Pass Points pt 6
A nurse is preparing a presentation for a pregnant client with diabetes. Which information would the nurse include to explain why a pregnant diabetic client is at risk for having a large-for-gestational-age infant? Excess sugar causing reduced placental functioning Insulin acting as a growth hormone on the fetus Maternal dietary intake of high calories Excess insulin reducing placental functioning
Insulin acting as a growth hormone on the fetus Explanation: Insulin acts as a growth hormone on the fetus. Therefore, pregnant diabetic clients must maintain good glucose control. Large babies are prone to complications and may have to be delivered by cesarean section. Neither excess sugar nor excess insulin reduces placental functioning. A high-calorie diet helps control the mother's disease and doesn't contribute to neonatal size.
A middle-age client recovering from major back surgery must wear a back brace and walk with a cane after experiencing leg weakness. During routine care, the client tells a nurse, "I'm sorry I had this operation. Before surgery I didn't look like I had a problem, but now I do." Which response by the nurse is appropriate? "People often suffer setbacks before they improve." "Maybe you should consult with your attorney." "I'm not sure why you went through with the surgery; you were told of the risks." "You sound concerned about your appearance. In what way are you worse off than before?"
"You sound concerned about your appearance. In what way are you worse off than before?" Explanation: Option 4 encourages the client to express her feelings about her change in body image. Option 1 minimizes the client's concerns and is condescending. It's inappropriate for the nurse to suggest that the client consult with her attorney. Option 3 is an unprofessional response that minimizes the client's decision-making ability.
The nurse is teaching accident prevention to the parents of a toddler. Which of the following instructions is appropriate for the nurse to tell the parents? The toddler should wear a helmet when rollerblading. Place locks on cabinets containing toxic substances. Teach the toddler water safety. Don't allow the toddler to use pillows when sleeping.
Place locks on cabinets containing toxic substances. Explanation: All household cleaners and poisons should be locked with childproof locks. The toddler's curiosity and the ability to climb and open doors and drawers makes poisoning a concern in this age-group. Rollerblading isn't an appropriate activity for toddlers. Toddlers lack the cognitive development to understand water safety. (Note that rollerblading protection and teaching water safety are appropriate for school-age children.) Pillows shouldn't be placed in the crib of an infant to avoid suffocation; however, toddlers may use them.
A client with type 1 diabetes is at 22 weeks' gestation after the first pregnancy ended in spontaneous abortion at 18 weeks' gestation. The nurse is reinforcing instructions with the client about exercise during her pregnancy. Which statement indicates that the client has an appropriate understanding of her exercise needs? "I need to walk with a friend or family member." "I need to vary the time of day when I exercise." "I need to exercise before meals." "I should not drink for an hour before walking."
"I need to walk with a friend or family member." Explanation: A pregnant client with type 1 diabetes should walk with a friend or family member in case she becomes hypoglycemic while exercising. The client should exercise at the same time each day to ensure control of her blood glucose levels. The client should exercise after meals, when blood sugar is high. Fluids are important before, during and after exercising to prevent dehydration.
A client with a mild concussion reports a headache. When offered acetaminophen, the client asks for a stronger pain medication. Which response by the nurse is appropriate? "You have a mild concussion; acetaminophen is strong enough." "Aspirin is avoided because of the danger of Reye syndrome in children or young adults." "Opioids are avoided after a head injury because they may hide a worsening condition." "Stronger medications may lead to vomiting, which increases intracranial pressure (ICP)."
"Opioids are avoided after a head injury because they may hide a worsening condition." Explanation: Opioids may mask changes in the level of consciousness (LOC) that indicate increased ICP and shouldn't be given. Saying acetaminophen is strong enough ignores the client's question and therefore isn't appropriate. Aspirin is contraindicated in conditions that may cause bleeding, such as trauma, and for children or young adults with viral illnesses because of the danger of Reye syndrome. Stronger medications may not necessarily lead to vomiting but will sedate the client, thereby masking changes in his LOC.
A child's parents ask for advice on the use of an insect repellent that contains DEET. Which statement would the nurse incorporate in the response? "Spray the child's clothing instead of the skin." "The repellent works better as the temperature increases." "The repellent isn't effective against the ticks responsible for Lyme disease." "Apply insect repellent as you would sunscreen, with frequent applications during the day."
"Spray the child's clothing instead of the skin." Explanation: DEET spray has been approved for use on children. It should be used sparingly on all skin surfaces. By concentrating the spray on clothing and camping equipment, the adverse effects and potential toxic buildup are significantly reduced. Repellent is lost to evaporation, wind, heat, and perspiration. Each 10° F increase in temperature leads to as much as a 50% reduction in protection time. DEET is very effective as a tick repellent.
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 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 client is admitted to the health care facility with a diagnosis of a bleeding gastric ulcer. The nurse instructs the nursing student to observe this client's stools for which finding? Coffee-ground-like Clay-colored Black and tarry Bright red
Black and tarry Explanation: Black, tarry stools are a sign of bleeding high in the GI tract, as from a gastric ulcer, and result from the action of digestive enzymes on the blood. Vomitus associated with upper GI tract bleeding commonly is described as coffee-ground-like. Clay-colored stools are associated with biliary obstruction. Bright red stools indicate lower GI tract bleeding.
A child is brought to the school nurse with the index finger of the left hand partially amputated and hanging by a shred of skin. Bleeding is moderate. What is the appropriate action by the nurse? Place the finger under warm running water and wrap in a towel. Cut the skin holding the finger and wrap the detached finger in a clean wet towel. Tightly squeeze the finger 1 inch above the cut to stop bleeding. Securely wrap the hand and finger and place them in a cold water-filled baggie.
Securely wrap the hand and finger and place them in a cold water-filled baggie. Explanation: Leaving the skin intact, first apply a dry, sterile dressing over the wound to control bleeding and then wrap the entire hand and finger sterile gauze moistened with normal saline solution. Place the hand in a cool solution to preserve cell life and increase the chance of successful reattachment. The finger should not be detached, warm water should not be used, and as long as blood loss is not life threatening, circulation to the finger should not be decreased by tightly squeezing about the cut.
A preschool-age child refuses to take prescribed medication. Which nursing strategy would be most appropriate? Mixing the medication in milk so the child isn't aware that it's there Explaining the medication's effects in detail to ensure cooperation Making the child feel ashamed for not cooperating Showing trust in the child's ability to cooperate even with an unpleasant procedure
Showing trust in the child's ability to cooperate even with an unpleasant procedure Explanation: To gain a preschooler's cooperation, the nurse should show trust and express faith in the child's ability to cooperate even with an unpleasant procedure. Hiding the medication in milk may foster mistrust. The nurse should provide simple, not detailed, explanations and should use terms the child can understand. Shaming the child is inappropriate and may lead to feelings of guilt.
The parents of a preschool-age child ask the nurse about nutrition. Which statement about a preschooler's nutritional requirements is accurate? Caloric requirements per kilogram of body weight increase slightly during the preschool-age period. A preschooler's nutritional requirements differ greatly from those of a toddler. The quality of food that a preschooler consumes is more important than the quantity. Protein should account for 25% of a preschooler's total caloric intake.
