pass point pt 4

A nurse is caring for a client who is receiving spironolactone (Aldactone) to treat hypertension. Which instruction should the nurse give the client? "Choose foods high in potassium." "Take potassium supplements each day." "Discontinue sodium restrictions." "Avoid salt substitutes."

"Avoid salt substitutes." Explanation: Because spironolactone is a potassium-sparing diuretic, the client should be taught to avoid salt substitutes because they have high potassium contents. Foods high in potassium and potassium supplements should also be avoided. Sodium restrictions should continue to reduce fluid volume overload.

A nurse is caring for a client with non-Hodgkin's lymphoma. Which statement indicates that the client diagnosed with non-Hodgkin's lymphoma needs further reinforcement from the education plan? "I know this all started when I felt that lump in my underarm." "Lymph tissue is in the spleen and bone and marrow." "Lymph tissue keeps the immune system in working condition." "If I stay healthy and eat right, I can cure this disease."

"If I stay healthy and eat right, I can cure this disease." Explanation: Non-Hodgkin's lymphoma cannot be cured by staying healthy. Medical treatments are prescribed to stop the disease progression. A lump can indicate a swollen lymph gland and maybe a sign of lymphoma. Lymph tissue is in the spleen and bone marrow. Lymph tissue makes lymphocytes and other immune system cells.

The nurse is assessing the puncture site of a client who has received a purified protein derivative test. Which finding indicates a need for further evaluation? 3-mm induration Blister Reddened area 15-mm induration

15-mm induration Explanation: A 10-mm induration strongly suggests a positive response in this tuberculosis screening test; a 15-mm induration clearly requires further evaluation. The other options aren't positive reactions to the test and require no further evaluation.

A client is upset to learn that corticosteroids need to be taken to control symptoms of systemic lupus erythematosus (SLE). While the nurse is preparing to administer medication, the client refuses to take it, stating, "This is turning me into an old woman before my time." What is the best response by the nurse? Explain that the symptoms of the disease are chronic and progressive and much worse than the side effects from the drugs. Ask about the medication side effects that are a concern and explain why suddenly stopping the drug can cause problems. Document the refusal to take the medication and notify the physician. Encourage the client to take the medication until able to consult with her physician regarding the side effects.

Ask about the medication side effects that are a concern and explain why suddenly stopping the drug can cause problems. Explanation: It is important to explore the client's concerns regarding the side effects. As a follow-up, it is important to reinforce what is the desired effect of the drug. It is critical to explain the importance of not suddenly discontinuing its use. Explaining the symptoms of the disease does not identify the reasons for the client's concern. Encouraging the client to take the medication or documenting the refusal does not identify the concerns.

A client with acute pyelonephritis is prescribed co-trimoxazole. Which finding best demonstrates that the client has followed the prescribed regimen? The red blood cell (RBC) count is normal. Flank and abdominal discomfort decrease. Urine output increases to 2,000 ml/day. Bacteria are absent on urine culture.

Bacteria are absent on urine culture. Explanation: Co-trimoxazole is a sulfonamide antibiotic used to treat urinary tract infections. Therefore, absence of bacteria on urine culture indicates that the drug has achieved its desired effect. Although flank pain may decrease as the infection resolves, this isn't a reliable indicator of the drug's effectiveness. Co-trimoxazole doesn't affect urine output or the RBC count. Add a Note

The health care practitioner uses nitrazine paper to determine whether a pregnant client's membranes have ruptured. If the membranes are ruptured, the nurse expects the paper will turn which color? Pink Blue Yellow Green

Blue Explanation: Nitrazine paper turns blue on contact with alkaline substances such as amniotic fluid. Normal vaginal discharge and urine are acidic and cause nitrazine paper to turn pink.

A nurse arriving for duty notes that an unlicensed assistive personnel (UAP) has been assigned to a complex client with treatments involving sterile technique. What is the responsibility of the nurse regarding the assignment of the UAP? Reassign the UAP to a client requiring basic tasks that the UAP has mastered. Provide the UAP with a list of resources to guide the implementation of care. Make sure the UAP has practiced sterile technique on at least one other occasion. Supervise the UAP during the treatments involving sterile technique.

Reassign the UAP to a client requiring basic tasks that the UAP has mastered.

A client receiving total parental nutrition is prescribed a 24-hour urine test. The nurse delegates the collection of the specimen to the unlicensed assistive personnel (UAP). The nurse is aware that the UAP is collecting the specimen correctly when he or she initiates the collection in which instance? Start after a client's known voiding that empties the bladder Start after the client eats breakfast Start with the client's first voiding of the day Ends with the client's last evening's void as the last sample

Start after a client's known voiding that empties the bladder Explanation: When initiating a 24-hour urine specimen, have the client void, and then start timing. The collection should start on an empty bladder. The exact time the test starts isn't important, but it's commonly started in the morning.

A child with leukemia has just completed a course of methotrexate therapy. How soon should the nurse expect to see signs of bone marrow depression in this client? Within hours After induction therapy is completed Within 1 month Within 2 weeks

Within 2 weeks Explanation: Bone marrow depression is most likely to occur 10 days after methotrexate is administered. Remediation:

A client with interstitial lung disease is prescribed prednisone to control inflammation. During client teaching, the nurse stresses the importance of taking prednisone exactly as prescribed and cautions against discontinuing the drug abruptly. A client who discontinues prednisone abruptly may experience: acute adrenocortical insufficiency. restlessness and seizures. hyperglycemia and glycosuria. GI bleeding.

acute adrenocortical insufficiency. Explanation: Administration of a corticosteroid such as prednisone suppresses the body's natural cortisol secretion, which may take weeks or months to normalize after drug discontinuation. Abruptly discontinuing such therapy may cause the serum cortisol level to drop low enough to trigger acute adrenocortical insufficiency. Hyperglycemia, glycosuria, GI bleeding, restlessness, and seizures are common adverse effects of corticosteroid therapy, not its sudden cessation.

A client with left-sided heart failure reports of increasing shortness of breath and is agitated and coughing up pink-tinged, foamy sputum. The nurse should recognize these as signs and symptoms of: right-sided heart failure. cardiogenic shock. acute pulmonary edema. pneumonia.

acute pulmonary edema. Explanation: Because of decreased contractility and increased fluid volume and pressure in clients with heart failure, fluid may be driven from the pulmonary capillary beds into the alveoli, causing pulmonary edema. In right-sided heart failure, the client would exhibit hepatomegaly, jugular vein distention, and peripheral edema. In pneumonia, the client would have a temperature spike and sputum that varies in color. Cardiogenic shock would show signs of hypotension and tachycardia.

Clients diagnosed with a chronic illness exhibit a general pattern of adaptation. What are the stages of the pattern of adaptation? Select all that apply. retrospective thinking exhaustion alarm awareness resistance

alarm exhaustion resistance Explanation: The three stages are alarm, resistance, and exhaustion. The remaining answers are incorrect.

Which client is at the greatest risk for developing sensory overload? a 28-year-old pregnant client reporting nausea and fatigue an 80-year-old client in the intensive care unit (ICU) a 4-year-old in a clinic for routine immunizations a 72-year-old client having dressings changed

an 80-year-old client in the intensive care unit (ICU) Explanation: Sensory overload is a condition in which the central nervous system receives much more auditory, visual, or other environmental stimuli than can be processed effectively. Because of the monitors, beeping sounds, lights, and constant activity in the ICU, an 80-year-old is most at risk for sensory overload. The pregnant client is experiencing symptoms that are not related to environmental stimuli. The 4-year-old receiving immunizations and the 72-year-old client having dressings changed are dealing with less overwhelming stimuli.

