process continues, the nurse asks the client if she needs pain medication. She declines the offer and reminds the nurse by saying, "My spouse told you I cannot have any pain medicine." What is the nurse's best response to the client? "I want to advocate for you and assist with the pain during this process." "I am going to talk to the provider about this." "I think that this is extreme. Pain medication will not affect the child." "I am sorry. I do not want to offend your husband."
"I want to advocate for you and assist with the pain during this process."
A 2-year-old child is admitted through the emergency department with a suspected diagnosis of Hirschsprung's disease (aganglionic megacolon). The parent asks about treatment of the disease. What would be an appropriate response from the nurse?
"Initially the child will have a temporary colostomy; later a second operation removes the abnormal part of bowel and reattaches the normal bowel down to the rectum." Repair of aganglionic megacolon in a child with a suspected diagnosis of Hirschsprung's disease requires dissection of the aganglionic segment and anastomosis with the unaffected intestine. It is usually done in a two-stage operation. The first surgery creates a colostomy to evacuate the bowel of stool and rest the distended portion of the bowel. The second surgery, done several months later, involves colostomy closure and a rectal "pull-through." The colostomy is not permanent. Only a two-stage operation is required. Chemotherapy and radiation therapy are not required for this condition; it is not cancer.
The X-rays of a client who was brought to the emergency department after falling on ice reveal a leg fracture. After a cast is applied and allowed to dry, the nurse teaches the client how to use crutches. Which instruction should the nurse provide about climbing stairs? "Place the injured leg and the crutch on the unaffected side on the first step; the unaffected leg and crutch on the injured side follow." "Place both crutches on the first step and swing both legs upward to this step." "Place the crutches and injured leg on the first step, followed by the unaffected leg." "Place the unaffected leg on the first step, followed by the crutches and the injured leg, which should move together."
"Place the unaffected leg on the first step, followed by the crutches and the injured leg, which should move together." When climbing stairs with crutches, the client should lead with the unaffected leg, followed by the crutches and injured leg moving together. Any other method is incorrect and could increase the client's risk of falling.
A client says to the nurse, "I know that I'm going to die." Which response by the nurse would be best? "Does the thought of dying scare you?" "Don't worry. I will stay with you now." "Tell me why you think you are going to die." "It sounds like you are worried about death."
"Tell me why you think you are going to die." A therapeutic approach would be to reflect on the client's comments, focusing on the specific words. Responding with a statement asking if the client is afraid is not therapeutic and does not respond to the client's statement. Saying "Don't worry" is placating and negates the client's feelings. Making a statement about being worried may be therapeutic during the conversation but not as the conversation opening statement.
The parents of a 3-year-old with a congenital heart disease report during a checkup that they are concerned about giving a flu vaccine to their child. Which statement is appropriate for inclusion in the nurse's response? "You are right to be concerned since this vaccine should be provided to children who are older than 3 years of age." "As long as you are careful who your child is exposed to, you should be fine to avoid giving this vaccine." "Since there are troubling side effects in the vaccine for your child, I would recommend that the other members of the household be immunized instead." "The flu vaccine is both safe and recommended to children who have chronic illness such as heart disease."
"The flu vaccine is both safe and recommended to children who have chronic illness such as heart disease."
A pregnant client is brought to the emergency department after being an unrestrained driver in a motor vehicle accident. When questioned about seatbelt use, the client states that she thought a seatbelt would harm her baby. Which response by the nurse is best? "I can see why you'd think that because the seatbelt comes over the lower abdomen." "I know that seat belts are uncomfortable." "The only way to safely secure yourself in a car is to use a seatbelt." "I don't use my seatbelt either."
"The only way to safely secure yourself in a car is to use a seatbelt." The nurse should explain that using a seatbelt is necessary to safely secure the client in the car and prevent injury. The nurse should also explain that, when worn properly, seatbelts won't cause harm to the baby. Options 1, 2, and 4 are neglectful because they don't encourage seatbelt use.
The nurse reinforces instructions about breathing exercises for a client with chronic bronchitis. Which information should the nurse include? "Inhale longer than you exhale." "Exhale through an open mouth." "Use diaphragmatic breathing." "Practice rhythmic chest breathing."
"Use diaphragmatic breathing." Explanation: In a client with chronic bronchitis, the diaphragm is flat and weak. Diaphragmatic breathing helps to strengthen the diaphragm and maximizes ventilation. Exhalation should be longer than inhalation to prevent collapse of the bronchioles. A client with chronic bronchitis should exhale through pursed lips to prolong exhalation, keep the bronchioles from collapsing, and prevent air trapping. Diaphragmatic breathing, not chest breathing, increases lung expansion.
A client who has just been diagnosed with hepatitis A asks, "How could I have gotten this disease?" What is the nurse's best response? "You could have gotten it by using I.V. drugs." "You must have received an infected blood transfusion." "You probably got it by engaging in unprotected sex." "You may have eaten contaminated restaurant food."
"You may have eaten contaminated restaurant food." Hepatitis A virus typically is transmitted by the oral-fecal route — commonly by consuming food contaminated by infected food handlers. The virus isn't transmitted by the I.V. route, blood transfusions, or unprotected sex. Hepatitis B can be transmitted by I.V. drug use or blood transfusion. Hepatitis C can be transmitted by unprotected sex.