The quality of food that a preschooler consumes is more important than the quantity. Explanation: Food quality is more important than quantity; a high caloric intake may include many empty calories. A preschooler's caloric requirement is slightly lower than a toddler's. Overall, however, a preschooler's nutritional requirements are similar to a toddler's. A preschooler's nutritional requirements can be met by including two meat servings, three milk servings, four bread servings, and four fruit and vegetable servings.
When gathering data on the heart, where would the nurse expect to find the point of maximal impulse on a 2-year-old child? third or fourth intercostal space second intercostal space, right midclavicular line second intercostal space, left midclavicular line fourth intercostal space, left midclavicular line
fourth intercostal space, left midclavicular line Explanation: The point of maximal impulse would be expected to be found at the fourth intercostal space, left midclavicular line. The aortic valve is assessed in the second intercostal space right midclavicular line. The pulmonic valve is assessed in the second intercostal space left midclavicular line. The tricuspid valve is assessed in the fourth intercostal space, left midclavicular line
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? reevaluate vital signs in 30 minutes increase the IV fluid infusion rate measure the urine output in an hour 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.
The nurse is teaching a client how to use a diaphragm. Which instruction should the nurse provide? "Insert the diaphragm 4 hours before intercourse." "Leave the diaphragm in place for at least 6 hours after intercourse." "Remove the diaphragm immediately after intercourse." "You may use the diaphragm without spermicidal jelly or cream."
"Leave the diaphragm in place for at least 6 hours after intercourse." Explanation: The diaphragm acts as a reservoir for spermicidal jelly or cream and must be left in place for at least 6 hours after intercourse to ensure spermicidal action. Inserting the diaphragm 4 hours before intercourse or removing it immediately afterward doesn't ensure spermicidal effectiveness. A diaphragm must be used with spermicidal jelly or cream.
A client complains of periorbital aching, tearing, blurred vision, and photophobia in the right eye. Ophthalmologic examination reveals a small, irregular, nonreactive pupil — a condition resulting from acute iris inflammation (iritis). As part of the client's therapeutic regimen, the physician prescribes atropine sulfate (Atropisol), two drops of 0.5% solution in the right eye twice daily. The nurse knows atropine sulfate belongs to which drug classification? Parasympathomimetic agent Sympatholytic agent Adrenergic blocker Cholinergic blocker
Cholinergic blocker Explanation: Atropine sulfate is a cholinergic blocker. It isn't a parasympathomimetic agent, a sympatholytic agent, or an adrenergic blocker.
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 with the client's first voiding of the day Start after a client's known voiding that empties the bladder Start after the client eats breakfast 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 client who has recently had surgery for prostate cancer expresses to the nurse feelings of anger toward God because of the diagnosis. Which nursing intervention is appropriate for this client? Leave the client alone to work through the anger. Refer the client to a counselor to talk about feelings of distress. Ask the client about religious beliefs and practices. Encourage the client to speak with a clergy member.
Encourage the client to speak with a clergy member. Explanation: Encouraging the client who is spiritually distressed following cancer surgery to discuss concerns with a clergy member is an appropriate intervention. The nurse should also encourage the client to discuss feelings about religious beliefs and practices. Referring the client to a counselor is not appropriate and does not build a therapeutic relationship with the client.
A client was admitted with a brain tumor. Which vital signs would the nurse expect to notice? T, 98° F (36.6° C); P, 108; R, 14; BP, 120/82 T, 97° F (36.1° C); P, 60; R, 23; BP, 158/94 T, 99° F (37.2° C); P, 52; R, 12; BP, 176/86 T, 99° F (37.2° C); P, 82; R, 16; BP, 149/82
T, 99° F (37.2° C); P, 52; R, 12; BP, 176/86 Explanation: A client with a brain tumor will experience an increase in intracranial pressure (ICP). One of the assessment findings in increased ICP is Cushing's triad, which includes hypertension, bradycardia, and widening pulse pressure.
A client with blood type B needs a blood transfusion. Which type of blood can this client receive? Type A or type O blood Type B or type O blood Type AB or type O blood Type A or type B
Type B or type O blood Explanation: Type B blood contains B antigens and anti-A antibodies, but no anti-B antibodies. Therefore, a client with type B blood can receive type B or type O blood (which contains neither anti-A nor anti-B antibodies).
Family members would like to bring in a birthday cake for a client with nerve damage. What cranial nerve will the nurse assess to determine if it is functioning so the client can chew? Cranial nerve II Cranial nerve V Cranial nerve IX Cranial nerve X
Cranial nerve V Explanation: Chewing is a function of cranial nerve V. Swallowing is a motor function of cranial nerves IX and X. Cranial nerve II doesn't have a motor function.
The nurse is caring for a client with panic disorder who has difficulty sleeping. Which nursing intervention will best help the client achieve healthy long-term sleeping habits? Administer a sleeping pill. Encourage the use of relaxation exercises. Suggest walking the halls for 30 minutes before bed. Recommend watching television before bedtime.
Encourage the use of relaxation exercises. Explanation: Relaxation exercises provide the client with a healthy way to gain control over anxiety. These exercises also produce a physiologic response that induces sleep; the response is opposite to that produced by stress. Administering a sleeping pill would provide short-term relief for sleeplessness but does not teach long-term healthy sleep habits. Suggesting that the client stay up and walk the halls will not help develop healthy sleep habits. Electronic use and television should be discontinued 1-2 hours before sleep.
When a nurse is preparing to restrain a violent client, which nursing intervention is initially most important? Reviewing facility policy regarding how long the client can be restrained Preparing an as-needed dose of the client's psychotropic medication Ensuring that the restraints have been applied correctly Asking whether the client needs to use the bathroom or is thirsty
Ensuring that the restraints have been applied correctly Explanation: The nurse must determine whether the restraints have been applied correctly to make sure that the client's circulation and respiration are not restricted and that adequate padding has been used to prevent injury. The nurse should document the client's response and status after the restraints are applied. All staff members involved in restraining clients should be aware of facility policy before using restraints. The client has the right to refuse medication; therefore, the nurse should not prepare the medication unless the client agrees to take it. The nurse should attend to the client's elimination and hydration needs after the client is properly restrained.
Which action by the nurse would help a client with conversion-disorder blindness to eat? Feed the client. See to the needs of the other clients in the dining room, then feed this client last. Establish a "buddy" system with other clients who can feed the client at each meal. Expect the client to feed himself after explaining the location of food on the tray.
Expect the client to feed himself after explaining the location of food on the tray. Explanation: The client is expected to maintain some level of independence by feeding himself. At the same time, the nurse should be supportive in a matter-of-fact way. Feeding the client leads to dependence.
A nurse is caring for an older adult client with chronic open-angle glaucoma. After the nurse administers pilocarpine, the client reports blurred vision. Which nursing action is most appropriate? Withhold the next dose and notify the healthcare provider. Treat the client for an allergic reaction. Suggest that the client put on eyeglasses. Explain that this is an expected side effect.