A client had a nephrectomy 2 days ago and is now complaining of abdominal pressure and nausea. The first nursing action should be to: palpate the abdomen. change the client's position. auscultate bowel sounds. insert a rectal tube.

auscultate bowel sounds. Explanation: If abdominal distention is accompanied by nausea, the nurse must first auscultate bowel sounds. If bowel sounds are absent, the nurse should suspect gastric or small intestine dilation and these findings must be reported to the physician. Palpation should be avoided postoperatively with abdominal distention. If peristalsis is absent, changing positions and inserting a rectal tube won't relieve the client's discomfort.

While obtaining data from a client, the nurse observes that the client has been prescribed tadalafil. What should the nurse carefully monitor for this client? temperature urine output blood pressure urine specific gravity

blood pressure Explanation: When a client is receiving tadalafil, the nurse should monitor the client's blood pressure carefully because this drug causes hypotension.

A client with pulmonary edema is receiving furosemide. To determine the effectiveness of this diuretic, what data should the nurse obtain? heart sounds breath sounds bowel sounds neurovascular status

breath sounds Explanation: Because a diuretic is prescribed to reduce pulmonary congestion, the nurse can evaluate its effectiveness by auscultating the lungs of a client with pulmonary edema, which should show clearing of adventitious breath sounds. Heart sounds are important but are not the indicator. Bowel sound auscultation is important in a client with paralytic ileus or another diuretic effectiveness for the treatment of pulmonary edema. Neurological status is not affected by pulmonary edema or furosemide therapy, so it does not need to be evaluated. Neurovascular checks evaluate cerebrovascular function, rather than respiratory function, which is the client's immediate problem.

The nurse cares for a client on the first postoperative day after repair of an abdominal aortic aneurysm. Which finding requires additional collaboration with the RN? cool, pink extremities reports of nausea tenderness at the incision site decreased urine output

decreased urine output Explanation: Indicators of blood loss following surgical repair of an abdominal aortic aneurysm include a drop in BP, urine output, an increased heart rate, and changes in mental status. Although peripheral tissue perfusion is a major concern in the postoperative period after an abdominal aortic aneurysm repair, the client's extremities are cool but pink. Peripheral pulses should be checked frequently during the first 24 hours, and a weak or absent pulse may be a sign of embolization or graft closure, especially if accompanied by a pale, cold, mottled extremity; the nurse should immediately report this finding to the surgeon. Nausea and tenderness at the incision site are expected findings.

A nurse is caring for a child with juvenile arthritis (JA) who has oral prednisone prescribed. The nurse knows that the drug will be given at the lowest possible dosage and for the shortest period of time in order to avoid which adverse effects? growth retardation and increased risk of infection hypoglycemia and hypovolemia fibrotic skin changes and increased muscle mass deafness and severe weight loss

growth retardation and increased risk of infection Explanation: Long-term prednisone use is associated with poor growth and immunosuppression; it may aggravate or mask serious infections. Prednisone is associated with weight gain and cataract formation, but not deafness. It may cause hyperglycemia, significant sodium and fluid retention, edema, and heart failure. Long-term use of prednisone may cause muscle wasting, weakness, and thin, fragile skin.

When gathering data from a client admitted with hypertension, the nurse should expect the client to report which symptom? epistaxis peripheral edema blurred vision headache

headache Explanation: An occipital headache is typical of hypertension owing to increased pressure in the cerebral vasculature. Blurred vision (due to arteriolar changes in the eye) and epistaxis (nosebleed) are far less common than headache, but can also be diagnostic signs. Peripheral edema can occur from an increase in sodium and water retention, but it's usually a latent sign.

A nurse is observing an infant with thyroid hormone deficiency. Which signs would the nurse commonly observe? dermatitis, dry skin, and round face tachycardia, profuse perspiration, and diarrhea hypertonia, small fontanels, and moist skin lethargy, feeding difficulties, and constipation

lethargy, feeding difficulties, and constipation Explanation: Hypothyroidism results from inadequate thyroid production to meet an infant's needs. Clinical signs include feeding difficulties, prolonged physiologic jaundice, lethargy, and constipation.

The nursing instructor is working with a student in a preoperative unit. The student notices that the informed consent has not been signed. Which is the best action taken by the student nurse for obtaining informed consent? asking the primary nurse to get the informed consent notifying the social worker notifying the physician involved with the procedure that the consent has not been signed asking the nurse working with the physician to get the informed consent

notifying the physician involved with the procedure that the consent has not been signed Explanation: The physician involved with the procedure is responsible for obtaining the client's informed consent. The primary nurse or the nurse working with the physician may witness the client's signature. The social worker may not obtain informed consent.

A client with bacterial meningitis is admitted to the inpatient unit. Which infection control measure should the nurse be prepared to use? strict hand washing respiratory isolation standard precautions reverse isolation

respiratory isolation Explanation: Because bacterial meningitis is transmitted by droplets from the nasopharynx, the nurse should prepare to use respiratory isolation. This type of isolation involves wearing a gown and gloves during direct client care and ensuring that everyone who enters the client's room wears a mask. Reverse isolation is unnecessary because it's used for immunosuppressed clients who are at high risk for acquiring infection. Strict hand washing and standard precautions are insufficient for this client because they don't require the use of a mask.

A client has just had a myocardial infarction (MI) and the nurse is preparing to administer morphine. What is the primary reason for administering morphine to this client? to sedate the client to decrease oxygen demand on the client's heart to decrease the client's anxiety to decrease the client's pain

to decrease the client's pain Explanation: Morphine is administered as analgesia because chest pain stimulates the sympathetic nervous system, leading to an increase in heart rate and vasoconstriction. In addition, morphine will reduce anxiety and the workload of the heart. However, the primary indication to administer morphine is to relieve chest pain.

A school-age child with fever and joint pain has just received a diagnosis of rheumatic fever. The child's parents ask a nurse if anything can be done to prevent the other children in the family from developing rheumatic fever. What is the best response by the nurse? "Be sure the other children are fully immunized against hepatitis B." "The other children should not be exposed to your child with rheumatic fever for at least two weeks." "The children have already been exposed, so they will all probably develop rheumatic fever." "Be sure that if any of the children have strep throat or scarlet fever they are properly treated with antibiotics."

"Be sure that if any of the children have strep throat or scarlet fever they are properly treated with antibiotics." Explanation: Rheumatic fever is a systemic inflammatory disease that follows a group A streptococcal infection. Therefore, early detection and treatment of streptococcal infections helps prevent the development of rheumatic fever. Hepatitis B vaccine provides immunity against the hepatitis B virus, not streptococci. Because rheumatic fever is not contagious, isolation measures are not necessary.

A nurse is reinforcing education for a client about the use of sublingual nitroglycerin. Which statement indicates the client understands the education plan? "I must swallow the tablet whole without chewing." "I should take a tablet 45 minutes before any strenuous activity." "I'll keep the nitroglycerin in its original dark, airtight container." "I'll take a tablet every 5 minutes until my chest pain stops."

"I'll keep the nitroglycerin in its original dark, airtight container." Explanation: To maintain potency, nitroglycerin should be kept in its original dark, airtight container. Sublingual nitroglycerin tablets should be placed under the tongue and allowed to dissolve; they should not be chewed or swallowed. Tablets can be placed under the tongue about 5 to 10 minutes before an activity known to cause angina. If angina occurs, one tablet should be placed under the tongue every 5 minutes until pain is relieved, up to a total of three tablets in 15 minutes. If the angina still is not relieved, the client should seek immediate medical attention.

To evaluate a client's chief concern, the nurse performs deep palpation to a client's abdomen. The client states, "Why are you pushing on my stomach?" Which statement by the nurse is best? "It helps evaluate hydration status." "It assists in determining skin turgor." "It helps detect resonance, which indicates air." "It shows me the position of your organs."

"It shows me the position of your organs." Explanation: The purpose of deep palpation, in which the nurse indents the client's skin approximately 1½" (4 cm), is to assess underlying organs and structures, such as the kidneys and spleen. Skin turgor and hydration can be assessed by using light touch or light palpation. Resonance is heard when sharply tapping the fingers against the body's surface and is associated with percussion, not deep palpation.