A client on an inpatient psychiatric unit is pacing up and down the hallway. The client has a history of aggression. Which comment made by the nurse would be the most appropriate? "You are pacing. Would you like some quiet time in your room?." "You are pacing. Does that help with your anxiety?" "You're pacing. Let's walk together and talk about it." "You are pacing. Would you like to have one of the techs walk with you?"
"You're pacing. Let's walk together and talk about it." The nurse should acknowledge the client's behavior and explore feelings. They should talk about the pacing. The other responses may be therapeutic further in the conversaton or in other situations. It is important the nurse walk with the client to offer support. Quiet time in the client's room does not address the pacing. Asking if pacing helps with the anxiety is therapeutic but does not offer the nurses support. Asking if the client would like to walk with a tech can be therapeutic but does not provide nursing support. Walking with the client offers positive regard.
A nurse is caring for a woman who is Rh-negative and experienced a spontaneous abortion. The nurse would expect the health care provider to prescribe which medication? magnesium sulfate Rho (D) immune globulin terbutaline betamethasone
Rho (D) immune globulin Explanation: After a spontaneous abortion, a woman who is Rh-negative should receive Rho (D) immune globulin to reduce the risk of possible isoimmunization of the fetus in a future pregnancy. Magnesium sulfate, terbutaline, and betamethasone are not indicated for this use.
The nurse is caring for a wheelchair-bound client. Which piece of equipment impedes circulation to the area it's meant to protect? Air-fluidized bed Ring or donut Gel flotation pad Water bed
Ring or donut 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.
Which of the following would the nurse expect of an elderly client's skin? Increased elasticity Increased sweat production Slowed healing Increased nail growth
Slowed healing
The nurse is caring for a child with acute rheumatic fever. Which data does the nurse anticipate in this child? leukocytosis normal electrocardiogram normal red blood cell count normal erythrocyte sedimentation rate
leukocytosis Explanation: Leukocytosis can be seen as an immune response triggered by colonization of the pharynx with group A streptococci. The electrocardiogram will show a prolonged PR interval as a result of carditis. A low-grade fever is a minor manifestation. There should be no change in red blood cell count. The inflammatory response will cause an elevated erythrocyte sedimentation rate.
When reviewing medications for a pharmacology examination, the nursing student recognizes which drugs may be abused because of tolerance and physiologic dependence? Lithium and divalproex Verapamil and chlorpromazine Alprazolam and phenobarbital Clozapine and amitriptyline
Alprazolam and phenobarbital Both benzodiazepines (such as alprazolam) and barbiturates (such as phenobarbital) are addictive, controlled substances. None of the other drugs listed are addictive substances.
Which scenario requires the licensed practical nurse (LPN) to notify the registered nurse (RN) immediately? Decrease in a client's blood pressure from 160/90 mm Hg to 140/84 mm Hg Complaint of pain that rates 7 on a 1-to-10 pain-rating scale Apical pulse rate of 90 beats/minute with a radial pulse rate of 70 beats/minute Family inquiry about the client's discharge time
Apical pulse rate of 90 beats/minute with a radial pulse rate of 70 beats/minute The LPN should immediately report an apical pulse rate of 90 beats/minute associated with a radial pulse rate of 70 beats/minute, which indicates a pulse deficit of 20 beats/minute. This finding signifies an irregular heartbeat that might lead to a decrease in cardiac output. Regarding the other answer options, the decrease in BP is a positive finding and doesn't need to be reported immediately; the LPN can assess pain and administer pain medications as prescribed; and the LPN can provide the family with an estimated discharge time without consulting the RN.
A client is found sitting on the floor of the bathroom in the day treatment clinic with moderate lacerations on both wrists. Surrounded by broken glass, she sits staring blankly at her bleeding wrists while staff members call for an ambulance. Which of the following approaches should the nurse initially utilize? Call for staff back-up before entering the room and restraining her. Enter the room quietly and move beside her to assess her injuries. Move as much glass away from her as possible and sit next to her quietly. Approach her slowly while speaking in a calm voice, calling her name, and telling her that the nurse is here to help her.
Approach her slowly while speaking in a calm voice, calling her name, and telling her that the nurse is here to help her. Ensuring the safety of the client and the nurse is the priority at this time. Therefore, the nurse should approach the client cautiously while calling her name and talking to her in a calm, confident manner. The nurse should keep in mind that the client shouldn't be startled or overwhelmed. After explaining that she is there to help, the nurse should observe the client's response carefully. If the client shows signs of agitation or confusion or poses a threat, the nurse should retreat and request assistance. The nurse shouldn't attempt to sit next to the client or examine injuries without first announcing her presence and assessing the dangers of the situation.
A client reports a lot of gas in the colostomy bag. Which instruction is best to give this client? Burp the bag. Eat fewer beans. Replace the bag. Put a tiny hole in the top of the bag.
Burp the bag. Letting air out of the bag by opening it and burping it is the best solution. The client can be encouraged to note which foods are causing gas and to eat fewer gas-forming foods. Replacing the bag is costly. Putting a hole in the bag will cause fluids to leak out.