Explain that this is an expected side effect. Explanation: Pilocarpine, a miotic drug used to treat glaucoma, achieves its effect by constricting the pupil. Blurred vision lasting 1 to 2 hours after eyedrop instillation is an expected side effect, so the drug does not need to be withheld or the healthcare provider notified. Likewise, the client does not need to be treated for an allergic reaction. Wearing glasses does not alter this temporary adverse effect. The client may also note difficulty adapting to the dark.
For a client with Graves' disease, which nursing intervention promotes comfort? Restricting intake of oral fluids Placing extra blankets on the client's bed Limiting intake of high-carbohydrate foods Maintaining room temperature in the low-normal range
Maintaining room temperature in the low-normal range Explanation: Graves' disease causes signs and symptoms of hypermetabolism, such as heat intolerance, diaphoresis, excessive thirst and appetite, and weight loss. To reduce heat intolerance and diaphoresis, the nurse should keep the client's room temperature in the low-normal range. To replace fluids lost via diaphoresis, the nurse should encourage, not restrict, intake of oral fluids. Placing extra blankets on the bed of a client with heat intolerance would cause discomfort. To provide needed energy and calories, the nurse should encourage the client to eat high-carbohydrate foods.
When monitoring a postpartum client 2 hours after birth of her newborn, the nurse notices heavy bleeding with large clots. Which action would the nurse perform first? Massage the fundus firmly. Perform bimanual compression. Administer ergonovine. Notify the primary health care provider.
Massage the fundus firmly. Explanation: Initial management of excessive postpartum bleeding is firm massage of the fundus and administration of oxytocin. Bimanual compression is performed by a primary health care provider. Ergonovine should be used only if the bleeding doesn't respond to massage and oxytocin. The primary health care provider should be notified if the client doesn't respond to fundal massage, but other measures can be taken in the meantime.
A client is diagnosed with obsessive-compulsive disorder. Which intervention should the nurse include when assisting with development of the plan of care? Setting strict limits on compulsive behavior Giving the client adequate time to perform rituals Increasing environmental stimulation Preventing ritualistic behavior
Giving the client adequate time to perform rituals Explanation: The nurse should give the client adequate time to perform rituals because this reduces anxiety. The other options would increase the client's anxiety.
The nurse is monitoring a client receiving tranylcypromine sulfate. Which serious adverse reaction can occur with high dosages of this monoamine oxidase (MAO) inhibitor? Hypotensive episodes Hypertensive crisis Muscle flaccidity Hypoglycemia
Hypertensive crisis Explanation: The most serious adverse reaction associated with high dosages of MAO inhibitors is hypertensive crisis, which can lead to death. Although not a crisis, orthostatic hypotension is also common and may lead to syncope with high dosages. Muscle spasticity (not flaccidity) is associated with MAO inhibitor therapy. Hypoglycemia isn't an adverse reaction of MAO inhibitors.
A child returns to the unit after a cardiac catheterization. The nurse should reinforce education for the child and parents on which point regarding mobility? The child may sit in a chair with the affected extremity immobilized. The child will be maintained on bed rest with no further activity restrictions. The child will be maintained on bed rest with the affected extremity immobilized. The child may get out of bed to go to the bathroom, if necessary.
The child will be maintained on bed rest with the affected extremity immobilized. Explanation: Following cardiac catheterization, the child should be maintained on bed rest with the affected extremity immobilized to prevent hemorrhage. Allowing the child to sit in a chair with the affected extremity immobilized, to move the affected extremity while on bed rest, or to have bathroom privileges places the child at risk for hemorrhage.
A child with asthma is receiving theophylline. The nurse knows that theophylline is administered primarily to: decrease coughing induced by postnasal drip. dilate the bronchioles. reduce airway inflammation. eradicate the infection.
dilate the bronchioles. Explanation: Methylxanthines, such as theophylline, are highly potent bronchodilators used to relieve asthma symptoms. Antihistamines typically are used to relieve a cough induced by postnasal drip; corticosteroids, to reduce airway inflammation; and antibiotics, to treat infection.
What is the most important postoperative instruction the nurse must give a client who has just returned from the operating room after receiving a subarachnoid block? "Avoid drinking liquids until the gag reflex returns." "Avoid eating milk products for 24 hours." "Notify a nurse if you experience blood in your urine." "Remain supine for the time specified by the physician."
"Remain supine for the time specified by the physician." Explanation: The nurse should instruct the client to remain supine for the time specified by the physician. Local anesthetics used in a subarachnoid block don't alter the gag reflex. No interactions between local anesthetics and food occur. Local anesthetics don't cause hematuria.
A client with a urinary tract infection is prescribed co-trimoxazole. The nurse should provide which medication instruction? "Take the medication with food." "Drink at least eight 8-oz glasses of fluid daily." "Avoid taking antacids during co-trimoxazole therapy." "Don't be afraid to go out in the sun."
"Drink at least eight 8-oz glasses of fluid daily." Explanation: When receiving a sulfonamide such as co-trimoxazole, the client should drink at least eight 8-oz glasses of fluid daily to maintain a urine output of at least 1,500 ml/day. Otherwise, inadequate urine output may lead to crystalluria or tubular deposits. For maximum absorption, the client should take this drug at least 1 hour before or 2 hours after meals. No evidence indicates that antacids interfere with the effects of sulfonamides. To prevent a photosensitivity reaction, the client should avoid direct sunlight during co-trimoxazole therapy.
The health care provider has prescribed olanzapine for a client. Which statement from the client would indicate the medication is having the desired effect? "I am feeling rested when I wake up in the morning." "My appetite is getting better." "I am feeling more comfortable talking with others." "It is getting easier to rest at night."
"I am feeling more comfortable talking with others." Explanation: Olanzapine is used in the treatment of paranoid personality disorders. If effective, the medication will help the client have control of symptoms, such as paranoia, that impair interactions with others. Restful sleep is not a goal of this medication. Appetite changes do not reflect that the medication is therapeutic.
The nurse is caring for a client in her 34th week of pregnancy who wears an external monitor. Which statement by the client indicates an understanding of the nurse's teaching? "I'll need to lie perfectly still." "You won't need to come in and check on me while I'm wearing this monitor." "I can lie in any comfortable position, but I should stay off my back." "I know that the external monitor increases my risk of a uterine infection."
"I can lie in any comfortable position, but I should stay off my back." Explanation: A woman with an external monitor should lie in the position that is most comfortable to her, although the supine position should be discouraged. She should be encouraged to change her position as often as necessary; however, the monitor may need to be repositioned after a position change. The nurse needs to frequently assess and provide emotional support to a woman in labor who's wearing an external monitor. Because an external monitor isn't invasive and is worn around the abdomen, it doesn't increase the risk of uterine infection.
