Passpoint exam 2
The nurse is counseling a 5-year-old girl whose mother recently died. Which statement reflects typical understanding about death at this age?
"My mommy died last week, but I am going to see her again." Explanation: Five-year-old children view death as reversible, so talking about seeing her mother again is a normal statement for a child of this age. A child this age would not usually state that she was glad Jesus took her mom but instead might be afraid that God would also take her or her dad. The idea of replacing her mother with a new one, as hinted in the statement that they got another dog after the dog died, has not been supported by studies of grieving children. Stating that mommy went to heaven and that the child will see her someday when the child dies is reflective of more advanced abstract thinking than a 5-year-old would demonstrate.
The nurse is preparing the morning insulin for a diabetic client on the unit. The order is for 20 units of Humulin 70/30. The nurse knows that this dose contains a mixture of intermediate-acting insulin and fast-acting insulin. How many units of intermediate-acting insulin does this dose contain? Record your answer using a whole number.
14 Explanation: Recall that Humulin 70/30 insulin contains both intermediate-acting insulin and fast-acting insulin. The 70 and 30 represent the percentages of each kind (the first number always pertains to the percentage of intermediate-acting insulin; the second, to the fast-acting insulin). Therefore, to calculate the amount of intermediate-acting insulin, the nurse must multiply the total number of units to be given by 0.7: 0.7 X 20 units = 14 units of intermediate-acting insulin.
A nurse is caring for a client who has returned to his room after a carotid endarterectomy. Which action should the nurse take first?
Ask the client if he has trouble breathing. Explanation: The nurse should first assess the client's breathing. A complication of a carotid endarterectomy is an incisional hematoma, which could compress the trachea causing breathing difficulty for the client. Although the other measures are important actions, they aren't the nurse's top priority.
Which condition is commonly seen in clients who abuse cocaine?
Bipolar cycling Explanation: Clients who abuse cocaine experience the rapid cycling effect of excitement then severe depression. These clients don't tend to experience panic attacks, expressive aphasia, or attention deficits.
A woman who speaks Spanish only and is very upset brings her child to the clinic with bleeding from the mouth. Which is the appropriate first action by the nurse who does not speak Spanish?
Give the ice to the mother, and demonstrate what to do. Explanation: Any injury to the mouth results in copious amounts of blood because the mouth is a highly vascular area. Because the nurse does not know the mother and does not speak Spanish, the most appropriate action is to give the mother the ice and demonstrate what she is to do. The child will be less fearful if the ice is applied by the mother. Calling for an interpreter is appropriate after caring for the immediate need of the child. Grabbing the child away will probably upset the mother more, further adding to the stress experienced by the child.
When performing a physical examination on an anxious client, a nurse should expect to find which effect produced by the parasympathetic nervous system?
Hyperactive bowel sounds Explanation: The parasympathetic nervous system would produce increased GI motility, resulting in hyperactive bowel sounds, possibly leading to diarrhea. Decreased urine output, constipation, and muscle tension would result from sympathetic nervous system stimulation.
The nurse is caring for a client at 39 weeks gestation who is being induced with oxytocin. Which of the following are maternal and fetal side effects that the nurse should report to the healthcare provider? Select all that apply.
Hyperstimulation of the uterus Water intoxication Cephalopelvic disproportion Explanation: Hyperstimulation of the uterus, water intoxication, and cephalopelvic disproportion are maternal side effects that need to be reported to the healthcare provider. Fetal accelerations and moderate variability are not side effects of oxytocin.
Which is the priority of care for the nulliparous client who is in the active phase of the first stage of labor?
Implementing nonpharmacologic measures for pain relief Explanation: The active phase of labor may last up to 6 hours for the nulliparous woman. Nonpharmacologic measures for pain relief should be tried before pharmacologic measures, as this stage of labor can last for quite some time before intensifying. Respecting the client's privacy is a self-esteem need, which prioritizes lower than pain relief. Providing information and education are important but will not prioritize higher than the client's physiologic need for pain relief.
A client with angina is taking nifedipine. What instruction should the nurse give the client? Monitor blood pressure monthly. Perform daily weights. Inspect gums daily. Limit intake of green leafy vegetables.
Inspect gums daily. Explanation: The client taking nifedipine should inspect the gums daily to monitor for gingival hyperplasia. This is an uncommon adverse effect but one that requires monitoring and intervention if it occurs. The client taking nifedipine might be taught to monitor blood pressure, but more often than monthly. These clients would not generally need to perform daily weights or limit intake of green leafy vegetables.
What is one disadvantage of using the rectal route?
It can result in incomplete drug absorption. Explanation: Incomplete drug absorption is a disadvantage of rectal drug administration. The drug itself, not the way in which it is administered, may cause orthostatic hypotension or hypersensitivity reactions. If inserted properly, drugs administered rectally won't cause rectal tears.
Which circumstance would exempt the nurse from professional negligence following an error in drug administration to a client?