The unlicensed assistive personnel (UAP) reports to the nurse that a client became short of breath while being bathed but is breathing better now. Which action should the nurse take first? Instruct UAP to observe the client for further shortness of breath. Check the client and gather subjective and objective data related to shortness of breath. Call the health care provider about the client's episode of shortness of breath. Instruct UAP to complete the bath after the client rests.
Check the client and gather subjective and objective data related to shortness of breath. The nurse must assess the client to determine what caused the episode and obtain a pulse oximetry reading, if indicated. Instructing the UAP to observe the client for further shortness of breath would be appropriate after the nurse has checked the client. It wouldn't be necessary at this time to call the health care provider about the client's episode of shortness of breath since the client's breathing has improved, but the health care provider should be informed in a timely manner, and this should be documented. After checking the client, the nurse may ask the UAP to complete the bath after allowing the client to rest.
A client has been NPO for 8 hours before a surgical procedure. When the nurse enters the room to take vital signs, the client is cool, diaphoretic, and unresponsive. After calling a rapid response, which intervention should the nurse perform? Perform an electrocardiogram. Check the glucose level. Perform an electroencephalogram. Administer naloxone.
Check the glucose level. Blood glucose level should be immediately measured when a client is unresponsive for no apparent reason or if hypoglycemia is suspected. This client is NPO and at risk for hypoglycemia. When blood glucose levels fall below 40 to 50 mg/dL, cerebral function declines rapidly. An ECG or EEG may be performed but would not be the priority in this situation. There is no indication that the client has received a narcotic, so the administration of a narcotic antagonist would be unnecessary.
A client is placed on oxygen therapy via a nasal cannula. Which should be the first action by the nurse? Make sure all electronic monitoring devices in use are properly grounded. Know the location of O2 turn-off valve on nursing unit. Instruct the client and family, as well as visitors, not to smoke. Confirm the health care provider's order for oxygen.
Confirm the health care provider's order for oxygen. The priority when administering oxygen is to check the health care provider's order because this is considered a medication. The nurse also should make sure all electronic monitoring devices are grounded, instruct everyone not to smoke, and should know the location of the turn-off valve for the O2.
A 76-year-old client who failed swallowing studies has a nasogastric (NG) tube in place for medication administration. When the nurse checks the client's medications, she notices that only tablets have been dispensed by the pharmacy. How should the nurse proceed? Return all of the medications to the pharmacy and request them in liquid form. Crush those tablets that may be crushed according to the manufacturer and administer them through the NG tube; request an alternate form of those that can't be crushed. Request that the pharmacy crush all of the client's medications. Notify the physician and request that he change the administration route of the medications to I.V.
Crush those tablets that may be crushed according to the manufacturer and administer them through the NG tube; request an alternate form of those that can't be crushed. The nurse should verify which drugs may be crushed according to the manufacturer. If some of the prescribed medications can't be crushed the nurse should ask the pharmacy if they can dispense liquid forms of those drugs. If a liquid form doesn't exist, the nurse should notify the physician and ask if he can prescribe an alternate route of administration.
A licensed practical nurse (LPN) is providing care to a client and is uncertain about a health care provider's prescription regarding a medication prescribed for the client. Which action would be most appropriate? Carry out the prescription without questioning it. Inform the health care provider about the concern after carrying out the prescription. Refuse to carry out the prescription under any circumstances. Decide whether to follow the prescription after conferring with the supervising registered nurse (RN).
Decide whether to follow the prescription after conferring with the supervising registered nurse (RN). Ambiguous prescription must be clarified with the health care provider. If the LPN believes the health care provider's prescription to be incorrect, the nurse should confer with the supervising RN about it. If they decide that the prescription is inappropriate, the supervising nurse can contact the health care provider about any concerns. The nurse's decision and all communication with the health care provider about the prescription must be documented.
The nurse is caring for a client with a blood pressure of 210/94 mm Hg. The health care provider prescribes enalapril 20 mg b.i.d. Which nursing action is best when instructing on the new medication regimen? Teach the client the name and frequency of the new medication. Inform the client about the new medication and provide a handout on the use. State the new medication, including name, use, and reason for the new medication. Use the package insert for medication instruction.
State the new medication, including name, use, and reason for the new medication. Medication administration and teaching is in the nurse's scope of practice and a common nursing action. It is important for the nurse to inform the client about the medication, including its name, use, and the reason for the medication change, because teaching the client about treatment regimen promotes compliance. The other responses are not as specific and inclusive.
The nurse is reinforcing education for a client taking tetracycline for severe inflammatory acne. Which instructions are important to reinforce? Take the drug on an empty stomach with small amounts of water. Take the drug with or without meals. Take the drug with milk and milk products. Take the drug 1 hour before or 2 hours after meals with large amounts of water.
Take the drug 1 hour before or 2 hours after meals with large amounts of water.
The nurse is discussing bacterial/infective endocarditis with the parent of a teen who has been diagnosed with the disorder. Which statement about bacterial/infective endocarditis indicates an understanding of the condition? It is caused by bacteria invading only tissues of the heart. It is an infection of the valves and inner lining of the heart. It is an inappropriate fusion of the endocardial cushions in fetal life. It is caused by alterations in cardiac preload, afterload, contractility, or heart rate.