When monitoring a client receiving amitriptyline therapy, the nurse should be alert for which potentially life-threatening adverse effect? Cardiac arrhythmias Hypertensive crisis Priapism Orthostatic hypotension
Cardiac arrhythmias Explanation: Tricyclic antidepressants such as amitriptyline affect norepinephrine and may cause cardiac electrical conduction problems (arrhythmias). An overdose can produce arrhythmias that may result in death. The nurse monitors clients receiving monoamine oxidase inhibitors for hypertensive crisis. Trazodone can cause the medical emergency priapism (persistent abnormal erection of the penis). Orthostatic hypotension isn't usually a life-threatening adverse effect.
A nurse is about to give a full-term neonate their first bath. What intervention should the nurse perform first? Check the neonate's temperature. Scrub the neonate's skin to remove the vernix caseosa. Fill a tub with warm water. Obtain medicated soap.
Check the neonate's temperature. Explanation: To guard against heat loss, the nurse should bathe the neonate only after his temperature and other vital signs have stabilized. The nurse should avoid scrubbing because it can cause abrasions that allow microorganisms to enter. The neonate should not be immersed in a tub of water until his umbilical cord stump has fallen off. The nurse should use water and mild soap to bathe the neonate because medicated soap can cause an allergic response or skin irritation.
Which problem would the nurse expect to find on the care plan of a 10-month-old infant to promote coping during hospitalization? self-care deficit powerlessness boredom anxiety
anxiety Explanation: Attachment is critical in infancy, and prolonged separation has been well documented as a risk factor that compromises normal infant development. Being separated from parents can cause high anxiety. Self-care deficit wouldn't be an issue for a 10 month old. Powerlessness is a concern after the toddler stage, when a child develops autonomy and independence. Boredom won't be an issue until the acute phase of the illness has passed. Providing diversion for infants is easily accomplished by the use of age-appropriate toys and play activities.
The nurse is caring for a client who was admitted with rectal bleeding. The client is at high risk for having colorectal cancer. The nurse anticipates preparing the client for which diagnostic test to confirm this suspicion? stool Hematest carcinoembryonic antigen (CEA) colonoscopy abdominal computed tomography (CT) scan
colonoscopy Explanation: Used to visualize the lower gastrointestinal tract, colonoscopy aids in detecting two-thirds of all colorectal cancers. Stool Hematest detects blood, which is a sign of colorectal cancer; however, the test doesn't confirm the diagnosis. CEA may be elevated in colorectal cancer but isn't considered a confirming test. An abdominal CT scan is used to stage the presence of colorectal cancer.
Which cells are involved in bone resorption? Chondrocytes Osteoblasts Osteoclasts Osteocytes
Osteoclasts Explanation: Osteoclasts carry out bone resorption by removing unwanted bone while new bone is forming in other areas. Chondrocytes are responsible for forming new cartilage. Osteoblasts are bone-forming cells that secrete collagen and other substances. Osteocytes, derived from osteoblasts, are the chief cells in bone tissue.
After undergoing a liver biopsy, the client should be placed in which position? Semi-Fowler's position Right lateral decubitus position Supine position Prone position
Right lateral decubitus position Explanation: After a liver biopsy, the client should be placed on the right side (right lateral decubitus position) to exert pressure on the liver and prevent bleeding. The other positions wouldn't achieve this goal.
A client reports an intermittent milky vaginal discharge. The client is not sexually active and does not report itching or burning. Which factor is the most likely cause of the milky discharge?' inadequate cleaning of the perineal area sensitivity to a feminine hygiene product normal fluctuation in estrogen and progesterone levels reaction to heat and moisture from wearing tight clothing
normal fluctuation in estrogen and progesterone levels Explanation: Vaginal fluid is clear, milky, or cloudy, depending on the fluctuating levels of estrogen and progesterone. A milky vaginal discharge is normal and is not associated with sensitivity, reaction to heat or moisture, or inadequate cleaning.
The employer of a client on a psychiatric unit calls the nursing station inquiring about the client's progress. The nurse is unsure whether the client has given consent for information to be shared with callers on the phone. Which response by the nurse would be best? "I'm not permitted to discuss the client's progress." "I'll give you the name and telephone number of the client's health care provider." "I'll have the client call you." "I can't confirm whether your employee is a client here."
"I can't confirm whether your employee is a client here." Explanation: The nurse's release of information to the client's employer without the client's consent is a breach of confidentiality. The stigma associated with psychiatric illness may affect the client's employment; therefore, it is better to maintain confidentiality and refrain from disclosing any information about the client, including whether the employee is a client in the hospital.
A client who was diagnosed with multiple sclerosis 3 years ago now presents with lower extremity weakness and heaviness. During the admission process, the client presents her advance directive, which states that she doesn't want intubation, mechanical ventilation, or tube feedings should her condition deteriorate. How should the nurse respond? "Thank you for providing this document; I'll include it in your permanent record." "Advance directives aren't necessary for clients your age." "It's important for us to have this information. You should review the document with your physician at every admission." "Your disease hasn't progressed enough to institute an advance directive."
"It's important for us to have this information. You should review the document with your physician at every admission." Explanation: An advance directive should be part of the client's medical record. The client should review the document with the physician at every admission because portions of the advance directive may be inappropriate if a particular condition is reversible and temporary. Option 1 doesn't address the need to review the directive with the physician. Advance directives are appropriate for clients of all ages.
Which statement regarding acute glomerulonephritis indicates that the parents of a child with this diagnosis understand the reinforced education provided by the nurse? "This disease occurs after a urinary tract infection." "This disease is associated with renal vascular disorders." "This disease occurs after a streptococcal infection." "This disease is associated with structural anomalies of the genitourinary tract."
"This disease occurs after a streptococcal infection." Explanation: Acute glomerulonephritis is an immune complex disease that occurs as a by-product of an antecedent streptococcal infection. Certain strains of the infection are usually beta-hemolytic streptococci.
A nurse is providing care for a pregnant client who asks how she can best deal with her fatigue. Which instruction would the nurse most likely reinforce with the client? "Take a sleeping pill every night to get a restful night's sleep." "Try to get more rest by going to bed earlier." "Be sure to take your prenatal vitamins and iron supplements." "Don't worry because this feeling will pass very soon."
"Try to get more rest by going to bed earlier." Explanation: The fatigued, pregnant client should listen to her body's way of telling her that she needs more rest and try going to bed earlier. Sleeping pills should not be consumed prenatally because they can harm the fetus. Vitamins do not take away fatigue. False reassurance is inappropriate, dismisses the client's concern, and does not help the client manage her fatigue.
A client with acute diarrhea is prescribed loperamide, 2 mg after each unformed stool up to 16 mg/day, until the diarrhea subsides. The client asks the nurse how soon the medication will start to work after the first dose is taken. The nurse responds that the medication will work in how much time? "Within 5 minutes" "Within 20 minutes" "Within 1 hour" "Within 2 to 4 hours"
"Within 1 hour" Explanation: Loperamide starts to act within 1 hour after administration. Onset of action isn't as rapid as 5 or 20 minutes or as slow as 2 to 4 hours.