Lack of harm to the client as a result of the errant drug administration Explanation: The four essential components of a valid lawsuit are duty, breach of duty, injury to the client, and injury to the client as a result of negligence.
The nurse is assessing a client admitted to the emergency department following a rape. Which are the nurse's client and legal responsibilities? Select all that apply.
Place client's clothing in a labeled bag. Have a nurse of the same sex stay with the client. Call for the nurse trained in evaluation of sexual assault victims. Prepare client for complete physical examination including Pap smear. Recognize that assessment charting may be used in legal proceedings. Explanation: The nurse should recognize that clothing and physical evidence should be collected and preserved. The nurse should provide supportive care to the client victim of assault. If possible the nurse staying with the client should be the same sex as the client to decrease stress and anxiety. A rape crisis nurse or nurse trained in caring for victims of sexual assault should be called to assess the client and collect and preserve evidence. Accurate charting of physical and emotional findings will be important. The client should be followed for possible STDs within 3 weeks or sooner if any symptoms appear.
Which intervention should a nurse try first when caring for a client who exhibits signs of sleep disturbance?
Promote a bedtime routine such as a warm bath, back rubs, and snacks. Explanation: The nurse should begin with the simplest interventions, such as a warm bath or snacks, before introducing interventions that require greater skill and time such as teaching relaxation techniques. Sleep medication should be avoided whenever possible. Asking the client about the quality of his sleep is appropriate if simpler interventions fail.
A client with heart failure is admitted to an acute care facility and is found to have a cystocele. When planning care for this client, the nurse is most likely to formulate which nursing diagnosis?
Stress urinary incontinence Explanation: Stress urinary incontinence is a urinary problem associated with cystocele — herniation of the bladder into the birth canal. Other problems associated with this disorder include urinary frequency, urinary urgency, urinary tract infection, and difficulty emptying the bladder. Total incontinence, functional incontinence, and reflex incontinence usually result from neurovascular dysfunction, not cystocele.
The nurse is caring for a 5-year-old child who is cognitively challenged. The parents ask the nurse how best to foster independence in the child. Which of the following teaching points should the nurse emphasize? Select all that apply.
Teach one step at a time to facilitate short-term memory. Use generous praise as a reward for learning. Limit principles and abstract concepts in the teaching. Use repetition to reinforce learning. Explanation: Teaching a cognitively challenged child should incorporate teaching one step at a time, using praise and limiting abstract concepts. These steps help the child learn in an environment that is supportive. Teaching a cognitively challenged child within a group of other children may lead to distraction and unsuccessful learning. Children with cognitive challenges need to be in an environment with little extra stimuli so they can focus on learning.
The nurse is planning dietary needs with a client who is in the early postoperative period after nasal surgery. The nurse should tell the client to:
increase fluid intake. Explanation: Although foods as tolerated are encouraged, the nurse should encourage the client with nasal packing to increase fluid intake because fluids are easier for the client at this time because nasal packing makes eating difficult and uncomfortable. The packing blocks the passage of air through the nose, creating a partial vacuum during swallowing. Using a straw will increase the vacuum. Antiemetics are needed only if the client experiences nausea or vomiting. There is no need to limit intake of high-fiber foods.
At 38 weeks' gestation, a primigravid client with poorly controlled diabetes and severe preeclampsia is admitted for a cesarean birth. The nurse explains to the client that childbirth helps to prevent which complication?
stillbirth Explanation: Stillbirths caused by placental insufficiency occur with increased frequency in women with diabetes and severe preeclampsia. Clients with poorly controlled diabetes may experience unanticipated stillbirth as a result of premature aging of the placenta. Therefore, labor is commonly induced in these clients before term. If induction of labor fails, a cesarean section is necessary. Induction and cesarean section do not prevent neonatal hyperbilirubinemia, congenital anomalies, or perinatal asphyxia.
A client recently diagnosed with cancer informs the nurse that she values and finds comfort in her faith. The nurse is aware that faith is best defined as which of the following?
A belief in something for which there is no proof or material evidence. Explanation: Faith is a belief in something for which there is no proof or material evidence. Hope is a positive outlook even in the bleakest moments. Religion is an organized belief system about a higher power. Spiritual beliefs are practices associated with all aspects of a person's life.
A physician prescribes clomipramine for a client with obsessive-compulsive disorder (OCD). What instructions should the nurse include when teaching the client about this medication? Select all that apply.
Avoid hazardous activities that require alertness or good coordination until adverse central nervous system effects are known. Avoid alcohol and other depressants. Use saliva substitutes or sugarless candy or gum to relieve dry mouth. Explanation: Clomipramine, a tricyclic antidepressant used to treat OCD, may cause adverse CNS effects. Therefore, the nurse should warn the client to avoid hazardous activities that require alertness or good coordination until the drug's effects are known. The client should also be instructed to avoid alcohol and other depressants. Dry mouth, a common adverse effect of this medication, can be relieved with saliva substitutes or sugarless candy or gum. The nurse should tell the client to take the medication with meals (not on an empty stomach), especially during the adjustment period, to minimize adverse gastrointestinal effects. Later in therapy, the client can take the entire daily dose at bedtime. The nurse should encourage the client to continue therapy, even if adverse reactions are troublesome. The client should not stop taking the medication without medical advice.