Which statement by a caregiver indicates that a 10 month old is at high risk for iron deficiency anemia? "The baby likes egg yolk in his cereal." "The baby is sleeping through the night without a bottle." "The baby likes all vegetables except carrots." "The baby drinks about five 8-oz bottles of milk per day."

"The baby drinks about five 8-oz bottles of milk per day." Explanation: The recommended intake of milk, which doesn't contain iron, is 24 oz per day; 40 oz per day exceeds the recommended allotment and may reduce iron intake from solid food sources, risking iron deficiency anemia. Sleeping through the night without a bottle is an anticipated behavior at this age. Egg yolk is a good source of iron and would minimize any risk factor related to nutritional anemia. Because only dark-green vegetables are good sources of iron, a dislike of carrots wouldn't be significant for this client.

The recipient of a donated organ asks the nurse, "What did the donor die from?" Which response by the nurse is most appropriate? "Did you want to send the donor family a thank you card?" "I will have the surgeon speak with you." "Contact between the donor and the recipient is prohibited." "The transplant coordinator can give you information about the donor's medical history."

"The transplant coordinator can give you information about the donor's medical history." Explanation: Confidentiality of the potential donor is always maintained unless the recipient and donor families both sign confidentiality waivers; however, medical history, such as history or hepatitis or HIV infection, is permitted. The transplant coordinator is the liaison for information regarding the donor.

An adolescent admitted with a fractured femur had an open reduction and internal fixation two days ago and is currently in traction and asks the nurse what would happen if a terrorist decided to bomb the hospital. What's the nurse's best response? "I wouldn't worry about that. Spend your energy on getting well and going home." "We have plans to call your parents and take care of you if there's a problem." "What do you think might happen if terrorists attacked?" "That's silly thinking. Why would anyone bomb a hospital?"

"What do you think might happen if terrorists attacked?" Explanation: Something prompted the child to ask such a question, and the nurse needs to take advantage of this opportunity to further explore his concerns and fears. Telling the child to concentrate on getting well discounts the boy's feelings and may actually increase his anxiety. Telling the boy that his parents would be called doesn't provide reassurance or help build a therapeutic relationship that can promote health and wellness. Telling the child his thinking is silly is dismissive and chides the boy for asking the question.

The nurse is caring for a client with pernicious anemia. Which question by the nurse explains the potential source of the anemia? "Did you have any surgery on your bladder?" "What type of diet do you follow?" "Do you have any changes in your vision?" "Have you added any new medications to your routine?

"What type of diet do you follow?" Explanation: The use of a vegan diet can lead to pernicious anemia from not eating foods such as meat, poultry, shellfish, eggs, and dairy products that maintain B12 levels. Bladder surgery will not cause B12 absorption problems. Visual changes and medications have not been related to pernicious anemia.

The nurse is caring for a client suspected of having a hydatidiform mole. Which signs and symptoms would confirm this diagnosis? heavy, bright-red bleeding every 21 days fetal cardiac motion after 6 weeks' gestation benign tumors found in the smooth muscle of the uterus "snowstorm" pattern on ultrasound with no fetus or gestational sac

"snowstorm" pattern on ultrasound with no fetus or gestational sac Explanation: Ultrasound is the technique of choice in diagnosing a hydatidiform mole. The chorionic villi of a molar pregnancy resemble a "snowstorm" pattern on ultrasound. Bleeding with a hydatidiform mole is usually dark brown and may occur erratically for weeks or months. There is no cardiac activity because there is no fetus. Benign tumors found in the smooth muscle of the uterus are leiomyomas or fibroids.

A client has been admitted to the hospital for treatment of kidney stones. The client asks the nurse where the Atkins diet items are on the menu. What is the nurse's understanding of the diagnosis and diet? A diet high in protein may strain the kidney function. A diet high in carbohydrates may increase insulin production. A diet low in fruits promotes higher glycemic control. A diet low in fat reduces cholesterol.

A diet high in protein may strain the kidney function. Explanation: High-protein, low-carbohydrate diets like the Atkins diet have been widely promoted as effective weight loss plans. The diet also allows for a high fat intake. The complications associated with this diet include high cholesterol, kidney problems, and osteoporosis.

For which rationale, when administering a Z-track injection, the nurse measures the correct medication dose and then draws a small amount of air into the syringe? Adding air decreases pain caused by the injection. Adding air prevents the drug from flowing back into the needle track. Adding air prevents the solution from entering a blood vessel. Adding air ensures that the client receives the entire dose.

Adding air prevents the drug from flowing back into the needle track. Explanation: The added air flushes the drug from the syringe, ensuring that the drug goes into the muscle tissue, and preventing it from flowing back into the needle track, which could cause skin staining. Adding air doesn't decrease pain (which results from the drug's chemical composition), and it has no bearing on whether the drug enters a blood vessel. Adding air isn't necessary to ensure that the client receives the entire dose.

A client reports muscle weakness, anorexia, and darkening of the skin. The nurse reviews laboratory data and notes findings of low serum sodium and high serum potassium levels. The nurse recognizes these signs and symptoms as associated with which condition? Cushing syndrome thyrotoxic crisis Addison's disease diabetes insipidus

Addison's disease Explanation: The clinical picture of Addison's disease includes muscle weakness, anorexia, darkening of the skin's pigmentation, low sodium level, and high potassium level. Cushing syndrome involves obesity, "buffalo hump," ""moon face"," and thin extremities. Symptoms of diabetes insipidus include excretion of large volumes of dilute urine. Thyrotoxic crisis can occur with severe hyperthyroidism.

During dinner a client suddenly begins to cough heavily, have deep inspirations, and grasp the throat. What is the nurse's immediate action? Start rescue breathing. Begin chest compressions. Perform the Heimlich maneuver. Ask the client if they can speak.

Ask the client if they can speak. Explanation: When a person chokes, if alert enough to be attempting to cough and force the obstruction up and out , it is best to let them do it alone, because there is more expelling force that way. Only when the person is not able to breathe beyond the obstruction should the Heimlich maneuver be performed. The nurse should continue to determine adequate air exchange by asking if they can speak until the client has cleared the obstruction.

When drawing up a medication, the nurse notes there are small air bubbles adhering to the interior surface of the syringe. The nurse knows which effect the bubbles might have on parenteral administration? Altered onset of action Altered duration Altered drug absorption Altered drug dose

Altered drug dose Explanation: Although not harmful to the client when injected, small air bubbles can change the dose of medication actually administered; therefore, the nurse should remove the air bubbles. The drug's onset of action, duration, and absorption won't be affected. Air bubbles may actually be helpful in some situations but should be added only after the dose of the drug has been withdrawn accurately. For example, with iron dextran, an air bubble and the Z-track method of injection help prevent permanent staining of the client's skin if the solution leaks into the subcutaneous tissue.

The parent of a 2-year-old child with epiglottitis states she has to leave to pick up another child from school. The 2-year-old child begins to cry with stridor. Which intervention by the nurse is best? Tell the 2-year-old that the nurse will stay. Ask the parent if someone else can pick up the older child. Tell the 2-year-old everything will be all right. Ask the parent how long she may be gone.

Ask the parent if someone else can pick up the older child.

An older adult client has a history of aortic valve stenosis. Identify the area where the nurse should place the stethoscope to best hear the murmur.

Aortic stenosis is heard best in the second intercostal space, to the right of the sternum. Aortic stenosis occurs from a constriction that restricts blood flow through the heart and causes the left ventricle to enlarge. This enlargement can lead to heart failure and the development of life-threatening irregular heartbeats. The murmur of aortic stenosis is low-pitched, rough, and rasping.