It is an infection of the valves and inner lining of the heart. Explanation: Bacterial/infective endocarditis is an infection of the valves and inner lining of the heart. It's usually caused by the bacteria Streptococcus viridans and frequently affects children with acquired or congenital anomalies of the heart or great vessels. Bacteria may grow into adjacent tissues and may break off and embolize elsewhere, such as the spleen, kidney, lung, skin, and central nervous system. Endocardial cushion defects result from inappropriate fusion of the endocardial cushions in fetal life. Alterations in preload, afterload, contractility, or heart rate occur in heart failure.
A client comes to the clinic seeking medical attention for a rash. The nurse gathers information about the rash and finds that the client's back and right side are covered with vesicles. A vesicular rash may be associated with which conditions? Select all that apply. contact dermatitis herpes zoster smallpox Kaposi's sarcoma cutaneous anthrax
contact dermatitis herpes zoster smallpox A vesicular rash is associated with contact dermatitis, herpes zoster, and the late stages of smallpox. Cutaneous anthrax and Kaposi's sarcoma are associated with a papular rash.
The infection control team has identified a 25% infection rate on the orthopedic floor. The nursing staff members are asked to record their care activities by recording them in a log to help identify the cause of the high infection rate. Which of the following care activities should be recorded in the activity log? Hand washing between client contacts Clean glove use when applying sterile dressings Sterile gown use when changing clients' linens Wearing a mask when changing sterile dressings
Hand washing between client contacts The best way to stop the spread of infection is by hand washing between each client contact. Therefore, the nursing staff should record each time they wash their hands. Recording this activity heightens the staff's awareness of hand washing, reinforces its importance, and helps determine whether lack of hand washing is at the root of the problem. The nurse should wear clean gloves to remove a dressing and then put on sterile gloves to apply a sterile dressing. A clean gown, not a sterile gown, should be worn when soiling of the nurse's clothing is likely during a linen change. A mask isn't required for all sterile dressing changes.
A healthcare provider informs a client that the client's diagnosis of ovarian cancer is terminal. The client, usually religiously observant, is expressing rage at God and the clergy. Which nursing intervention is appropriate for this client? Engage the client in diversional activities to distract them from the present situation. Help the client use effective coping strategies. Encourage the client to read everything possible about the treatment of ovarian cancer. Allow the client time and space to bargain with God for a cure.
Help the client use effective coping strategies. A client newly diagnosed with ovarian cancer has to rely on his or her ability to cope (or learns new coping strategies) to be able to ease spiritual distress and possibly return to religious practice. Developing effective coping strategies will help the client handle spiritual distress more effectively than diversional activities or reading about treatment of ovarian cancer. Bargaining with God for a cure is an element of the grieving process; however, this client is expressing anger, not grief.
For a client newly diagnosed with radiation-induced thrombocytopenia, the nurse should include which intervention in the plan of care? Placing the client in strict isolation Inspecting the skin for petechiae once every shift Providing frequent rest periods Administering aspirin if the temperature exceeds 102° F (38.8° C)
Inspecting the skin for petechiae once every shift Because thrombocytopenia impairs blood clotting, the nurse should inspect the client regularly for signs of bleeding, such as petechiae, purpura, epistaxis, and bleeding gums. The nurse should avoid administering aspirin because it may increase the risk of bleeding. Frequent rest periods are indicated for clients with anemia, not thrombocytopenia. Strict isolation is indicated only for clients who have highly contagious or virulent infections that are spread by air or physical contact.
The nurse is observing an infant who may have acute bacterial meningitis. Which finding should the nurse anticipate? Flat fontanel Calm, relaxed demeanor Irritability, fever, and vomiting Jaundice, drowsiness, and refusal to eat
Irritability, fever, and vomiting Findings associated with acute bacterial meningitis may include irritability, fever, and vomiting along with seizure activity. Fontanels would be bulging as intracranial pressure rises. Jaundice, drowsiness, and refusal to eat indicate a GI disturbance rather than meningitis. Clients with meningitis would be irritable and hyperactive, not calm.
A client sees a dermatologist for a skin problem. Later, the nurse reviews the client's chart and notes that the chief concern was intertrigo. This term refers to which condition? Inflammation of a hair follicle Spontaneously occurring wheals Irritation of opposing skin surfaces caused by friction A fungus that enters the skin's surface, causing infection
Irritation of opposing skin surfaces caused by friction
Which factor does the nurse inform the parents will place a child at increased risk for an asthma-related death? Use of an inhaler at home One admission for asthma last year Prior admission to the general pediatric floor Prior admission to an intensive care unit for asthma
Prior admission to an intensive care unit for asthma Asthma results in varying degrees of respiratory distress. A prior admission to an intensive care unit marks an increased severity and need of immediate therapy. Two or more hospitalizations for asthma, a recent hospitalization or emergency department visit in the past month, or three or more emergency department visits in the past year puts a child at high risk for asthma-related death. Although current use of systemic steroids would also be a risk factor, not all inhalers contain steroids.
When caring for a client who has had constipation for 4 days, what should be the nurse's primary client care concern? Promoting defecation Relieving pain Providing nutrition Monitoring output
Promoting defecation Constipation for 4 days is a problem that needs attention. The nurse's primary concern should be assisting the client's bowel motility and fecal elimination. Though pain is an important concern associated with constipation, the pain will not subside until the constipation is resolved. Nutrition is a secondary concern when a client is severely constipated. Until bowel motility is reestablished, there will be no fecal output to monitor.