The nurse is caring for a client in labor who is worried about having an episiotomy. Which of the following interventions will the nurse include in the client's plan of care? Select all that apply. Encouraging immediate pushing after epidural placement Avoiding the lithotomy position while pushing Placing warm or hot compresses on the perineum Avoiding side-lying position for pushing Encouraging a gradual expulsion of the infant
Avoiding the lithotomy position while pushing Placing warm or hot compresses on the perineum Encouraging a gradual expulsion of the infant Explanation: Avoiding the lithotomy position while pushing, placing warm or hot compresses on the perineum, and gradual expulsion of the infant are recommendations to prevent an episiotomy. Encouraging pushing after an epidural placement is inappropriate because the client will not be able to feel where to push. The side-lying position is recommended for prevention of an episiotomy.
While assessing a multigravid client at 10 weeks' gestation, the nurse notes a purplish color to the vagina and cervix. The nurse documents this as what finding?
Chadwick's sign Explanation: A purplish blue discoloration of the vagina and cervix is termed Chadwick's sign; it is caused by increased vascularity of the vagina during pregnancy and is considered a probable sign of pregnancy. Goodell's sign, also considered a probable sign of pregnancy, refers to a softening of the cervix during pregnancy. Hegar's sign, also a probable sign of pregnancy, refers to a softening of the lower uterine segment. Melasma, the mask of pregnancy, refers to the pigmentation of the skin on the face during pregnancy. Melasma is considered a presumptive sign of pregnancy.
When planning diet teaching for the client with a colostomy, the nurse should develop a plan that emphasizes which dietary instruction? Foods containing roughage should not be eaten. Liquids are best limited to prevent diarrhea. Clients should experiment to find the diet that is best for them. A high-fiber diet will produce a regular passage of stool.
Clients should experiment to find the diet that is best for them. Explanation: It is best to adjust the diet of a client with a colostomy in a manner that suits the client rather than trying special diets. Severe restriction of roughage is not recommended. The client is encouraged to drink 2 to 3 L of fluid per day. A high-fiber diet may produce loose stools.
The nurse is providing care to a client with Alzheimer's-type dementia. Which nursing intervention is the priority?
Control the environment by providing structure and consistent boundaries Explanation: By controlling the environment and providing structure and consistent boundaries, the nurse is helping to keep the client safe and secure. Establishing a routine that reinforces memories, supports former habits, maintains pleasant surroundings, and structures a daily routine fosters a supportive environment; however, keeping the client safe and secure is the priority.
The Women's Clinic nurse is instructing a client on the proper use of an applicator to instill vaginal cream. Which of the following instructions is applicable when teaching a client about vaginal medication insertion?
Direct the tip of the applicator toward the sacrum. Explanation: The normal position of the vagina slants up and back toward the sacrum. Directing the tip of the applicator toward the sacrum allows it to follow the normal slant of the vagina and minimizes tissue trauma. The applicator would be inserted about 2" (5 cm). The medication can be administered by placing continuous pressure until the tip of the plunger hits the applicator, taking 10 to 15 seconds. This eliminates the medication from the applicator placing it in the vagina. Should the applicator need to be reused, the applicator may be washed thoroughly and placed on a towel to dry.
The nurse is teaching dietary consideration to a client who had a gastric resection. The nurse understands that the instruction has been effective if the client says which of the following?
"I will lie down for 30 minutes after eating." Explanation: Client should lie down after eating, not sit up. Liquids are only taken between meals, not with meals, to prevent the onset of dumping syndrome. Fluids should be consumed after 1 hour before or after eating instead of during meals. Foods containing lactose and are high in sugar promote gastric emptying. Because the stomach has been reduced in size surgically, it is important to slow digestion as much as possible. Protein is required postsurgery for proper healing.
The nurse teaches a female client who has cystitis methods to relieve her discomfort until the antibiotic takes effect. Which response by the client would indicate that she understands the nurse's instructions?
"I will take hot tub baths." Explanation: Hot tub baths promote relaxation and help relieve urgency, discomfort, and spasm. Applying heat to the perineum is more helpful than cold because heat reduces inflammation. Although liberal fluid intake should be encouraged, caffeinated beverages, such as tea, coffee, and cola, can be irritating to the bladder and should be avoided. Voiding at least every 2 to 3 hours should be encouraged because it reduces urinary stasis.
A nurse completes an afternoon assessment of a client who is a nurse and who is visiting the area on vacation. The client states that the nurse must be having a busy shift and asks about the maximum number of clients that the nurse is allowed to care for. What is the nurse's best response?