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 Family inquiry about the client's discharge time 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

Apical pulse rate of 90 beats/minute with a radial pulse rate of 70 beats/minute Explanation: 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 2-year-old returns from surgery after a bowel resection as a result of Hirschsprung disease. A temporary colostomy is in place. Which immediate postoperative nursing intervention would have priority? Irrigate the colostomy with 100 mL of normal saline solution. Auscultate lung sounds. Suction the nasopharynx frequently to remove secretions. Change the surgical dressing

Auscultate lung sounds. Explanation: The immediate nursing intervention after bowel resection surgery is to evaluate pulmonary function. The surgical dressing should not require changing right away. Suctioning should be performed only if the client cannot maintain a patent airway. Colostomy irrigation is not warranted.

A child with a Wilms tumor has had surgery to remove a kidney and has received chemotherapy. The nurse should include which instructions at discharge? Avoid contact with other children. Avoid contact sports. Decrease sodium intake. Decrease fluid intake.

Avoid contact sports. Explanation: Because the child is left with only one kidney, certain precautions, such as avoiding contact sports, are recommended to prevent injury to the remaining kidney. Decreasing fluid intake is not indicated; fluid intake is essential for renal function. The child's sodium intake should not be reduced. Avoiding other children is unnecessary, will make the child feel self-conscious, and may lead to regressive behavior.

The nurse is aware that Standard Precautions represent the first tier of Centers for Disease Control guidelines for isolation precautions. Which is the nurse's primary responsibility when following Standard Precautions? Wear gloves for all contact with the client. Consider all body substances potentially infectious. Place a body substance isolation sign on the client's door. Wear gloves and a gown whenever caring for the client.

Consider all body substances potentially infectious. Explanation: Standard precautions are based on the concept that all body substances are potentially infectious and direct contact with them must be avoided. The nurse should wear gloves when contact with body substances — not unsoiled articles or intact skin — is anticipated. Because all body substances from all clients are considered potentially infectious, signs on doors are unnecessary. Gloves and gowns are necessary only when contact with body fluids is likely.

A nurse is caring for a morbidly obese client who has undergone surgery for weight loss. The client reports pain 8/10 despite morphine sulfate 1 mg/hour continuous infusion being administered via a patient-controlled analgesia (PCA) pump. Which action will best protect the nurse from issues of liability? Provide the client with nonpharmacologic means of pain control Explain to the client that pain is expected with weight loss surgery Add morphine sulfate 1 mg/8 min IV as a client-administered dose to the continuous infusion Contact the health care provider with a request for a change in PCA

Contact the health care provider with a request for a change in PCA Explanation: State Boards of Nursing and the provincial or territorial nursing regulatory bodies set acceptable standards for nursing for a particular state or Canadian province or territory. Practicing within those guidelines will protect the nurse from liability. A nurse has a legal responsibility to address and manage a client's pain. The nurse would recognize that morphine 1 mg/hour continuous intravenous infusion may not provide adequate pain control in a morbidly obese client. The best option to avoid liability issues regarding pain control would be to contact the health care provider to request a change in analgesia for this client. Offering nonpharmacologic means of pain control is appropriate, but fails to address the need for a change in PCA. Adding a self-administered dose of morphine sulfate via PCA without a health care provider prescription would be outside the scope of practice for a registered nurse. Explaining to the client that pain is to be expected does nothing to meet the legal responsibility the nurse has to manage a client's pain and increases a nurse's risk of liability.

A client must take streptomycin for tuberculosis. Before therapy begins, the nurse should instruct the client to notify the physician if which health concern occurs? Increased appetite Impaired color discrimination Decreased hearing acuity Increased urinary frequency

Decreased hearing acuity Decreased hearing acuity indicates ototoxicity, a serious adverse effect of streptomycin therapy. The client should notify the physician immediately if it occurs so that streptomycin can be discontinued and an alternative drug can be prescribed. The other options aren't associated with streptomycin. Impaired color discrimination indicates color blindness; increased urinary frequency and increased appetite accompany diabetes mellitus.

The nurse is assisting with the development of a plan of care for a client with generalized anxiety disorder (GAD). Which intervention is important to include? Encourage the client to engage in activities that increase feelings of power and self-esteem. Promote the client's interaction and socialization with others. Assist the client to make plans for regular periods of leisure time. Encourage the client to use a diary to record when anxiety occurred, its cause, and which interventions may have helped.

Encourage the client to use a diary to record when anxiety occurred, its cause, and which interventions may have helped. Explanation: One of the nurse's goals is to help the client with generalized anxiety disorder associate symptoms with an event, thereby beginning to learn appropriate ways to eliminate or reduce distress. A diary can be a beneficial tool for this purpose. Although encouraging the client to engage in activities that increase feelings of power and self-esteem; promoting interaction and socialization with others; and assisting the client to make plans for regular periods of leisure time may be appropriate, they are not the priority.

The nurse is caring for a woman receiving a lumbar epidural anesthetic block to control labor pain. What should the nurse do to prevent hypotension? Administer ephedrine to raise her blood pressure. Administer oxygen using a mask. Place the woman flat on her back with her legs raised. Ensure adequate I.V. hydration according to the physician's order before the anesthetic is administered.

Ensure adequate I.V. hydration according to the physician's order before the anesthetic is administered. Explanation: Because the woman is in a state of relative hypovolemia, administering fluids I.V. before the epidural anesthetic is given may prevent hypotension. Administration of an epidural anesthetic may lead to hypotension because blocking the sympathetic fibers in the epidural space reduces peripheral resistance. Ephedrine may be administered after an epidural block if a woman becomes hypotensive and shows evidence of cardiovascular decompensation. However, ephedrine isn't administered to prevent hypotension. Oxygen is administered to a woman who becomes hypotensive, but it won't prevent hypotension. Placing a pregnant woman in the supine position can contribute to hypotension because of uterine pressure on the great vessels.

A client with benign prostatic hyperplasia (BPH) does not respond to medical treatment and is admitted to the facility for surgical intervention, transurethral resection of the prostate (TURP). In the postoperative period, the nurse reviews the laboratory values for which potential electrolyte imbalance? Hyponatremia Ketonuria Hypocalcemia Leukopenia

Hyponatremia Explanation: Due to the large amount of bladder irrigation, the fluid may be retained by the tissues, causing fluid overload, hypertension, and hyponatremia. The laboratory values are observed for high white blood cell count, not leukopenia. The client should not experience ketonuria or hypocalcemia.

A nurse is teaching family members of a client with hepatitis A (HAV). The family members were exposed to the client and, therefore, should receive immunoglobulin (Ig). What should the nurse tell the family members about Ig? Ig provides immunity to HAV for life. Ig prevents HAV infection in all people. Ig should be administered even if the client has anti-HAV antibodies. Ig must be administered within 2 weeks of exposure.

Ig must be administered within 2 weeks of exposure.

The nurse is performing vital signs on a client. What should the nurse do to avoid recording an erroneously low systolic blood pressure because of failure to recognize an auscultatory gap? Inflate the cuff to at least 200 mm Hg. Take blood pressure readings in both arms. Inflate the cuff at least another 30 mm Hg after the radial pulse becomes impalpable. Have the client lie down while taking his or her blood pressure.

Inflate the cuff at least another 30 mm Hg after the radial pulse becomes impalpable. Explanation: The nurse should wrap an appropriately sized cuff around the client's upper arm and then place the diaphragm of the stethoscope over the brachial artery. The nurse should then rapidly inflate the cuff until she can no longer palpate or auscultate the pulse and continue inflating until the pressure rises another 30 mm Hg. The other options aren't appropriate measures.

A client with metastatic brain cancer is admitted to the oncology floor. According to the Patient Self-Determination Act of 1991 (PSDA), what is the hospital required to do concerning the execution of advance directives? Decide on a treatment plan if the client cannot. Inform the client or legal guardian of the right to execute an advance directive. Respect individuals' moral rights. Advise clients not to execute an advance directive because it limits treatment options.