The nurse is on the telephone with the health care provider to share the stat potassium result on a client. The health care provider gives the nurse a telephone order for potassium chloride 60 mEq oral every 6 hours for 2 days. What should the nurse do first? Enter the potassium chloride order in the computer system. Call the pharmacy to send the potassium chloride dosage to the unit. Let the client know that potassium chloride 60 mEq orally for 2 days has been ordered. Repeat the potassium chloride order back to the health care provider. Let the charge nurse know the healthcare provider has ordered potassium chloride.
Repeat the potassium chloride order back to the health care provider. The first thing the nurse should do is repeat the potassium chloride order back to the health care provider to ensure the order is correct. This is done to ensure the client receives the proper medication via the proper route and correct dosage. The nurse should enter the potassium chloride order in the computer system next, so the pharmacy can fill the order quickly. The nurse can call the pharmacy and tell them to send the potassium chloride dosage to the unit next. Because the order has been put in the computer system, the pharmacy will be able to fill it quickly and will be aware of the order because the nurse called. Next, the nurse can inform the client about the order.
A nurse is caring for a woman who is Rh-negative and experienced a spontaneous abortion. The nurse would expect the health care provider to prescribe which medication? magnesium sulfate Rho (D) immune globulin terbutaline betamethasone
Rho (D) immune globulin After a spontaneous abortion, a woman who is Rh-negative should receive Rho (D) immune globulin to reduce the risk of possible isoimmunization of the fetus in a future pregnancy. Magnesium sulfate, terbutaline, and betamethasone are not indicated for this use.
The parent of a child with a ventriculoperitoneal shunt calls the nurse saying that the child has a temperature of 101.2° F (38.4° C), a blood pressure of 108/68 mm Hg, and a pulse of 100 beats/minute. The child is lethargic and vomited the night before. Other children in the family have had similar symptoms. Which nursing intervention is most appropriate? Tell the parent to bring the child to the primary health care provider's office. Consult the primary health care provider. Advise the parent that this is a viral infection. Provide symptomatic treatment.
Tell the parent to bring the child to the primary health care provider's office. One of the complications of a ventriculoperitoneal shunt is a shunt infection. Shunt infections can have similar symptoms as a viral infection, so it's best to have the child examined. These symptoms may be due to the same viral infection that the siblings have, but it's better to rule out a shunt infection because it can progress quickly to a very serious illness.
A primigravida client had an emergency cesarean birth because of fetal distress. Three days after the birth, the client seems preoccupied and troubled, and a nurse observes her crying in her room after visitors leave. She tells the nurse that her incision is ugly and that she "feels like a failure." In responding to the client, the nurse should consider which factor? The client is experiencing abnormal feelings and needs psychiatric care. The client is tired and upset from having too many visitors. The client is grieving the loss of her anticipated birth experience. The client is in the dependent taking-in phase described by Rubin.
The client is grieving the loss of her anticipated birth experience.
A child with muscular dystrophy has lost complete control of his lower extremities. There is some strength bilaterally in the upper extremities, but poor trunk control. Which mechanism would be the most important to have on the wheelchair? headrest support extended brakes wheelchair belt anti-tip device
Wheelchair belt Explanation: This client has poor trunk control; a belt will prevent him from falling out of the wheelchair. Antitip devices, head rest supports, and extended breaks are all important options but aren't the most important options in this situation
A 6-month-old infant is admitted with a diagnosis of bacterial meningitis. The nurse would place the infant in which room? a room with a 12-month-old infant with a urinary tract infection a two-bed room in the middle of the hall a private room near the nurses' station a room with an 8-month-old infant with failure to thrive
a private room near the nurses' station A child who has the diagnosis of bacterial meningitis is considered contagious, and will need to be placed in a private room until he has received IV antibiotics for 24 hours. Additionally, bacterial meningitis can be quite serious; therefore, the child should be placed near the nurses' station for close monitoring and easier access in case of a crisis.
A client with anorexia nervosa is admitted to the emergency department. Which finding does the nurse anticipate? blood pressure 150/90 mm Hg diaphoresis eats food and then purges amenorrhea for 1 year
amenorrhea for 1 year Explanation: Anorexia nervosa is an eating disorder characterized by self-imposed starvation with subsequent emaciation, nutritional deficiencies, and atrophic and metabolic changes. Typically, the client is hypotensive and dehydrated (e.g., dry mucous membranes). Clients with anorexia nervosa often cease to menstruate (amenorrhea). Depending on the severity of the disorder, anorexic clients are at risk for circulatory collapse (indicated by hypotension), dehydration, and death. Diaphoresis and hypertension would not be expected in this client. Bulimia nervosa is an eating disorder characterized by binge eating followed by self-induced vomiting (purging).