"Some jurisdictions have staffing laws which allow for nurses to be involved in staffing ratios." Explanation: Staffing laws exist in some jurisdiction, but not others. Staffing laws tend to fall into one of three general approaches: The first is to require hospitals to have a nurse driven staffing committee which create staffing plans that reflect the needs of the patient population and match the skills and experience of the staff. The second approach is for legislators to mandate specific nurse to patient ratios in legislation or regulation. A third approach is requiring facilities to disclose staffing levels to the public and/or a regulatory body. A facility is required to disclose staffing levels to the public.
Which of the following variables should the nurse judge as least likely to indicate high risk when assessing a client's potential for suicide?
Angry behavior. Explanation: Anger is a low risk factor for suicide. Risk factors for completed suicide are hopelessness; medical illness; severe anhedonia (loss of ability to feel pleasure); male gender; Caucasian, Native American, or Aboriginal ethno-racial background; living alone; age 60 or older; unemployment; financial distress; or previous suicide attempt. Age 60 and older is a risk factor for completed suicide. Living alone is a risk factor for completed suicide. Previous suicide attempt is a risk factor for completed suicide.
A nurse is planning care for a client who has undergone a L4-L5 laminectomy. What is the most important intervention for the nurse to include on the first postoperative day? 2/10/2017 0900 56-year-old client underwent a L4-L5 lumbar laminectomy yesterday to alleviate pain caused by neural impingement from lumbar spinal stenosis. Client's progressing as expected.
Encourage the client to be out of bed Explanation: In most cases, clients should be out of bed the first postoperative day to prevent the formation of blood clots and skin breakdown. Frequent repositioning, use of a chair-like brace for the lower back when out of bed, and a firm mattress will help minimize complications.
A preterm neonate admitted to the neonatal intensive care unit at about 30 weeks' gestation is placed in an oxygenated isolette. The neonate's mother tells the nurse that she was planning to breastfeed the neonate. Which instructions about breastfeeding would be most appropriate? Breastfeeding is not recommended, because the neonate needs increased fat in the diet. Once the neonate no longer needs oxygen and continuous monitoring, breastfeeding can be done. Breastfeeding is contraindicated because the neonate needs a high-calorie formula every 2 hours. Gavage feedings using breast milk can be given until the neonate can coordinate sucking and swallowing.
Gavage feedings using breast milk can be given until the neonate can coordinate sucking and swallowing. Explanation: Many intensive care units that care for high-risk neonates recommend that the mother pump her breasts, store the milk, and bring it to the unit so the neonate can be fed with it, even if the neonate is being fed by gavage. As soon as the neonate has developed a coordinated suck-and-swallow reflex, breastfeeding can begin. Secretory immunoglobulin A, found in breast milk, is an important immunoglobulin that can provide immunity to the mucosal surfaces of the gastrointestinal tract. It can protect the neonate from enteric infections, such as those caused by Escherichia coli and Shigella species. Some studies have also shown that breastfed preterm neonates maintain transcutaneous oxygen pressure and body temperature better than bottle-fed neonates. There is some evidence that breast milk can decrease the incidence of necrotizing enterocolitis. The preterm neonate does not need additional fat in the diet. However, some neonates may need an increased caloric intake. In such cases, breast milk can be fortified with an additive to provide additional calories. Neonates who are receiving oxygen can breastfeed. During feedings, supplemental oxygen can be delivered by nasal cannula.
Which nursing action is appropriate when planning care for a client who is being battered? Select all that apply.
Give information about a safe home. Provide a cell phone and the crisis help line telephone number. Teach the client about the cycle of violence. Discuss the client's legal and personal rights. Explanation: When working with a battered client, the nurse should give information about a safe home and provide a cell phone and information about the crisis help line. The nurse should also help the client understand the cycle of violence as well as personal and legal rights. The nurse should help the client share and discuss her anger, frustration, guilt, shame, and other feelings. Displacing, that is, placing feelings onto another person or object, is not helpful to the client and is not a healthy way to handle feelings.
A high school student tells a nurse in an outpatient clinic the reason he is depressed and suicidal is that he is being bullied at school. While discussing the circumstances of the bullying, the student indicates he is gay, which he thinks contributes to his being bullied. He tells the nurse his sexual orientation in confidence, stating that his parents do not know and that he does not want that information revealed to them. Which actions should the nurse take? Select all that apply.
Give the client the crisis line phone number and contact information for a support group for gay teens. Question the client about the bullying and his current status regarding suicidal thoughts/plans. Help him develop a safety plan regarding suicidal thoughts/plans. Notify the school about the bullying without identifying the specific student. Explanation: Exploring the bullying and giving the student resources as well as planning for his safety will help the client remain safe. Notifying the school is essential to ensuring the safety of other students in the community. Notifying the parents against the client's wishes destroys trust and could make him feel more desperate. A better action would be to help the student prepare to reveal his sexual orientation to his parents.