Inform the client or legal guardian of the right to execute an advance directive. Explanation: The PSDA of 1991 requires all health care facilities to notify clients upon admission of their right to execute an advance directive. The facility's ethics committee can decide on a treatment plan if the client is unable to do so, and if a durable power of attorney has not been appointed. Hospitals are not required by law to respect individuals' moral rights; however, health care professionals should do so as part of their professional responsibility. Health care professionals are sometimes concerned that advance directives prevent treatment that might help the client. However, the hospital should not advise clients not to execute an advance directive.

Which of the following would be appropriate for a client with arterial blood gas (ABG) values of pH 7.5, PaCO2 26 mm Hg, O2 saturation 96%, HCO3- 24 mEq/L, and PaO2 94 mm Hg? Offer the client fluids frequently. Administer a prescribed decongestant. Instruct the client to breathe into a paper bag. Administer prescribed supplemental oxygen.

Instruct the client to breathe into a paper bag. Explanation: The ABG results reveal respiratory alkalosis. The best intervention to raise the PaCO2 level would be to have the client breathe into a paper bag. All of the other options — such as administering a decongestant, offering fluids frequently, and administering supplemental oxygen — wouldn't raise the lowered PaCO2 level.

A client with lung cancer has developed an intractable, nonproductive cough that is unrelieved by nonopioid antitussive agents. The physician prescribes codeine, 10 mg by mouth every 4 hours. When discussing this medication with a nursing colleague, which statement that accurately describes codeine will the nurse include? It is a centrally acting antitussive and does not cause dependence. It is a peripherally acting antitussive and can cause dependence. It is a peripherally acting antitussive and does not cause dependence. It is a centrally acting antitussive and can cause dependence.

It is a centrally acting antitussive and can cause dependence. Explanation: As a centrally acting antitussive, codeine suppresses the cough reflex by directly affecting the sensitivity of the cough center in the medulla to incoming stimuli. Because codeine is an opioid, it can cause dependence.

A nurse provides care for a client who developed hives after having an allergic reaction to strawberries. Which finding indicates to the nurse that the client has experienced improvement of symptoms? Itching is relieved. Erythema decreases. The rash improves. The pain of the rash subsides.

Itching is relieved. Explanation: Urticaria (hives) causes wheals surrounded by redness, swelling, and severe itching. When the client obtains relief from urticarial (blocking the histamine response), the symptoms, including itching, subside. Treatment will help to improve the rash, redness, and skin irritation that are signs of an allergic reaction. Symptoms are subjective findings reported by the client.

A parent brings a child to the emergency department after the child ingested a poisonous hydrocarbon. What is a priority nursing action? Induce vomiting. Keep the child calm and relaxed. Scold the child for the wrongdoing. Keep the parents away from the child.

Keep the child calm and relaxed. Explanation: Keeping the child calm and relaxed will help prevent vomiting in a child who has ingested poisonous hydrocarbons. If vomiting occurs, there's a great chance the esophagus will be damaged from regurgitation of the gastric poison. Additionally, the risk of chemical pneumonitis exists if vomiting occurs. Scolding may upset the child. The parents should remain with the child to help keep the child calm.

A male client is receiving digoxin and furosemide to treat heart failure. He reports feeling weak and having muscle cramps. His apical pulse is 76 beats/minute; respirations, 16 breaths/minute; and blood pressure, 148/86 mm Hg. What action should the nurse take? Tell the client that he's probably weak from inactivity. Look at the chart for his last potassium level and contact the physician. Look at the chart for his last digoxin level and notify the physician. Notify the physician that the client is experiencing heart failure.

Look at the chart for his last potassium level and contact the physician. Explanation: Muscle weakness and cramping are signs of hypokalemia, which can be an adverse effect of furosemide. If the nurse doesn't follow up on his complaints, the client's hypokalemia will worsen. The client isn't exhibiting symptoms indicative of digoxin toxicity or heart failure, so there's no need to notify the physician.

An infant is hospitalized for treatment of nonorganic failure to thrive. Which nursing action is most appropriate for this child? Encouraging the infant to hold a bottle Maintaining a consistent, structured environment Keeping the infant on bed rest to conserve energy Rotating caregivers to provide more stimulation

Maintaining a consistent, structured environment Explanation: The nurse caring for an infant with nonorganic failure to thrive should strive to maintain a consistent, structured environment. Encouraging the infant to hold a bottle would reinforce an uncaring feeding environment. The infant should receive social stimulation rather than be confined to bed rest. The number of caregivers should be minimized to promote consistency of care.

A client with chronic obstructive pulmonary disease (COPD) is intubated and placed on continuous mechanical ventilation. Which equipment is most important for the nurse to keep at this client's bedside? Tracheostomy cleaning kit Manual resuscitation bag Oxygen analyzer Water-seal chest drainage set-up

Manual resuscitation bag Explanation: The client with COPD depends on mechanical ventilation for adequate tissue oxygenation. The nurse must keep a manual resuscitation bag at the bedside to ventilate and oxygenate the client in case the mechanical ventilator malfunctions. Because the client doesn't have chest tubes or a tracheostomy, keeping a water-seal chest drainage set-up or a tracheostomy cleaning kit at the bedside isn't necessary. Although the nurse may keep an oxygen analyzer (pulse oximeter) on hand to evaluate the effectiveness of ventilation, this equipment is less important than the manual resuscitation bag.

A client in the emergency department is diagnosed with a communicable disease. When complications of the disease are discovered, the client is admitted to the hospital and placed in respiratory isolation. Which infection warrants respiratory isolation? Cholera Measles Chickenpox Impetigo

Measles Explanation: Measles warrants respiratory isolation, which aims to prevent disease transmission primarily over short distances through the air (droplet transmission). Other infections necessitating respiratory isolation include epiglottitis or pneumonia caused by Haemophilus influenzae, erythema infectiosum, meningitis caused by H. influenzae or meningococci, meningococcal pneumonia, meningococcemia, mumps, and pertussis. Chickenpox calls for strict isolation; impetigo, contact isolation; and cholera, enteric isolation.

A client with amebiasis, an intestinal infection, is prescribed metronidazole. The nurse is providing information about adverse reactions of this drug. Which information should the nurse include in his or her teaching plan? Metallic taste Tinnitus Blurred vision Loss of smell

Metallic taste Explanation: Metronidazole commonly causes a metallic taste. Other adverse reactions include nausea, anorexia, headache, and dry mouth. The drug isn't associated with tinnitus, blurred vision, or loss of smell.

While examining a client's leg, the nurse notes an open ulceration with visible granulation tissue in the wound. Until a wound specialist can be contacted, which type of dressings is most appropriate for the nurse to apply? Sterile petroleum gauze Moist sterile saline gauze Dry sterile dressing Povidone-iodine-soaked gauze

Moist sterile saline gauze Explanation: Sterile saline dressings are the most appropriate choice, as they support wound healing and are cost-effective. Dry sterile dressings adhere to the wound and debride the tissue when removed, whereas saline helps keep the area moist. Petroleum supports healing but is expensive. Povidone-iodine is used as an antiseptic cleaning agent; however, it can irritate epithelial cells and is contraindicated for use on an open wound.

A nurse is caring for a postoperative thyroidectomy client at risk for hypocalcemia. What intervention should the nurse implement in this client's care? Observe for swelling of the neck, tracheal deviation, and severe pain. Evaluate the quality of the client's voice postoperatively, noting any drastic changes. Monitor laboratory values daily for an elevated thyroid-stimulating hormone. Observe for muscle twitching and numbness or tingling of the lips, fingers, and toes.