A client is diagnosed with genital herpes simplex. Concerned about spread of the virus to others, the nurse questions the client about recent sexual activity. What is the average incubation period for localized genital herpes simplex infection? 6 to 18 hours 1 to 2 days 3 to 7 days 10 to 14 days
3 to 7 days Explanation: The average incubation period for localized genital herpes simplex infection is 3 to 7 days. (For generalized herpes simplex infection, the average incubation period is 2 to 12 days.)
A client comes to the clinic for a skin assessment from the health care provider. When obtaining data, the nurse knows that which finding increases this client's risk of skin cancer? A deep sunburn A dark mole on the client's back An irregular scar on the client's abdomen White, irregular patches on the client's arm
A deep sunburn Explanation: A deep sunburn is a risk factor for skin cancer. A dark mole or an irregular scar is a benign finding. White, irregular patches are abnormal but aren't a risk factor for skin cancer.
A client comes to the emergency department complaining of severe pain in the right flank, nausea, and vomiting. The physician tentatively diagnoses right ureterolithiasis (renal calculi). When planning this client's care, the nurse should assign highest priority to which nursing diagnosis? Acute pain Risk for infection Deficient knowledge related to medication regimen Imbalanced nutrition: Less than body requirements
Acute pain Explanation: Ureterolithiasis typically causes such acute, severe pain that the client can't rest and becomes increasingly anxious. Therefore, the nursing diagnosis of Acute pain takes highest priority. Diagnoses of Risk for infection and Deficient knowledge related to medication regimen are appropriate when the client's pain is controlled. A diagnosis of Imbalanced nutrition: Less than body requirements isn't pertinent at this time.
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 Explanation: Both benzodiazepines (such as alprazolam) and barbiturates (such as phenobarbital) are addictive, controlled substances. None of the other drugs listed are addictive substances.
The nurse is examining a client's scalp for evidence of lice. The nurse should pay particular attention to which part of the scalp? Temporal area Top of the head Behind the ears Middle area
Behind the ears Explanation: Adult lice usually bite the scalp behind the ears and along the back of the neck. Because such lice are tiny (1 to 2 mm) with grayish white bodies, they are hard to see. However, their bites result in visible pustular lesions. Although lice may bite any part of the scalp, bites are less common on the temporal area, top of the head, and middle area.
During a well-child visit, the nurse is reinforcing education with the parents of a 2-year-old child. What is the best recommendation a nurse can give to the parents regarding frequent temper tantrums? Move the toddler to a different setting. Allow the toddler more choices. Ignore the behavior when it happens. Give into the toddler's demands.
Ignore the behavior when it happens. Explanation: The nurse should instruct the parents of a 2-year-old to ignore the tantrums because paying attention to this undesirable behavior reinforces it. Changing the toddler's setting can increase the tantrum behavior. Allowing the toddler more choices may increase tantrum behavior if the toddler is unable to follow through with choices. The toddler should be offered only allowable and reasonable choices. Giving in to the toddler's demands is not recommended because doing so promotes tantrum behavior.
What is the first action that a nurse should take after accidentally failing to administer an ordered medication? Notify the prescriber, nursing supervisor, and pharmacist. Document the omission and the reason. Write an incident report. Give an extra dose at the next scheduled time.
Notify the prescriber, nursing supervisor, and pharmacist. Explanation: When a nurse has accidentally omitted an ordered medication, she should first notify the prescriber, nursing supervisor, and pharmacist. She should then document the omission and the reason in the client's chart and, depending on facility policy, write an incident report. The nurse shouldn't give an extra dose at the next scheduled time because adverse reactions or toxicity could occur.
A client reports abdominal pain. When examining this client, when should the nurse collect data? Any quadrant first The symptomatic quadrant first The symptomatic quadrant last The symptomatic quadrant either second or third
The symptomatic quadrant last Explanation: The nurse should systematically collect data on all areas of the abdomen, if time and the client's condition permit, concluding with the symptomatic area. Otherwise, the nurse may elicit pain in the symptomatic area, causing the muscles in other areas to tighten. This tightening would interfere with further data collection.
Following a splenectomy, a client has a hemoglobin (Hb) level of 7.5 g/dl and has vertigo when getting out of bed. The nurse suspects abnormal orthostatic changes. The vital sign values that would most support the nurse's suspicions are: rise in blood pressure and heart rate. rise in blood pressure and drop in heart rate. drop in blood pressure and heart rate. drop in blood pressure and rise in heart rate.
drop in blood pressure and rise in heart rate. Explanation: The client had blood loss during the splenectomy and developed subsequent anemia. With a subnormal Hb level and vertigo when getting out of bed, the nurse is accurate in suspecting orthostasis. Orthostatic changes develop from hypovolemia and cause a drop in blood pressure and a compensatory rise in the heart rate when the client rises from a lying position.
An adolescent client ingests a large number of acetaminophen tablets in an attempt to commit suicide. Which laboratory result is most consistent with an acetaminophen overdose? metabolic acidosis elevated liver enzyme levels increased serum creatinine level increased white blood cell (WBC) count
elevated liver enzyme levels Explanation: Elevated liver enzyme levels, which could indicate liver damage, are associated with acetaminophen overdose. Metabolic acidosis isn't associated with acetaminophen overdose. An increased serum creatinine level may indicate renal damage. An increased WBC count indicates infection.
Using which part of the hands is appropriate when performing chest compressions on a child between ages 1 and 8? heels of both hands heel of one hand index and middle fingers thumbs of both hands
heel of one hand Explanation: The heel of one hand is recommended for performing chest compressions on children between ages 1 and 8. Two hands are used for adult cardiopulmonary resuscitation. Chest thrusts administered with the middle and third fingers, and in some cases the thumbs of each hand, are used on infants younger than age 1.
A client has been taking a decongestant for allergic rhinitis. During a follow-up visit, which data collected by the nurse suggest that the decongestant has been effective? clear nasal drainage increased tearing less sneezing headache
less sneezing Explanation: Decongestants relieve congestion and sneezing and reduce labored respirations. When effective, decongestants constrict blood vessels and reduce swelling in the nasal mucosa, permitting freer passage of air and secretions. Because decongestants alleviate congestion, they also relieve headaches, which can be caused by congestion. Clear nasal secretions and increased tearing are not evidence the decongestant is working.
A child, age 8, is immobilized with a hip spica cast. To minimize the child's feelings of isolation, the nurse should: let the child visit the playroom daily. sit with the child for an hour in the room. place a telephone in the child's room. arrange a visit by a cooperative child from the same unit.
let the child visit the playroom daily. Explanation: School-age children need peer interaction and thrive on peer approval and acceptance. Allowing the child to visit the playroom daily provides a nonthreatening atmosphere for peer interaction and helps the child feel less isolated. Sitting with the child for an hour wouldn't foster the necessary peer interaction. Placing a telephone in the child's room would allow the child to communicate with family and friends but could reinforce feelings of isolation. Having another child visit would be appropriate only if the child is of the same age-group.
A client diagnosed with systemic lupus erythematosus and taking daily prednisone reports severe back pain after manually opening a garage door. What adverse effect of long-term corticosteroid therapy is most likely responsible for the pain? hypertension osteoporosis muscle wasting truncal obesity
osteoporosis Explanation: All of the options listed are adverse effects of long-term corticosteroid therapy; however, osteoporosis commonly causes compression fractures of the spine. The other adverse effects are not likely causes of severe back pain.