A client is admitted to the emergency department with an acute coronary syndrome. The client reports a history of atrial fibrillation and a stroke 1 month ago. What is the appropriate action of the nurse? Hold the administration of alteplase (tPA) Administer the full dose of alteplase (tPA) Administer the half of the prescribed dose of alteplase (tPA) Assess the client's PTT, PT, and INR levels
Hold the administration of alteplase (tPA) Explanation: Due to the risk of bleeding, a recent stroke (within 2 months) is an absolute contraindication to thrombolytic therapy. The nurse should hold the administration of alteplase (tPA) and notify the healthcare provider. Remediation:
A nurse is preparing a teaching plan for a client who was prescribed enalapril maleate for the treatment of hypertension. Which instructions would the nurse include in the teaching plan? Select all that apply.
Instruct the client to avoid salt substitutes. Advise the client to report facial swelling or difficulty breathing immediately. Advise the client not to change the position suddenly to minimize the risk of orthostatic hypotension. Explanation: The nurse would tell the client to avoid salt substitutes because they may contain potassium, which can cause light-headedness and syncope. Facial swelling or difficulty breathing would be reported immediately because they may be signs of angioedema, which would require discontinuation of the drug. The client would also be advised to change positions slowly to minimize the risk of orthostatic hypotension. The nurse would tell the client to report light-headedness, especially during the first few days of therapy, so dosage adjustments can be made. The client would also report signs of infection, such as sore throat and fever, because the drug may decrease the white blood cell (WBC) count. Because this effect is generally seen within 3 months, the WBC count and differential should be monitored periodically.
A nurse manager of the crisis access center of a psychiatric facility in a major city notices a sudden increase in the number of incoming calls one afternoon. After quickly surveying the call sheets, the nurse finds that most callers are very anxious after military aircraft flew very low over the city. Which strategies would be most appropriate in this situation? Select all that apply.
Instruct the crisis workers to additionally screen callers about where they were during the 9/11/2001 attacks and their memories of that event. Give the crisis workers a list of symptoms of posttraumatic stress disorder (PTSD) and techniques for dealing with these symptoms. Give the crisis workers a list of symptoms of posttraumatic stress disorder (PTSD) and techniques for dealing with these symptoms. Ask for an emergency meeting with the managers of the inpatient and outpatient services to formulate a contingency plan for increased services if needed. Ask the major media outlets in the city to make a scripted public service announcement about the possible recurrence of symptoms experienced after the events of 9/11/2001. Prepare for a scripted interview with the local media about PTSD symptoms and techniques for dealing with these symptoms. Explanation: All of the options are correct and in an appropriate sequence of actions except for option 6. The flyover is likely to trigger vivid memories and emotions in those living near the city related to the tragedy of the Twin Towers on 9/11/2001. The severity of the flashbacks will vary in degree, just as they did after the original event. Asking the military for an apology will not address the caller's symptoms.
A mother is discontinuing breast-feeding after 3-1/2 months. The mother is seeking education on what to feed her baby now that she is no longer breast-feeding. The nurse teaches the mother about infant feeding and suggests the following:
Iron-fortified formula alone Explanation: The American Pediatric Society (Canadian Pediatric Society and Health Canada) recommends iron-rich formula for 5-month-old infants and cautions against giving infants solid food — even baby food — until 4 to 6 months of age. The American Pediatric Society (Canadian Pediatric Society and Health Canada) does not recommend whole milk before the age of 12 months or skim milk before the age of 2 years.
A pregnant client complains of nausea every morning and again before meals. As a result of the nausea, she's been unable to eat enough and has lost weight. Which nonpharmacologic intervention should the nurse recommend? Drinking water with every meal Keeping crackers at the bedside to eat before getting out of bed Eating three large meals per day Drinking liquids with dry foods
Keeping crackers at the bedside to eat before getting out of bed The nurse should advise the client to keep crackers at the bedside because eating dry crackers before getting out of bed and before the stomach becomes empty helps prevent nausea. Drinking water with every meal does not alleviate nausea. Eating six small meals per day, rather than three large meals, prevents nausea by preventing the stomach from becoming empty. Drinking liquids with dry food increases nausea. The client should be instructed to wait at least 30 minutes to consume liquids after eating dry food.
Following the discharge of a client from the day clinic, the nurse cannot find the client's health record (chart). Which of the following steps taken by the nurse would be most appropriate? Document the most recent care from memory. Notify the client that the record is missing. Create a new health record (chart) for the client. Ensure that the next shift is aware that the client was discharged.
Notify the client that the record is missing. Explanation: The client must be notified of the missing record and updated as the search progresses. The other options are incorrect because they do not describe the steps that must be taken when a health record is missing. The records must be tracked and an incident report completed.
A postoperative client has an abdominal incision. While getting out of bed, the client reports feeling a "pulling" sensation in the abdominal wound. The nurse assesses the client's wound and finds that it has separated and that the abdominal organs are protruding. Which nursing interventions are most appropriate at this time? Select all that apply.