The nurse anticipates the transfer of which burn clients to a burn center? Select all that apply. an adult with 1.5% total body surface area (TBSA) third-degree burns of face an adult with an electrical burn a child with burns of hands and feet a child with 15% TBSA second-degree burns on torso an adult with 20% TBSA second-degree burns on lower extremities
an adult with 1.5% total body surface area (TBSA) third-degree burns of face an adult with an electrical burn a child with burns of hands and feet Major burn injuries include second-degree burns > 25% in adults or > 20% in children, any electrical injuries, and any burns involving eyes, ears, face, hands, feet, perineum, and joints. Remediation:
The nurse is teaching the parents of a young child how to handle suspected poisoning. If the child ingests poison, the parents should first: call an ambulance. punish the child for being bad. administer ipecac syrup. call the poison control center.
call the poison control center. Before intervening in any way, the parents should call the poison control center for specific instructions. Ipecac syrup is no longer recommended for poisonings because of the danger imposed by induced vomiting. The parents may have to call an ambulance after calling the poison control center. Punishment for being bad isn't appropriate because the parents are responsible for making the environment safe.
A client experiences weight loss, abdominal distention, crampy abdominal pain, and intermittent diarrhea after the birth of her second child. Diagnostic tests reveal gluten-induced enteropathy. Which foods would the nurse instruct the client to eliminate from her diet permanently? milk and dairy products protein-containing foods cereal grains (except rice and corn) carbohydrates
cereal grains (except rice and corn) To manage gluten-induced enteropathy, the client must eliminate gluten, which means avoiding all cereal grains except rice and corn. In initial disease management, clients eat a high-calorie, high-protein diet with mineral and vitamin supplements to help normalize the nutritional status. Lactose intolerance is sometimes an associated problem, so milk and dairy products are limited until improvement occurs. Cereal grains are the only carbohydrates this client must eliminate.
A client with a pneumothorax has a chest tube inserted that is connected to water-seal drainage. Which intervention should the nurse perform to prevent air leaks? place the drainage system below the level of the chest keep the head of the bed slightly elevated check and tape all of the connections maintain the patency of the chest tube
check and tape all of the connections Air leaks in a chest tube commonly occur if the system is not secure. Taping all connections and routinely checking them helps to prevent air leaks. The chest drainage system is kept lower than the chest to promote drainage, not to prevent air leaks. The head of the bed may be elevated to promote drainage. Chest tubes that are not patent may lead to tension pneumothorax but would not cause air leaks.
The nurse is gathering data from a client that is diagnosed with Kawasaki disease. What data does the nurse determine is associated with this diagnosis? vesicular lesions dry, cracked lips, strawberry tongue Koplik spots tonsillar exudate
dry, cracked lips, strawberry tongue
A licensed practical nurse (LPN) is assisting a registered nurse in caring for a primigravida client with acquired immunodeficiency syndrome (AIDS) who is at term and in early labor. When providing care to this client, which area would the LPN focus on as the priority? infection control measures crisis intervention fetal oxygenation fluid balance
infection control measures Infection at any time is a problem for a client with AIDS because the immune system is depressed. Invasive procedures, which always increase the risk of infection, are numerous during labor and birth. Clients with AIDS may be anxious or overwhelmed but not in crisis. Fluid balance is not a major concern for the client at this time. Although the fetus may acquire AIDS in utero, the current belief is that AIDS does not directly affect the placenta or oxygen transfer to the fetus.
The nurse is assuming care for a 10-year-old client who has been diagnosed with irritable bowel syndrome (IBS). Which assessment finding is most concerning to the nurse? fever constipation generalized abdominal pain bloating
fever Explanation: Irritable bowel syndrome (IBS) refers to a pattern of symptoms affecting the large intestine, or colon, that includes abdominal pain, abdominal cramping, bloating, gas, and constipation or diarrhea. It does not have an identifiable cause and occurs more often in females than in males. It is considered a functional disorder, meaning that the gastrointestinal tract behaves abnormally but the colon's tissues are not damaged. Triggers, such as gas-producing foods, food sensitivities, and stress, have been identified as seeming to irritate the bowel and instigate symptoms. The nurse will be most concerned about a fever; this is not a sign associated with IBS, so it suggests the emergence of a new health problem for this client. Although the nurse will be attentive to the client's reports of constipation, generalized abdominal pain, and bloating, these are expected symptoms associated with IBS.
The nurse is caring for a postpartum client after giving birth to a healthy neonate. When checking the client's fundus, which finding would the nurse most likely note? fundus slightly to right; 2 cm above umbilicus on postpartum day 2 fundus 1 cm above the umbilicus on postpartum day 3 fundus 1 cm above the umbilicus 1 hour postpartum fundus palpable in the abdomen at 2 weeks postpartum
fundus 1 cm above the umbilicus 1 hour postpartum Within the first 12 hours postpartum, the fundus is usually approximately 1 cm above the umbilicus. The fundus should be below the umbilicus by postpartum day 3. The fundus shouldn't be palpated in the abdomen after day 10. A uterus that isn't midline or is above the umbilicus on postpartum day 3 might be caused by a full, distended bladder or a uterine infection.
A child is admitted to the hospital for an asthma exacerbation. The nursing history reveals this client was exposed to chickenpox 1 week ago. When would this client require isolation if he or she were to remain hospitalized? isolation isn't required immediate isolation is required 10 days after exposure 12 days after exposure
immediate isolation is required The incubation period for chickenpox is 2 to 3 weeks, commonly 13 to 17 days. A client is commonly isolated 1 week after exposure to avoid the risk of an earlier breakout. A person is infectious from 1 day before eruption of lesions until after the vesicles have formed crusts.