Observe for muscle twitching and numbness or tingling of the lips, fingers, and toes. Explanation: Muscle twitching and numbness or tingling of the lips, fingers, and toes are signs of hyperirritability of the nervous system caused by hypocalcemia. The other options describe complications for which the nurse should also be observing; however, tetany and neurologic alterations are primary indications of hypocalcemia.

The nurse would explain to the parents of a newborn with a cleft lip and palate that they will need to schedule an appointment with which specialist? Nutritionist Otolaryngologist Neurologist Cardiologist

Otolaryngologist Explanation: An appointment with an otolaryngologist is important because ear infections are common in the neonate with a cleft lip and palate, along with hearing loss. Brain and cardiac function are usually normal. A nutritionist is not needed unless the neonate becomes malnourished.

When reviewing a client's file, the nurse reviews the following medication order "Vitamin K 10 mg intramuscular (I.M.) daily × 3 days?" The nurse recognizes this as which type of order? Single order Stat order Standing order Standard written order

Standard written order Explanation: This is a standard written order. Prescribers write a single order for medications given only once. A stat order is written for medications given immediately for an urgent client problem. A standing order, also known as a protocol, establishes guidelines for treating a particular disease or set of symptoms in special care areas such as the coronary care unit. Facilities also may institute medication protocols that specifically designate drugs that a nurse may not give.

A client returns to the client care area after undergoing abdominal surgery. As the nurse inspects the client's dressing, she notes that it's completely saturated with bright-red blood. Which action should the nurse take? Remove the saturated dressing and re-dress the surgical site with sterile dressings. Immediately obtain the client's vital signs and then change the dressing. Reinforce the dressing and continue to monitor the client. Reinforce the dressing and contact the physician.

Reinforce the dressing and contact the physician. Explanation: The nurse should reinforce the dressing and notify the physician. A saturated dressing might signal postoperative hemorrhage. Continuing to monitor the client without notifying the physician delays treatment. The nurse should also monitor the client's vital signs. The first postoperative dressing should be changed by the physician, not the nurse. Remediation:

A nurse observes that an alternate personality (a child) of an adult client with dissociative identity disorder (DID) is in control. The client is sitting in the dayroom, interacting with others. Which action would be most appropriate? Ask to speak to one of the adult alter personalities of the host personality. Remove the client from the dayroom and allow the client to play with toys. Remove the client from the dayroom and reorient in a safe place. Forcibly remove the client to prevent interaction with clients in the dayroom.

Remove the client from the dayroom and reorient in a safe place. Explanation: Removing the client forcibly is assault and the client is doing nothing to warrant removal at this time. Reorienting the client discourages dissociation and encourages integration. Asking to speak to an alter personality encourages dissociation. Allowing the client to play with toys would reinforce this behavior and encourage dissociation.

A client states, "I'd feel so much better if I could just sleep!" What method to promote sleep can the nurse reinforce to the client? Take sleeping pills to help with falling asleep. Perform exercises before bed to help with relaxation. Resist napping during the day. Drink a glass of wine before going to bed.

Resist napping during the day. Explanation: Napping during the day can cause difficulty sleeping at night. Alcoholic beverages promote sleep initially but interfere with normal, rapid eye movement sleep, causing early wakening. Regular exercise helps with sleep, but exercise needs to be done early in the day. Exercising late in the evening can cause sleep disturbances. Sleeping pills, even over-the-counter medications, should never be taken unless prescribed or recommended by a physician.

The nurse is caring for a child with symptomatic aortic stenosis. Which instruction should be provided to the child and parents. Avoid prostaglandin E1. Allow the child to exercise freely. Restrict exercise. Avoid digoxin and diuretics.

Restrict exercise. Explanation: In a child with symptomatic aortic stenosis, exercise should be restricted due to low cardiac output and left ventricular failure. Prostaglandin E1 is recommended to maintain the patency of the ductus arteriosus in neonates. This allows for improved systemic blood flow. Digoxin and diuretics may be required for critically ill children experiencing heart failure as a result of severe aortic stenosis. Strenuous activity has been reported to result in sudden death from the development of myocardial ischemia.

While preparing a client for a postpartum tubal ligation, a nurse overhears the client tell her husband that they can always have reversal surgery if they decide they want more children in the future. Which intervention by the nurse would be best? Inform the couple that successful reversal is unlikely. Report the conversation to the health care provider. Complete the perioperative checklist. Review the client's understanding of the procedure in private.

Review the client's understanding of the procedure in private. Explanation: Informed consent requires that the client has full disclosure and understanding of information before the surgical procedure. The nurse needs to ensure that the client and her husband understand that surgical sterilization, tubal ligation, is considered a permanent end to fertility because reversal surgery is not always successful. The nurse should review the client's understanding of the procedure with the client in private to maintain her confidentiality. After the conversation, the nurse should evaluate whether the supervising nurse and health care provider should be notified based on the client's level of understanding. It is inappropriate to assume that a signed consent form indicates informed consent.

The nurse suspects that a client is not swallowing the administered dose of an anxiolytic medication and is concerned that the client may be disposing of it in the trash. Which action should the nurse take first? Report the suspicions to the healthcare provider. Talk with the client about the concerns. Search the client's room for further evidence. Tell the client that this behavior must stop.

Talk with the client about the concerns. Explanation: Before reporting to the primary care provider, the nurse should discuss the perceived problem about the medications with the client in order to gather more information about the client's attitudes toward antianxiety medications. Searching the client's room for the medications is a violation of the client's right to privacy. The nurse and the healthcare provider can talk to the client about the benefits of taking the medication prescribed; however, the client has the right to refuse the medication.

The nurse is developing a teaching plan for a client who has just been diagnosed with breast cancer. The nurse should expect the health care practitioner to prescribe which medication? Progesterone Acetaminophen Dopamine Tamoxifen

Tamoxifen

A client with suspected renal insufficiency is scheduled for a comprehensive diagnostic workup. The nurse develops a teaching plan to explain the diagnostic tests. Which portion of the kidney does the nurse plan to include as the "working" or functional unit? The tubular system Bowman's capsule The nephron The glomerulus

The nephron Explanation: The nephron, the functioning unit of the kidney, includes the glomerulus, Bowman's capsule, and tubular system, which work together to form urine from the blood.

The newly hired graduate nurse asks the nurse preceptor what is the only advantage of using a floor stock system. Which rationale does the preceptor give the graduate nurse? The nurse can implement medication orders quickly. The nurse receives input from the pharmacist. The system minimizes transcription errors. The system reinforces accurate calculations.

The nurse can implement medication orders quickly. Explanation: A floor stock system enables the nurse to implement medication orders quickly. However, this method is considered unsafe because it doesn't allow for pharmacist input, nor does it minimize transcription errors or reinforce accurate calculations.

A client with bladder cancer had the bladder removed and an ileal conduit created for urine diversion. While changing this client's pouch, the nurse observes that the area around the stoma is red, weeping, and painful. What should the nurse conclude? A skin barrier was applied properly. The pouch faceplate does not fit the stoma. The skin was not lubricated before the pouch was applied. Stoma dilation was not performed.

The pouch faceplate does not fit the stoma.

The nurse is teaching a client how to rotate insulin injection sites. What is the purpose of rotating injection sites? To prevent bruising To prevent medication leakage from the tissue or muscle To prevent erratic drug distribution To prevent the formation of hard nodules

To prevent the formation of hard nodules Explanation: Rotating injection sites promotes adequate drug absorption and prevents the formation of hard nodules caused by repeated injections into the same site. Nodules may impede drug absorption with future injections. Rotating sites doesn't prevent bruising, medication leakage, or erratic drug distribution.

A client is about to undergo cardiac catheterization for which informed consent was obtained. As the nurse enters the room to administer sedation for the procedure, the client states, "I'm really worried about having this open heart surgery." Based on this statement, how should the nurse proceed? Medicate the client and document his comment. Withhold the medication and cancel the procedure. Explain that cardiac catheterization does not involve open heart surgery, and then medicate the client. Withhold the medication and notify the physician immediately.