Notify the client's primary physician. Cover the wound with saline-soaked sterile guaze. Explanation: Dehiscence (separation of the surgical incision) and evisceration (protruding of the abdominal organs) are considered medical emergencies. Therefore, the client's physician should be notified immediately and the nurse should prepare the client for surgery. While the nurse is waiting for the physician to arrive, the wound and the abdominal organs should be covered with saline-soaked sterile gauze. Saline is an isotonic solution that prevents damage to the client's tissue, and sterile gauze is used to prevent wound infection. Even though wound infection is the most common cause of dehiscence, administering antibiotics without a physician's order is not permissible and can result in the loss of a nursing license. An abdominal binder may be appropriate but only after the client returns from the operating room and with a physician's order. Pushing the organs back into the abdomen is inappropriate and could result in rupture, hemorrhage, or strangulation of the bowel. The nurse should also monitor the client's vital signs.
A child is admitted with a diagnosis of possible appendicitis. The child is in acute pain. Which nursing intervention would be appropriate prior to surgery to decrease pain? Select all that apply.
Offer an ice pack. Encourage the child to assume a position of comfort. Limit the child's activity. Explanation: Cold is a vasoconstrictor and supplies some degree of anesthesia. The child is usually more comfortable on his side with his legs flexed to take the strain off the inflamed appendix. Limiting the child's activity puts less stress on the inflamed appendix and lessens the discomfort. Heat increases circulation to an area, causing more engorgement and pain and, possibly, rupture of the appendix. Heat is contraindicated in any situation where rupture or perforation is a possibility. A cathartic is contraindicated when appendicitis is suspected. Increasing peristalsis can cause the appendix to rupture.
A client with a history of polysubstance abuse is admitted to the facility. He complains of nausea and vomiting 24 hours after admission. The nurse who assesses the client notes piloerection, pupillary dilation, and lacrimation. The nurse suspects that the client is going through withdrawal from which substance?
Opioids Explanation: Piloerection, pupillary dilation, and lacrimation are specific to opioid withdrawal. A client with alcohol withdrawal would show elevated vital signs. There is no real withdrawal from cannabis. Symptoms of cocaine withdrawal include depression, anxiety, and agitation.
A suicidal client is placed in the seclusion room and given lorazepam because she tried to harm herself by banging her head against the wall. After 10 minutes, the client starts to bang her head against the wall in the seclusion room. What action should the nurse take next?
Place the client in restraints. Explanation: The nurse and staff should place the client in restraints to protect her from further self-harm. The client's behavior is out of control and necessitates external controls for her safety. The healthcare team is trained to deal with this type of behaviors so there is no reason to call hospital security at this time. Calling the HCP for additional medication prescriptions is not appropriate because the lorazepam given by the nurse may take effect if the client remains still. The nurse is responsible for judging whether additional medication is needed later. Instructing a staff member to sit in the room with the client is unsafe for the client and the staff member.
A client is admitted to the postanesthesia care unit following a left hip replacement. The initial nursing assessment is: temperature, 96.6° F (35.9° C); pulse, 90 bpm; respiration rate, 14 breaths/min; and blood pressure, 128/80 mm Hg. The client only responds with moaning when spoken to. What should the nurse do first? Observe the surgical dressing. Position the client on the right side. Remove the oral airway remaining from surgery. Administer sedation reversal agent such as flumazenil.
Position the client on the right side. Explanation: During the immediate postanesthesia period, the unconscious client should be positioned on the side to maintain an open airway and promote drainage of secretions; because of the type of surgery, the client should be positioned on the right side. Removing the oral airway and observing the surgical dressing is appropriate, but other actions should be implemented before these. Respiratory depression can occur in a client after a procedure requiring sedation. If the client cannot be aroused, the sedation drugs can be reversed by administering a sedation reversal agent, but this client's respiratory rate is 14, and the client is moaning, indicating expected recovery from anesthetics.
A client is in the operating room having surgery to replace a hip. Prior to starting the surgery, there is confusion about the view of the hip on the x-ray The surgical team requests a "time out" and stops the surgery. When can surgery continue? Select all that apply.
The surgeon verifies the correct procedure. The surgeon verifies correct surgical site. The surgical team identifies the client using two sources of identification. Explanation: When a "time out" is called prior to surgery, the surgical team must read back all orders, verify the correct site, identify the client again and double-check the echocardiogram. The sterile field has not been disrupted and does not need to be set up again. It is not necessary to obtain another x-ray as long as the confusion is clarified and the surgical team is satisfied all are ready to begin the surgery.
When performing a scrotal examination, a nurse finds a nodule. What should the nurse do next?
Transilluminate the scrotum. Explanation: The nurse who discovers a nodule, swelling, or other abnormal finding during a scrotal examination should transilluminate the scrotum by darkening the room and shining a flashlight through the scrotum behind the mass. A scrotum filled with serous fluid transilluminates as a red glow; a more solid lesion, such as a hematoma or mass, doesn't transilluminate and may appear as a dark shadow. Although the nurse should notify the physician of the abnormal finding, performing transillumination first provides the physician with additional information. The nurse can't uncover more information about a scrotal mass by changing the client's position and repeating the examination or by performing a rectal examination.