The nurse is applying an elastic bandage to a client's arm. In order to prevent circulatory impairment, which method is best? wrap the bandage around the arm loosely stretch the bandage slightly while wrapping toward the heart apply heavy pressure with each turn of the bandage start applying the bandage at the upper arm and work toward the lower arm
stretch the bandage slightly while wrapping toward the heart Explanation: Stretching the bandage slightly maintains uniform tension on the bandage. Wrapping toward the heart promotes venous return to the heart. Wrapping the bandage loosely wouldn't secure it on the arm and wouldn't be therapeutic. Using heavy pressure would cause circulatory impairment. Wrapping from the upper arm to the lower arm would cause uneven application of the bandage.
A client is taking chlorpromazine as part of a treatment plan. Which response by the client indicates that the client understands the education about the drug? "I can reduce the dosage if I feel better." "It's okay if I have an occasional drink once in a while." "I should stop taking the drug immediately if adverse reactions develop." "I need to schedule appointments for routine medication checks."
"I need to schedule appointments for routine medication checks." Explanation: Ongoing assessment by a practitioner is important to assess for adverse reactions to chlorpromazine and continued therapeutic effectiveness. The dosage should be cut only after checking with the practitioner. Alcoholic beverages are contraindicated while taking an antipsychotic drug. Adverse reactions should be reported immediately to determine if the drug should be discontinued.
The nurse is providing teaching for a client with hepatitis A. Which statement by the client indicates the need to reinforce the teaching? "I should not share bath towels with my family." "I should not share utensils with my family." "Hand washing is very necessary after using the bathroom." "It is all right to French kiss my partner."
"It is all right to French kiss my partner." Explanation: Hepatitis A is an infection transmitted via the fecal-oral route. The client should not share bath towels and utensils with family members. Hand washing is essential to prevent transmission. French kissing the partner may cause transmission of the hepatitis infection and should not be encouraged.
The nurse has completed teaching about type 1 diabetes to a newly diagnosed adolescent client and the parent. Which client statement indicates an understanding of this teaching? "It is good that this condition will not require me to make a lot of life changes." "I will need to take insulin until I get my blood sugar under control." "It is important that I monitor myself carefully if I get sick." "My insulin needs will likely go up when I am physically active."
"It is important that I monitor myself carefully if I get sick." Explanation: Type 1 diabetes results from a lack of the body's ability to produce insulin. The client who understands that close monitoring is needed any time they become ill has demonstrated an understanding of the teaching. Failure to note symptoms of illness or of out of control blood sugar can result in the rapid progression to diabetic ketoacidosis, and, potentially, to diabetic coma. The client who thinks that type 1 diabetes does not require many life changes has not demonstrated an understanding of the teaching. The client who states that insulin is only taken until blood sugar is under control requires further teaching; insulin will be needed for life. The client who states that insulin needs will likely increase during activity needs to be corrected; glucose needs rise during activity, and insulin needs generally decrease.
The nurse is documenting a prenatal history of gravida 4, para 2 on the woman's clinic paperwork. The paperwork is sent to the birthing center for review. Upon the expectant mother's admission to the birthing center, the admission nurse is most correct to confirm which prenatal history? A client has been pregnant 4 times and had 2 miscarriages. A client has been pregnant 4 times and had 2 children born after 20 weeks of gestation. A client has been pregnant 4 times and had 2 cesarean deliveries. A client has been pregnant 4 times and had 2 spontaneous abortions.
A client has been pregnant 4 times and had 2 children born after 20 weeks of gestation. Explanation: Gravida refers to the number of times a client had been pregnant; para refers to the number of viable children born after 20 weeks of gestation. Therefore, the client who is gravida 4, para 2 has been pregnant 4 times and had 2 live-born children.
When caring for a client experiencing an acute gout attack, the nurse anticipates administering which medication? Allopurinol Colchicine Prednisone Propoxyphene hydrochloride
Colchicine Explanation: The physician usually prescribes colchicine for a client experiencing an acute gout attack. This drug decreases leukocyte motility, phagocytosis, and lactic acid production, thereby reducing urate crystal deposits and relieving inflammation. Allopurinol is used to decrease uric acid production in clients with chronic gout. Although corticosteroids are prescribed to treat gout, the nurse wouldn't give them because they must be administered interarticularly to this client. Propoxyphene, an opioid, may be used to treat osteoarthritis.
A client must be placed on airborne precautions for several days. To help meet the client's emotional needs, what should the nurse do? Tell the client that family members and significant others can't visit but may telephone at any time. Gently explain that the client's movements must be limited while in the isolation room. Describe the reasons for isolation and how it's carried out, and provide reassurance. Tell the client to bring whatever personal items are desired into the isolation unit.
Describe the reasons for isolation and how it's carried out, and provide reassurance. Explanation: To meet the client's need for information and help reduce anxiety, the nurse should describe the reasons for isolation and how it's carried out and also should provide reassurance and empathy. Visitors should be allowed to reduce the client's feelings of isolation. The client doesn't have to limit movements while in the isolation room. Unless personal items are needed, they usually aren't permitted in the isolation room.
Several days before admission, a client reports finding a small lump in the left breast near the nipple. What should the nurse tell the client to do? Inform the physician immediately. Squeeze the nipple to check for drainage. Check the area after her next menses. Put a heating pad on the area to reduce inflammation.
Inform the physician immediately. Explanation: The client should notify the physician immediately because a breast lump may be a sign of breast cancer. The client shouldn't squeeze the nipple to check for drainage until the physician examines the area. The client shouldn't wait until after her next menses to inform the physician of the breast lump because prompt treatment may be necessary. The client doesn't need to place a heating pad on the area because it would have no effect on a breast lump.
A client is experiencing an early postpartum hemorrhage. Which action by the nurse is most appropriate? Inserting an indwelling urinary catheter Performing fundal massage Administering packed red blood cells Performing a pad count
Performing fundal massage Explanation: The nurse should immediately perform fundal massage to ensure that the uterus is well contracted. After performing fundal massage, the nurse should notify the physician. The physician will likely order insertion of an indwelling catheter to make sure that a distended bladder, which prevents uterine contraction, isn't causing the hemorrhage. The physician will also prescribe an oxytocic agent. If hemorrhaging persists, the physician may prescribe packed red blood cells. A pad count is inappropriate in this situation.
A client with anorexia nervosa describes herself as "a whale." However, the nurse's data collection reveals that the client is 5' 8" (1.7 m) tall and weighs only 90 lb (40.8 kg). Considering the client's unrealistic body image, which intervention should be included in the plan of care? Asking the client to compare her figure with magazine photographs of women her age Assigning the client to group therapy in which participants provide realistic feedback about her weight Confronting the client about her actual appearance during one-on-one sessions, scheduled during each shift Telling the client of the nurse's concern for her health and desire to help her make decisions to keep her healthy
Telling the client of the nurse's concern for her health and desire to help her make decisions to keep her healthy Explanation: A client with anorexia nervosa has an unrealistic body image that causes consumption of little or no food. Therefore, the client needs assistance with making decisions about health. Instead of protecting the client's health, options 1, 2, and 3 may serve to make the client defensive and more entrenched in her unrealistic body image.