The school nurse is gathering data related to the diabetic status of a 15-year-old athlete. Which physiologic change should the nurse anticipate as a diabetic teenager becomes more physically active during the day? increased need for food decreased need for food decreased risk of insulin shock increased risk of hyperglycemia
increased need for food If a child is more active at one time of the day than another, food intake or insulin can be adjusted to meet this increased activity pattern. Ideally, food intake should be increased, typically with a snack, when a diabetic teen is more physically active. The child would have an increased risk of insulin shock and a decreased risk of hyperglycemia when more physically active.
A nurse is caring for a client with an acute head injury and is ready to begin rehabilitation. When transferring the client from the bed to a chair, what should the nurse do to ensure client safety? place socks on the client's feet position the chair 2 feet from the bed raise the side rails on both sides of the bed lock the brakes on the bed
lock the brakes on the bed Locking the wheels of the bed (and wheelchair, if one is used) helps to prevent the bed (and chair) from sliding away, thus preventing injuries. The side rail on the side of the bed where the nurse is standing should be lowered to facilitate the transfer. Positioning the chair alongside the bed, rather than 2 feet away, helps the client to pivot into the chair. The nurse should place shoes or slippers with nonskid soles on the client's feet to help prevent slipping during the transfer.
Metoprolol is prescribed to control angina in a client with type 1 diabetes. The nurse should be aware that: metoprolol alters insulin requirements in previously stabilized clients. metoprolol should be administered 1 hour before or 1 hour after meals. tachycardia may develop if metoprolol is given with monoamine oxidase (MAO) inhibitors. metoprolol can be safely prescribed in breast-feeding women.
metoprolol alters insulin requirements in previously stabilized clients. Explanation: The nurse should be aware that metoprolol alters insulin requirements in previously stabilized clients. This drug should be administered with food to increase absorption. Bradycardia, not tachycardia, may develop if metoprolol is administered with MAO inhibitors. Metoprolol isn't recommended for breast-feeding women.
The nurse is working as part of multidisciplinary team in developing the plan of care for a premature neonate. Breast milk is being encouraged as part of the plan. The nurse understands that the use of breast milk for this neonate would help prevent which condition? necrotizing enterocolitis Turner syndrome Down syndrome hyaline membrane disease
necrotizing enterocolitis Components specific to breast milk have been shown to lower the incidence of necrotizing enterocolitis in premature neonates. Hyaline membrane disease isn't directly influenced by breast milk or breast-feeding. Down syndrome and Turner syndrome are genetic defects that aren't influenced by breast milk.
While in the emergency department, a client with C8 quadriplegia develops a blood pressure of 80/44 mm Hg, pulse of 48 beats/minute, and respiratory rate of 18 breaths/minute. The nurse suspects which condition? autonomic dysreflexia hemorrhagic shock neurogenic shock pulmonary embolism
neurogenic shock Explanation: Symptoms of neurogenic shock include hypotension, bradycardia, and warm, dry skin due to loss of adrenergic stimulation below the level of the lesion. Hypertension, bradycardia, flushing, and sweating of the skin are seen with autonomic dysreflexia. Hemorrhagic shock presents with anxiety, tachycardia, and hypotension; this wouldn't be suspected without an injury. Pulmonary embolism presents with chest pain, hypotension, hypoxemia, tachycardia, and hemoptysis; this may be a later complication of spinal cord injury due to immobility.
When assisting with development of a postoperative care plan for a client after gastric resection, which would be the priority? body image nutritional needs skin care spiritual needs
nutritional needs After gastric resection, a client may require total parenteral nutrition or jejunostomy tube feedings to maintain adequate nutritional status. Body image isn't much of a problem for this client because clothing can cover the incision site. Wound care of the incision site is necessary to prevent infection; otherwise, the skin shouldn't be affected. Spiritual needs may be a concern, depending on the client, and should be addressed as the client demonstrates readiness to share concerns.
A client hasn't voided since before surgery, which took place 8 hours ago. When collecting data on the client, the nurse should: be unable to palpate the bladder. feel that the bladder is smooth. palpate the bladder above the symphysis pubis. palpate the bladder at the umbilicus.
palpate the bladder above the symphysis pubis. Eight hours is a long time not to have voided. Typically, the kidneys produce 35 to 55 ml of urine in 1 hour. After 8 hours of not voiding, the bladder should be full of urine and palpable above the symphysis pubis. If the bladder isn't full after 8 hours, the client's kidneys may be malfunctioning or the client may be dehydrated.
A child is seeing the health care provider for bone and joint pain. Which other signs and symptoms may suggest leukemia? abdominal pain increased activity level increased appetite petechiae
petechiae The most common signs and symptoms of leukemia result from infiltration of the bone marrow. These include petechiae, fever, pallor, and joint pain with decreased activity level. Abdominal pain is caused by areas of inflammation from normal flora in the GI tract. Increased appetite can occur, but it usually isn't a presenting symptom.