A nurse is preparing a discharge teaching plan for a client with atopic dermatitis. Which instruction should the nurse include in her teaching plan? Wear only synthetic fabrics. Use a topical skin moisturizer daily. Bathe only three times per week. Keep the thermostat above 75° F (23.9° C ).
Use a topical skin moisturizer daily. Explanation: The nurse should instruct the client to use a topical skin moisturizer daily to help keep the skin hydrated. Likewise, the client should be encouraged to bathe daily. To minimize irritation, the client should wear only cotton fabrics. The client should maintain a room temperature between 68° F (20° C) and 72° F (22.2° C).
The nurse is assessing a client diagnosed with liver cancer. What findings are consistent with this diagnosis? Select all that apply.
Weight gain Decrease in appetite Palpable enlarged liver Ascites fluid wave Explanation: Advancing liver cancer involves an enlarged liver, fluid shift and retention, especially in the abdominal cavity, demonstrated by the ascites fluid wave. This also causes weight gain. A decrease in appetite results from fluid pressure in the abdomen. Fever is not specifically associated with liver cancer.
A nurse is obtaining consent for a bone marrow aspiration. Which actions should the nurse take? Select all that apply.
Witness the client signing the consent form. Evaluate that the client understands the procedure. Verify that the client is signing the consent form of his or her own free will. Determine that the client understands postprocedure care. Explanation: The nurse can serve as a witness for consent for procedures. The nurse also ascertains whether the client has an understanding that is consistent with the procedure listed on the form, determines that the client is signing the consent of his or her own free will, and determines that the client understands post-procedure care. The nurse's role does not include explaining the risks of the procedure; that responsibility belongs to the person who is to perform the procedure, such as the health care provider (HCP).
The nurse has received a change-of-shift report. The nurse should assess which client first? a 72-year-old admitted 2 days ago with a blood alcohol level of 0.08 a 36-year-old with chest tube due to spontaneous pneumothorax with current respiratory rate 18 breaths/min, oxygen saturation 95% on oxygen at 2 L per nasal cannula a 28-year-old who is 2 days postappendectomy with discharge prescriptions written and whose husband is waiting to take her home a 62-year-old admitted with a recent gastrointestinal (GI) bleeding whose hemoglobin is 13.8 g/dL (138 g/L)
a 72-year-old admitted 2 days ago with a blood alcohol level of 0.08 Explanation: The nurse should closely monitor the client admitted with an elevated blood alcohol level for several hours for signs and symptoms of withdrawal, administering sedation as needed; delirium tremens, the most severe form of withdrawal, usually peaks at 48 to 72 hours following the last drink. The client with the chest tube is not in any distress and has no pressing needs. For an older client who has had GI bleeding, a hemoglobin of 13.8 g/dL (138 g/L) is within normal limits. After assessing all clients' needs, the nurse will prepare the client who had an appendectomy for discharge as soon as possible.
What activity orders would be appropriate for a client with an internal radium implant for cervical cancer? out of bed as tolerated within the room bed rest with bathroom privileges bed rest in position of comfort bed rest with the head of the bed flat
bed rest with the head of the bed flat Explanation: The client with a cervical implant is kept on strict bed rest, flat in bed. Limitation of movement is designed to prevent accidental displacement or dislodgment of the implant. Client knowledge and understanding are critical to compliance with these restrictions. The client will not be allowed out of bed while the implant is in.
A nurse is caring for a client with an ileal conduit. When assessing the stoma, which outcomes are not desirable? Select all that apply.
dermatitis bleeding fungal infection Explanation: Dermatitis with alkaline encrustations may occur when alkaline urine comes in contact with exposed skin. Yeast infections (or fungal infections) are another common peristomal skin problem. If the stoma is irritated from rubbing, there will be bleeding. The nurse and client should avoid irritating the stoma. Adhesive solvent should be used on a gauze pad to remove old adhesive and should, therefore not contact the stoma directly. Only a minimal amount of skin cement is applied to the faceplate of the collection bag and skin to secure the appliance over the stoma, so obstruction of the stoma by the cement would not be possible if correct technique is followed.
When performing Leopold's maneuvers on a primigravid client at 22 weeks' gestation, the nurse performs the first maneuver to accomplish which action?
determine what is in the fundus Explanation: In the first maneuver, which is done with the nurse facing the client's head, both hands are used to palpate and determine which fetal body part (e.g., the head or buttocks) is in the fundus. This first maneuver helps to determine the presenting part of the fetus. In the second maneuver, also done with the nurse facing the client's head, the palms of both hands are used to palpate the sides of the uterus and determine the location of the fetal back and spine. In the third maneuver, one hand gently grasps the lower portion of the abdomen just above the symphysis pubis to determine whether the fetal head is at the pelvic inlet. The fourth maneuver, done with the nurse facing the client's feet, determines the degree of fetal descent and flexion into the pelvis.