A school-age child is being discharged with a diagnosis of rheumatic fever. Which of the following should be included in the teaching plan for the family? The child should stay on penicillin and return for a follow-up appointment. At home, be sure to keep the child on bed rest. All children with rheumatic fever need monthly blood tests. The child should stay out of school until the source of the infection is determined.
The child should stay on penicillin and return for a follow-up appointment. Explanation: A child with rheumatic fever, which is caused by group A beta-hemolytic streptococci, should stay on penicillin — either oral daily or a monthly injection — to prevent a recurrence. A follow-up appointment is needed to determine how the child is responding to treatment. Neither bed rest nor monthly blood tests will be prescribed for all children. Rheumatic fever is caused by group A beta-hemolytic streptococci, so the source of the infection is already known.
A nurse is reinforcing education with a client on use of an incentive spirometer. The nurse identifies the teaching as successful when the client demonstrates which technique? blows quickly and hard into the mouthpiece inhales slowly and deeply through the nose inhales quickly and deeply through the mouthpiece inhales slowly and deeply through the mouthpiece
inhales slowly and deeply through the mouthpiece Explanation: The client should be taught to inhale through the mouth slowly and deeply through the mouthpiece of the incentive spirometer to properly inflate the alveoli. Blowing can cause the alveoli to collapse. Inhalation must occur through the mouth, not the nose. Inhalation should not be quick.
When assessing the neonate of a client who used heroin during her pregnancy, the nurse expects to find: lethargy 2 days after birth. irritability and poor sucking. a flattened nose, small eyes, and thin lips. congenital defects such as limb anomalies.
irritability and poor sucking. Explanation: Neonates of heroin-addicted mothers are physically dependent on the drug and experience withdrawal when the drug is no longer supplied. Signs of heroin withdrawal include irritability, poor sucking, and restlessness. Lethargy isn't associated with neonatal heroin addiction. A flattened nose, small eyes, and thin lips are seen in infants with fetal alcohol syndrome. Heroin use during pregnancy hasn't been linked to specific congenital anomalies.
A neonate born 8 weeks preterm has no spontaneous respirations but is successfully resuscitated. Within several hours, the neonate develops respiratory grunting, cyanosis, tachypnea, nasal flaring, and retractions and is diagnosed with respiratory distress syndrome, intubated, and placed on a ventilator. When implementing the neonate's plan of care, which intervention would be most appropriate to assist in preventing retinopathy of prematurity? covering the neonate's eyes while the neonate receives oxygen keeping the neonate's body temperature low monitoring partial pressure of oxygen (PaO2) levels Humidifying the oxygen.
monitoring partial pressure of oxygen (PaO2) levels Explanation: Monitoring PaO2 levels and reducing the oxygen concentration to keep PaO2 within normal limits reduces the risk of retinopathy of prematurity in a premature neonate receiving oxygen. Covering the neonate's eyes is appropriate for a neonate receiving phototherapy. Humidifying the oxygen aids in keeping the mucous membranes of the respiratory tract moist. Neither helps to reduce the risk of retinopathy of prematurity. Because cooling increases the risk of acidosis, the neonate should be kept warm to reduce the metabolic demands and prevent exacerbating his or her already stressed respiratory status.
A nurse is caring for a client who was admitted with pernicious anemia. Which set of findings should the nurse expect when gathering data for this client? reduced pulse pressure and hypotension pallor, tachycardia, and a sore tongue sore tongue, dyspnea, and weight gain angina, double vision, and anorexia
pallor, tachycardia, and a sore tongue Explanation: Pallor, tachycardia, and a sore tongue are all characteristic findings in pernicious anemia. Other clinical manifestations include anorexia; weight loss; a smooth, beefy red tongue; a wide pulse pressure; palpitations; angina; weakness; fatigue; and paresthesia of the hands and feet. Bradycardia, reduced pulse pressure, weight gain, and double vision are not characteristic findings in pernicious anemia.
A nurse working in the emergency department (ED) is caring for several clients. The nurse determines that obtaining informed consent for treatment would be unnecessary for which client? the client who is diagnosed with a mental illness the client who refuses to give informed consent the client who is bleeding profusely from a car crash the client who asks the nurse to give substituted consent
the client who is bleeding profusely from a car crash Explanation: The law does not require informed consent in an emergency situation such as the client who is bleeding profusely, when the client is unable to give consent and no next of kin is present. A mentally competent client may refuse or revoke consent at any time. The client may also refuse treatment. Even though a client who has been declared mentally incompetent cannot give informed consent, mental illness does not by itself indicate that the client is incompetent to give informed consent. Although the nurse may act as a client advocate, the nurse can never give substituted consent.
The nurse at a family health clinic is reinforcing educating a group of parents about normal infant development. What patterns of communication should the nurse tell parents to expect from an infant at age 1? squeals and makes pleasure sound understands "no" and other simple commands uses speechlike rhythm when talking with an adult uses multisyllabic babbling
understands "no" and other simple commands Explanation: At age 1, most babies understand the word "no" and other simple commands. Children at this age also learn one or two other words. Babies squeal, make pleasure sounds, and use multisyllabic babbling at age 3 to 6 months. Using speechlike rhythm when talking with an adult usually occurs between ages 6 to 9 months.
The nurse explains to new parents the importance of maintaining their infant's safety during hospitalization. Which action best ensures the infant's safety? Identifying and confronting suspicious-looking visitors Encouraging the parents to room-in with the infant Keeping security cameras and alarms activated at all times Instructing the mother to notify staff when she showers to avoid leaving the infant unattended
Instructing the mother to notify staff when she showers to avoid leaving the infant unattended Explanation: Parents should be instructed to avoid leaving the infant unattended in the hospital, even while simply showering. Confronting suspicious visitors is dangerous. Suspicious visitors should instead be reported to hospital security. Rooming-in promotes bonding but doesn't ensure infant safety. Infant abductions can occur despite locked units and security equipment.
A client undergoes hip-pinning surgery to treat an intertrochanteric fracture of the right hip. The nurse should include which intervention in the postoperative plan of care? Performing passive range-of-motion (ROM) exercises on the client's legs once each shift Keeping a pillow between the client's legs at all times Turning the client from side to side every 2 hours Maintaining the client in semi-Fowler's position
Keeping a pillow between the client's legs at all times Explanation: After hip pinning, the client must keep the affected leg abducted at all times; placing a pillow between the legs reminds the client not to cross the legs and to keep the leg abducted. Passive or active ROM exercises shouldn't be performed on the affected leg during the postoperative period because this could damage the operative site and cause hip dislocation. Most clients should be turned to the unaffected side, not from side to side. After hip pinning, the client must avoid acute flexion of the affected hip to prevent possible hip dislocation; therefore, semi-Fowler's position should be avoided.