A nurse is caring for a client with a chest tube. If the chest drainage system is inadvertently disconnected, what is the nurse's priority action? apply an occlusive dressing, and notify the health care provider immediately clamp the chest tube secure the chest tube with tape place the end of the chest tube in a container of sterile saline solution
place the end of the chest tube in a container of sterile saline solution
The nurse observes a client, who has left-sided paralysis from a stroke, dress independently. Which action by the client indicates proper technique for dressing the upper-extremities? buttons the shirt first before placing it on over the head puts the shirt over the head before pulling it onto the affected arm requests help because this activity is impossible to do independently places the affected arm in the shirt before the unaffected arm
places the affected arm in the shirt before the unaffected arm By placing the affected arm in the shirt first, the unaffected arm of the client who experienced a stroke and developed paralysis is free to pull the shirt around to the other side and put the other sleeve on. Pulling a buttoned shirt on over the head is difficult to do with only one arm. If the client uses proper techniques, becoming independent in upper-extremity dressing is possible.
A nurse is caring for a confused, older adult client. Which action should the nurse prioritize for this client's care? promoting safety by protecting from injury identifying the underlying cause of confusion monitoring for deteriorating of neurologic status. encouraging participation in activities of daily living (ADLs)
promoting safety by protecting from injury The nurse's first responsibility is always to protect the client from injury. Determining the cause of the confusion and protecting the older adult client's neurologic status from deterioration are the primary care provider's responsibilities. Encouraging the client to participate in ADLs is a nursing intervention, but it is not the most important consideration.
A client sustained a C6 spinal injury when diving into a shallow lake. What residual effect does the nurse expect to observe? aphasia hemiparesis paraplegia quadriplegia
quadriplegia Explanation: Quadriplegia occurs as a result of cervical spine injuries. Paraplegia occurs as a result of injury to the thoracic cord and below. Hemiparesis describes weakness of one side of the body. Aphasia refers to difficulty expressing or understanding spoken words.
A nurse working in the emergency department is caring for a 2-year-old child with a skull fracture. The parent states that the child rolled off the sofa, but the injuries do not match the story that the parents tell. Which of the following is the most appropriate action by the nurse? reporting suspected child abuse to appropriate agencies instructing parents in home safety precautions for toddlers asking the child if someone has hurt him/her instruct the parents in head injury care after discharge
reporting suspected child abuse to appropriate agencies The nurse should report suspected child abuse to the appropriate authorities. The incompatibility between the history and the injury, in this case, the skull fracture and rolling off the sofa, is the most important criterion on which to base the decision to report suspected child abuse. Nurses are mandated to report suspected child abuse, so the nurse must report the suspected abuse to the appropriate agencies. Personnel from the reporting agency will then follow up with the child/parent as appropriate. Instructing the parent on home safety for toddlers will not address the issue of child abuse.
A nurse is obtaining data from a child with left-sided heart failure. Which symptoms does the nurse correlate with the diagnosis? weight gain peripheral edema neck vein distention tachypnea and dyspnea
tachypnea and dyspnea Explanation: Respiratory symptoms, such as tachypnea and dyspnea, are seen due to pulmonary congestion. Weight gain, peripheral edema, and neck vein distention are seen with systemic venous congestion or right-sided failure. Fluid accumulates in the interstitial spaces due to blood pooling in the venous circulation.
A primigravid client, age 20, has just completed a difficult, forceps-assisted delivery of twins. Her labor was unusually long and required oxytocin augmentation. The nurse who's caring for her should stay alert for: uterine inversion. uterine atony. uterine involution. uterine discomfort.
uterine atony. Explanation: Multiple fetuses, extended labor stimulation with oxytocin, and traumatic delivery commonly are associated with uterine atony, which may lead to postpartum hemorrhage. Uterine inversion may precede or follow delivery and commonly results from apparent excessive traction on the umbilical cord and attempts to deliver the placenta manually. Uterine involution and some uterine discomfort are normal after delivery.
A client with peptic ulcer disease is prescribed aluminum-magnesium complex. When teaching about this antacid preparation, the nurse should instruct the client to take it with: fruit juice. water. a food rich in vitamin C. a food rich in vitamin D.
water. Water helps transport an antacid to the stomach. The client shouldn't take an antacid with fruit juice or a food rich in vitamins C or D because the antacid may impair absorption of important nutrients in the juice or food.
A nurse is caring for a client who underwent a nephrectomy. While gathering data about client's response to the surgery, the nurse should stay alert for which signs and symptoms of hemorrhage? cyanosis, nausea, vomiting, and constricted pupils weak, irregular pulse; cool, moist skin; and hypotension even, unlabored respirations; tachycardia; and hemoptysis restlessness, confusion, increased urine output, and warm, dry skin
weak, irregular pulse; cool, moist skin; and hypotension Explanation: A weak, irregular pulse; cool, moist skin; and hypotension are all signs of hemorrhage in a client who underwent a nephrectomy. Hemorrhage may also cause cyanosis, nausea, vomiting, and dilated (not constricted) pupils. Although hemorrhage produces tachycardia and hemoptysis, it usually results in irregular, labored respirations rather than even, unlabored ones. Hemorrhage also results in restlessness and confusion, along with decreased urine output and skin that is cool and moist.
When collecting data on a client who has just been admitted to the medical-surgical unit, the nurse discovers scabies. To prevent scabies infection in other clients, the nurse should: remove any observable mites. wear gloves when providing care and isolate the client's bed linens until the client is no longer infectious. apply a topical corticosteroid to the lesions. place the client on enteric precautions.
wear gloves when providing care and isolate the client's bed linens until the client is no longer infectious.