Total parenteral nutrition (TPN) is prescribed for a client who has recently had a significant small and large bowel resection and is currently not taking anything by mouth. The nurse should:
handle TPN using strict aseptic technique. Explanation: Total parenteral nutrition (TPN) is a hypertonic, high-calorie, high-protein intravenous (IV) fluid that should be provided for clients who do not have functional gastrointestinal track motility, in order to better meet metabolic needs of the client, and to support optimal nutrition and healing. TPN is prescribed once daily, based on the client's current electrolyte and fluid balance, and must be handled with strict aseptic technique (due to the high glucose content, it is a perfect medium for bacterial growth). Also, because of the high tonicity, TPN must be administered through a central venous access, not a peripheral IV line. There is no specific need to auscultate for bowel sounds to determine whether TPN can safely be administered.
Even when the client understands problems and is motivated to change, the client may have fears about failing. Which intervention is most likely to facilitate change?
having the client practice new behaviors Explanation: Practicing new behaviors builds confidence and reinforces appropriate behaviors. Reality testing, asking about fears, and teaching new communication skills are some of the many steps when trying out new behaviors.
The nurse is caring for a client with an exacerbation of ulcerative colitis. The nurse should instruct the client to: maintain a high-fiber diet. avoid lifting more than 5 pounds (2.3 kg). obtain frequent rest periods. use antidiarrheal medications regularly.
obtain frequent rest periods. Explanation: It is important for the client to have frequent rest periods. Repeated episodes of diarrhea interrupt sleep patterns, and poor nutrition may also cause the client to feel weak. If the client is experiencing a severe exacerbation of ulcerative colitis, bed rest may be prescribed. Antidiarrheal medications can be used selectively in ulcerative colitis but are not recommended for regular use as they can lead to colonic dilation. The client should maintain a low-residue, high-calorie, caffeine-free diet. It is not necessary to limit weight lifting.
After instructing a 20-year-old nulligravid client about adverse effects of oral contraceptives, the nurse determines that further instruction is needed when the client states which as an adverse effect? weight gain nausea headache ovarian cancer
ovarian cancer Explanation: The nurse determines that the client needs further instruction when the client says that one of the adverse effects of oral contraceptive use is ovarian cancer. Some studies suggest that ovarian and endometrial cancers are reduced in women using oral contraceptives. Other adverse effects of oral contraceptives include weight gain, nausea, headache, breakthrough bleeding, and monilial infections. The most serious adverse effect is thrombophlebitis.
When preparing a 20-month-old for removal of a foreign body in the nasal passage by the health care provider (HCP), the nurse should use which method of restraint? jacket restraint elbow restraint use of father to hold papoose board
papoose board Explanation: Because a toddler is strong and moves frequently, the child needs to be restrained during the removal procedure by a total body restraint. To protect the child, the papoose board is best because the arms, legs, chest, and head can be fully restrained. A jacket restraint would immobilize only the child's upper body. Elbow restraints would immobilize only the child's arms. The father should be available to provide comfort before and after the procedure but not to hold the child down during the procedure.
After teaching a multiparous client about the effects of hemolysis due to Rh sensitization on the neonate at birth, the nurse determines that the client needs further instruction when the mother reports that the neonate may have which complication?
polycythemia Explanation: The Rh-sensitized neonate generally does not have problems related to polycythemia. Therefore, the client needs additional teaching. In general, moderate to severe Rh sensitization can cause anemia, enlarged spleen, and cardiac decompensation. Cardiac decompensation (as in heart failure) occurs because of severe anemia. Anemia is caused by the destruction of red blood cells by antibodies as the severity of hemolytic disease of the neonate increases. Splenic enlargement is caused by the excessive destruction of fetal red blood cells.
The nurse should instruct the family of a child with newly diagnosed hyperthyroidism to: keep their home warmer than usual. encourage plenty of outdoor activities. promote interactions with one friend instead of groups. limit bathing to prevent skin irritation.
promote interactions with one friend instead of groups. Explanation: Children with hyperthyroidism experience emotional lability that may strain interpersonal relationships. Focusing on one friend is easier than adapting to group dynamics until the child's condition improves. Because of their high metabolic rate, children with hyperthyroidism feel too warm. Bright sunshine may be irritating because of disease-related ophthalmopathy. Sweating is common, and bathing should be encouraged.
While assessing the fundus of a multiparous client 36 hours after birth of a term neonate, the nurse notes a separation of the abdominal muscles. The nurse should tell the client:
to perform exercises involving head and shoulder raising in a lying position. Explanation: The client is experiencing diastasis recti, a separation of the longitudinal muscles (recti) of the abdomen that is usually palpable on the third postpartum day. An exercise involving raising the head and shoulders about 8 inches (20.3 cm) with the client lying on her back with knees bent and hands crossed over the abdomen is preferred. This exercise helps to pull the abdominal muscles together, and the client gradually works up to performing this exercise 50 times per day. However, until the diastasis has closed, the client should avoid exercises that rotate the trunk, twist the hips, or bend the trunk to one side, because further separation may occur. The condition does not need a surgical repair, and limited activity and bed rest are not necessary. Correct posture and adequate diet assist the body to return to its prepregnancy state more quickly but do not resolve the separation of abdominal muscles.