A client is prescribed prednisone daily. Which statement best explains why the nurse should instruct the client to take this drug in the morning? Taking the drug at the same time every day establishes a regular routine, reducing the risk of forgetting a dose. Prednisone has a longer half-life with morning administration, which makes it more effective. Morning administration of prednisone mimics the body's natural corticosteroid secretion pattern. Prednisone is best absorbed when taken on an empty stomach first thing in the morning.
Morning administration of prednisone mimics the body's natural corticosteroid secretion pattern. Explanation: Early-morning prednisone administration mimics the circadian rhythm of natural corticosteroid secretion — higher in the morning and lower in the evening. Although establishing a regular medication routine helps prevent missing a dose, this isn't the reason for taking prednisone in the morning. The half-life of prednisone doesn't depend on the time of administration. The client should take prednisone with food or milk to minimize GI upset.
The nurse realizes she's 1 hour late in administering a dose of medication for her 4-year-old client. She gives the medication immediately and assesses the client. The client isn't harmed by the delay. Which action should the nurse take next? No further action is necessary. The nurse should notify the physician of the error. The nurse should follow facility procedures for reporting an error. The nurse should document a medication error in the client's chart.
The nurse should follow facility procedures for reporting an error. Explanation: Although no harm came to the client, this scenario is an example of a medication error. The nurse should follow the facility's procedure for reporting the error. Reporting the error allows the facility to assess the system's causes of medication errors, and isn't meant to place blame on any one person. The nurse, in this instance, doesn't need to notify the physician because there was no harm to the client. The nurse shouldn't document in the client's chart that an error took place; doing so may place her at risk in case of a lawsuit.
A 2-year-old child is diagnosed with bronchiolitis caused by respiratory syncytial virus (RSV). The client has an 8-year-old sibling. Which statement is correct? RSV isn't highly communicable in infants. RSV isn't communicable to older children and adults. The 2-year-old client must be admitted to the hospital for isolation. The siblings should be separated to prevent the spread of the infection.
The siblings should be separated to prevent the spread of the infection. Explanation: RSV is communicable among children and adults, so the siblings should be separated to prevent the spread of the infection. Older children and adults may have mild symptoms of the disorder. Hospitalization is indicated only for children who need oxygen and I.V. therapy.
The nurse evaluates a client who is 36-hours postoperative. Which sign or symptom indicates to the nurse that the client is experiencing a complication? presence of dark colored urine oral temperature of 100° F (37.8° C) a warm, erythematous tender incision white blood cell (WBC) count of 9.6 x 103/μl
a warm, erythematous tender incision Explanation: Redness, warmth, and tenderness around the incision area would lead the nurse to suspect a postoperative infection. The presence of dark colored urine does not necessarily indicate infection or a complication. An oral temperature of 100° F is a normal expectation in a postoperative client because of the inflammatory process. A normal WBC count ranges from 4-10 x 103/μl
A client comes to the clinic with back pain that has been unrelieved by continuous ibuprofen use over the past several days. Current prescription medications include captopril and hydrochlorothiazide. Which laboratory value should the nurse report? blood urea nitrogen (BUN) of 26 mg/dL and serum creatinine of 2.35 mg/dL sodium of 145 mEq/L and potassium of 5.4 mEq/L creatine phosphokinase of 21 U/L white blood cell count of 9,000 cells/mm3
blood urea nitrogen (BUN) of 26 mg/dL and serum creatinine of 2.35 mg/dL Explanation: Nonsteroidal anti-inflammatory drugs can decrease the antihypertensive effect of angiotensin-converting enzyme inhibitors and predispose clients to the development of acute renal failure as indicated by the increased levels of BUN and serum creatinine. The other lab values do not reflect damage to the kidneys.
The nurse cares for a client who is recovering from general anesthesia. Which finding indicates to the nurse that the client is experiencing a complication? decreased bibasilar breath sounds urine output 200 mL in 4 hours pale, dry mucous membranes 1+ pitting edema of the ankles
decreased bibasilar breath sounds Explanation: Decreased bibasilar breath sounds are a sign of atelectasis, and it can occur when a postoperative client fails to move, cough, and breathe deeply enough to expand the lungs and alveoli. Even though urinary retention is one of the common immediate postoperative complications, this client's urine output is within normal range (30 mL/hour). Postoperative fluid shifts can result in pale, dry mucous membranes, dehydration and peripheral edema, but the client is at greatest risk for atelectasis, which is an immediate threat to the client's recovery from anesthesia.
The client is being evaluated for hypothyroidism. The nurse should stay alert for: exophthalmos and conjunctival redness. flushed, warm, moist skin. systolic murmur at the left sternal border. decreased body temperature and cold intolerance.
decreased body temperature and cold intolerance. Explanation: Hypothyroidism markedly decreases the metabolic rate, causing a reduced body temperature and cold intolerance. Other signs and symptoms include dyspnea, hypoventilation, bradycardia, hypotension, anorexia, constipation, decreased intellectual function, and depression. The other options are typical findings in a client with hyperthyroidism.
When collecting data on an infant, which condition would alert the nurse as a subtle sign of hypothyroidism? diarrhea lethargy severe jaundice tachycardia
lethargy Explanation: Subtle signs of hypothyroidism that may be seen shortly after birth include lethargy, poor feeding, prolonged jaundice, respiratory difficulty, cyanosis, constipation, and bradycardia. Diarrhea in the neonate isn't normal and isn't associated with this disorder. Severe jaundice needs immediate attention by the primary health care provider and isn't a subtle sign. Tachycardia typically occurs in hyperthyroidism, not hypothyroidism.
When teaching the parents of a school-age child about signs and symptoms of fever that require immediate notification of the physician, which of the following descriptions should the nurse include? Burning or pain with urination Reports of a stiff neck Fever disappearing for longer than 24 hours, then returning History of febrile seizures
Reports of a stiff neck Explanation: A child with a fever and a stiff neck should be evaluated immediately for meningitis. All other symptoms should be addressed by the physician but can wait until office hours.
When caring for a client with a 3-cm stage II pressure ulcer on the coccyx, which action can the nurse institute independently? cleaning the wound three times per day with a povidone-iodine wash gently irrigating the wound with a normal saline solution and applying a protective dressing as necessary applying an antibiotic cream to the area three times per day cleaning the wound with a wound cleanser and applying a hydrogel wound dressing
gently irrigating the wound with a normal saline solution and applying a protective dressing as necessary Explanation: Gently irrigating the area with normal saline solution and applying a protective dressing are within the nurse's realm of interventions and will protect the area. Using a povidone-iodine wash, an antibiotic cream, and a hydrogel wound dressing require a physician's order.
A client tells a nurse, "I've been clean from drugs for the past 5 years, but my life really hasn't changed." Which concept should be explored with this client? further education conflict resolution career development personal development
personal development Explanation: True recovery involves changing the client's distorted thinking and working on personal and emotional development. Before the client pursues further education, conflict resolution skills, or career development, it's imperative to devote energy to emotional and personal development.