Withhold the medication and notify the physician immediately. Explanation: The nurse should withhold the medication and notify the physician that the client does not understand the procedure. The physician then has the obligation to explain the procedure better to the client and determine whether or not the client understands. If the client does not understand, there cannot be a true informed consent. If the medication is administered before the physician explains the procedure, the sedation may interfere with the client's ability to clearly understand the procedure. The nurse may not just medicate the client and document the finding; the physician must be notified. The procedure does not need to be cancelled, only postponed until the client receives more education and is able to give informed consent.

A nurse working in the triage area of an emergency department sees that several pediatric clients arrive simultaneously. Which child is treated first? a 3-year-old child with Down syndrome who's pale and asleep in his or her mother's arms a 2-month-old infant with stridorous breath sounds, sitting up in his or her mother's arms and drooling a 3-year-old child with a barking cough and flushed appearance a crying 4-year-old child with a laceration on his or her scalp

a 2-month-old infant with stridorous breath sounds, sitting up in his or her mother's arms and drooling Explanation: The 2-month-old infant with the airway emergency should be treated first because of the risk of epiglottitis. The 3-year-old with the barking cough and fever should be suspected of having croup and should be seen promptly, as should the child with the laceration. The nurse would need to gather more information about the child with Down syndrome to determine the priority of care.

A client has been diagnosed with primary pulmonary tuberculosis (TB). Which condition should the nurse monitor the patient for? a positive skin test active TB within 1 month active TB within 2 weeks a fever requiring hospitalization

a positive skin test Explanation: A primary TB infection occurs when the bacillus has successfully invaded the entire body after entering through the lungs. At this point, the bacilli are walled off, and skin tests read positive. However, all but infants and immunosuppressed people will remain asymptomatic. The general population has a 10% risk of developing active TB over their lifetime, often because of a break in the body's immune defenses. The active stage shows the classic symptoms of TB: fever, hemoptysis, and night sweats.

A client comes to the emergency department reporting chest discomfort and tingling of the fingers. The electrocardiogram shows a heart rate of 136 beats/minute and no other changes; respirations are 28 and shallow. Which nursing intervention has the greatest priority? apply O2 at 3 L via nasal cannula maintaining the client's IV fluids helping the client to calm down obtaining a detailed medical history

apply O2 at 3 L via nasal cannula Explanation: The client is exhibiting anxiety and the nurse should assist the client to calm down. Feelings of panic and/or fear, cold or sweaty hands and/or feet, shortness of breath/hyperventilation, heart palpitations, numbness or tingling in the hands or feet, nausea, and dizziness are signs and symptoms of panic from anxiety. Anxiety can adversely affect the client's heart rate and rhythm by stimulating the autonomic nervous system. The threat of death is an immediate and real concern for the client. The other nursing interventions are valid, but they are not the priority in this situation.

The nurse is caring for a client who is receiving antibiotics to treat a gram-negative bacterial infection. Because antibiotics destroy the body's normal flora, the nurse must monitor the client for: oliguria and dysuria. diarrhea. platelet dysfunction. stomatitis.

diarrhea. Explanation: Broad-spectrum antibiotics that destroy aerobic and anaerobic bacteria also destroy the normal flora of the GI tract, which are responsible for absorbing water and certain nutrients (such as vitamin K). Destruction of the GI flora, in turn, leads to diarrhea. Although antibiotics may cause platelet dysfunction, stomatitis, renal dysfunction (indicated by oliguria and dysuria), and liver dysfunction, these adverse effects don't result from destruction of the GI flora.

A client is admitted to the hospital displaying sinus bradycardia, nausea, anorexia, and blurred vision. What should the nurse suspect this client to be experiencing? hypertensive crisis myocardial infarction cor pulmonale digoxin toxicity

digoxin toxicity

A client is experiencing cardiac tamponade after a chest trauma. Which type of shock will the nurse monitor for? anaphylactic hypovolemic cardiogenic septic

digoxin toxicity Explanation: Digoxin toxicity typically causes bradycardia, nausea, anorexia, and vision disturbances. Myocardial infarction, hypertensive crisis, and cor pulmonale usually do not cause vision disturbance.

An older adult client has a wound that is not healing normally. What factor should the nurse consider for the nonhealing wound? laboratory test results kidney function test results poor wound healing expected as part of the aging process diminished immune function interfering with ability to fight infection

diminished immune function interfering with ability to fight infection Explanation: Immune function is important in the healing process, and diminished response may slow or prevent the healing process from taking place. Although immune function declines with age, there are healthy behaviors that will enhance the older adult's response to tissue trauma (e.g., nutrition, exercise). Kidney function and laboratory results are important, but are not solely responsible for health outcomes.

A surgeon is discussing surgery with a client diagnosed with colon cancer. The client is visibly shaken over the possibility of a colostomy. Based on the client's response, the surgeon should collaborate with which health team member? social worker staff nurse clinical educator enterostomal nurse

enterostomal nurse Explanation: The surgeon should collaborate with the enterostomal nurse, who can address the client's concerns. The enterostomal nurse may schedule a visit with a client who has a colostomy to offer support to the client. The clinical educator can provide information about the colostomy when the client is ready to learn. The staff nurse and social worker aren't specialized in colostomy care, so they aren't the best choices for this situation.

The red blood cell (RBC) production in a client with chronic renal failure (CRF) has decreased. The nurse should monitor this client for: nausea and vomiting. diarrhea and hypokalemia. thrush and circumoral pallor. fatigue and weakness.

fatigue and weakness. Explanation: RBCs carry oxygen throughout the body. Decreased RBC production diminishes cellular oxygen, leading to fatigue and weakness. Diarrhea, nausea, and vomiting may occur in CRF but don't result from faulty RBC production. Thrush, which signals fungal infection, and circumoral pallor, which reflects decreased oxygenation, aren't signs of CRF. Clients with CRF commonly experience hyperkalemia, not hypokalemia.

Which symptom, if reported by a client, would lead the nurse to suspect possible gastric cancer? weight gain feeling of fullness abdominal cramping constant hunger

feeling of fullness Explanation: The client with gastric cancer may report a feeling of fullness in the stomach but not enough to cause the client to seek medical care. Abdominal cramping isn't associated with gastric cancer. Anorexia and weight loss (not increased hunger or weight gain) are common symptoms of gastric cancer.

A client is admitted to the hospital disoriented and weak, has an irregular pulse, and takes hydrochlorothiazide. Which imbalance should the nurse suspect as the underlying cause for the client's symptoms? hyperkalemia hypernatremia hypokalemia hyponatremia

hypokalemia Explanation: The symptoms of hypokalemia include gastrointestinal, cardiac, renal, respiratory, and neurologic disturbances. The use of potassium-wasting diuretics, such as hydrochlorothiazide, without potassium replacement therapy is a primary cause of hypokalemia.

A client is recovering from surgical repair of a dissecting aortic aneurysm. The nurse should evaluate the client for signs of bleeding or recurring dissection. These signs include: hematuria and decreased urine output. hypotension and tachycardia. increased urine output and bradycardia. hypotension and bradycardia.

hypotension and tachycardia. Explanation: When caring for a client recovering from surgical repair of a dissecting aortic aneurysm, the nurse must monitor for hypotension with reflex tachycardia, decreased urine output, and unequal or absent peripheral pulses — all potential signs of bleeding or recurring dissection. Hematuria, increased urine output, and bradycardia aren't signs of bleeding from aneurysm repair or recurring dissection.

A client continues to improve after a left hemisphere cerebrovascular accident (CVA). The interprofessional team is planning a transfer to a rehabilitation unit for follow-up care. Which nursing diagnosis is the priority? impaired physical mobility decreased gastrointestinal motility impaired swallowing risk for isolation

impaired swallowing Explanation: Impaired swallowing is the priority nursing diagnosis for this client because there is a risk for aspiration. The other choices are appropriate, but not the priority.

A nurse is providing fluid replacement for a client with burns on 35% of the body that occurred 12 hours previously. The client's blood pressure is 85/60 mm Hg, pulse is 124 beats/minute, and urine output was 25 mL during the past hour. What prescription should the nurse expect to receive from the health care provider? measure the urine output in an hour reevaluate vital signs in 30 minutes increase the IV fluid infusion rate administer a vasoconstrictor

increase the IV fluid infusion rate Explanation: During the first 24 hours after a burn, interstitial and intracellular fluid shifts occur, and intravascular fluid volume decreases. Hypovolemia calls for fluid replacement therapy to maintain vital organ perfusion. Keeping IV fluids at the current rate would not correct the client's fluid deficit. A vasoconstrictor would be inappropriate because it does not correct fluid volume deficits. Vital signs should be reevaluated sooner than 30 minutes and immediately after the intervention to determine effectiveness. Urine output may take longer than 1 hour to correct and should be ongoing.

A client is experiencing an acute myocardial infarction (MI) and I.V. morphine is prescribed. Morphine is given because it: eliminates pain, reduces cardiac workload, and increases myocardial contractility. lowers resistance, reduces cardiac workload, and decreases myocardial oxygen demand. raises the blood pressure, lowers myocardial oxygen demand, and eliminates pain. increases venous return, lowers resistance, and reduces cardiac workload.

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

A licensed practical nurse is providing care for a client who is undergoing opiate withdrawal. The client is receiving medication therapy to minimize the effects. Which drug would the nurse expect to administer to the client? methadone phenobarbital dextroamphetamine diazepam

methadone Explanation: Methadone is used to detoxify opiate users because it binds with opioid receptors at many sites in the central nervous system; it breaks the cycle of the physical discomforts associated with detoxification without the "high" associated with the effects of other opiates, such as cocaine, heroin, and morphine. Barbiturates, such as phenobarbital, amphetamines, such as dextroamphetamine, and benzodiazepines, such as diazepam, are not used in the treatment of opioid withdrawal.

An increase in the creatine kinase-MB isoenzyme (CK-MB) can be caused by: I.M. injection. myocardial necrosis. skeletal muscle damage due to a recent fall. cerebral bleeding.

myocardial necrosis. Explanation: An increase in CK-MB is related to myocardial necrosis. An increase in total CK might occur for several reasons, including brain injury, such as cerebral bleeding; skeletal muscle damage, which can be caused by I.M. injections or falls; muscular or neuromuscular disease; vigorous exercise; trauma; or surgery.

A child receives prednisone after a heart transplant. For which adverse reaction to prednisone would a nurse monitor in this child? weight loss anorexia hyperpyrexia poor wound healing

poor wound healing Explanation: Common adverse reactions to prednisone include poor wound healing, weight gain, delayed temperature response, increased appetite, delayed sexual maturation, growth impairment, and a Cushingoid appearance. The school-aged child who has received prednisone is usually overweight and has a moon-shaped face.

The nurse is reinforcing nutritional information with a client with a leukocyte (WBC) count of 2,500/µL (2.50 × 109/L). What food should the nurse instruct the client avoid? well-done steak white bread raw carrot sticks stewed apples

raw carrot sticks Explanation: The normal leukocyte (WBC) count is 4.500/µL to 11,000/µL (4.50 × 109/L to 11.00 × 109/L). A WBC count of 2,500/µL (2.50 × 109/L) is low, making the client prone to infection. A low-bacteria diet is indicated, which excludes raw fruits and vegetables.

nurse is assigned to a client with a cardiac disorder. The nurse should question an order to monitor the client's body temperature by which route? oral tympanic axillary rectal

rectal Explanation: When caring for a client with a cardiac disorder, the nurse should avoid using the rectal route to take temperature. Using this route could stimulate the vagus nerve, possibly leading to vasodilation and bradycardia. The other options are appropriate routes for measuring the temperature of a client with a cardiac disorder.

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

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

What are important nursing responsibilities when a referral to other health team members has been made for a client? ensuring that the physician reports the level of functioning of the client recommending that each health team member independently completes an assessment and then consult with each other recommending that each member read the history and nurse's notes to understand the client's progress sharing assessment information and information on the client's capability and level of participation in meeting activities of daily living

sharing assessment information and information on the client's capability and level of participation in meeting activities of daily living

A nurse notes that a client frequently coughs while eating. The licensed practical nurse (LPN) reports this finding to the registered nurse and discusses possible options to address this problem. Based on the discussion, which health team member would the LPN expect to become involved? respiratory therapist speech therapist wound, ostomy, and continence nurse smoking cessation counselor

speech therapist Explanation: Frequent coughing while eating may indicate a problem with swallowing. Therefore, a speech therapist should be consulted. This therapist can perform a swallowing evaluation. A respiratory therapist should be consulted for problems concerning the client's breathing pattern. A wound, ostomy, and continence nurse should be consulted for ostomy and wound care issues. The nurse cannot assume that the client smokes simply because the client coughs while eating.

The client refused an injection, but the nurse administered it anyway. The client wants to sue the nurse. The attorney informs the client that this lawsuit must be filed within two years. What is this time frame called? statute of limitation discovery rule alternative dispute resolution grace period

statute of limitation Explanation: Statute of limitation is the time interval during which a case must be filed; after this time the injured party is barred from bringing the lawsuit. The statute of limitations typically gives clients 2 years from the time of discovery to file a lawsuit; however, this may vary from state to state. Statutes of limitations are set by state legislatures. Discovery rule is the term for the time the client discovers the injury. A grace period refers to any period specified in a contract during which payment is permitted without penalty, beyond the due date of the debt. Alternative dispute resolution refers to any means of settling disputes outside the courtroom setting.

A 1-year-old underwent hypospadias repair yesterday; he has a urethral catheter in place and an IV. Which rationale is appropriate for administering propantheline on an as-needed basis? to decrease the chance of infection at the suture line to increase urine flow from the kidney to the ureters to prevent bladder spasms while the catheter is present to decrease the number of organisms in the urine

to prevent bladder spasms while the catheter is present Explanation: Propantheline is an antispasmodic that works effectively on children. It prevents bladder spasms while the catheter is in place. It isn't an antibiotic and therefore won't decrease the chance of infection or the number of organisms in the urine. The drug has no diuretic effect and won't increase urine flow.

A client is diagnosed with shigellosis. The nurse teaches the client and family how the disease is transmitted and treated and discusses the need for enteric precautions. The nurse should explain that enteric precautions must be maintained: during the acute disease stage and as long as the virus is shed (up to 30 days). during the acute disease stage and up to 48 hours after diarrhea stops. for 24 to 48 hours after anti-infective therapy begins. until three fecal cultures are negative for Shigella.

until three fecal cultures are negative for Shigella. Explanation: Enteric precautions are required until three fecal cultures are negative for Shigella. Absence of diarrhea doesn't indicate absence of Shigella. Shigellosis is a bacterial infection, so no virus is shed. Shigella still may be present 48 hours after anti-infective therapy begins.

Nurses who provide care in a large, long-term care facility use charting by exception (CBE) as the preferred method of documentation. This documentation method may have which drawbacks? vulnerability to legal liability because the nurse's safe, routine care is not recorded failure to identify and record problems and associated interventions significant differences in charting among nurses from lack of standardization increased workload for nurses to complete necessary documentation

vulnerability to legal liability because the nurse's safe, routine care is not recorded

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? even, unlabored respirations; tachycardia; and hemoptysis cyanosis, nausea, vomiting, and constricted pupils restlessness, confusion, increased urine output, and warm, dry skin weak, irregular pulse; cool, moist skin; and hypotension

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.