PassPoint NCLEX

1)Perform hand hygiene. 2)Secure a gait belt around client's waist. 3)Place the cane in the right hand. 4)Hold the cane on the right side and advance the left leg. 5)Advance the cane 6 to 10 inches (15 to 25 cm) with each step.

A nurse explains the process of cane usage to a hospitalized client with left-sided weakness. Prioritize the steps of proper cane usage. All options must be used. -Perform hand hygiene. -Secure a gait belt around client's waist. -Place the cane in the right hand. -Hold the cane on the right side and advance the left leg. -Advance the cane 6 to 10 inches (15 to 25 cm) with each step.

d)tympanic temperature of 94° F (34.4° C) Explanation: Hypothyroidism leads to a hypodynamic state, so a low body temperature is expected after the levothyroxine has been metabolized. Each of the other symptoms is indicative of a hypermetabolic state, and, although the client may exhibit these problems, they're probably related to infection and dehydration.

An unemployed client cannot afford prescription medications and has not taken the prescribed levothyroxine for some time. The client reports, "I've been getting sicker by the day." Which symptom is most likely related to not taking this medication? a)diarrhea and vomiting b)rapid heart rate c)warm, dry, flushed skin d)tympanic temperature of 94° F (34.4° C)

c)Use sunglasses that wrap around the side of the face when in bright light. Explanation: To prevent discomfort from bright light the client should wear sunglasses that cover the front and side of the face, thus minimizing light that comes into the eye from any direction. It is not necessary to remain in dim light or inside. Attaching sun shields or sunglasses to existing glasses will not cover the eye sufficiently, and bright light will come in on the side of the face. It is not necessary to patch the affected eye.

One day after cataract surgery, the client is having discomfort from bright light. What should the nurse advise the client to do? a)Dim lights in the house and stay inside for one week. b)Attach sun shields to existing eyeglasses when in direct sunlight. c)Use sunglasses that wrap around the side of the face when in bright light. d)Patch the affected eye when in bright light.

b)2 to 4 weeks Explanation: Full benefit from an antidepressant medication usually takes about 2 to 4 weeks on an adequate dose.

The nurse is counseling a client regarding treatment of the client's newly diagnosed depression. The nurse emphasizes that full benefit from antidepressant therapy usually takes how long? a)1 week b)2 to 4 weeks c)5 to 7 weeks d)8 weeks

c)high pitched gurgling noises in four abdominal quadrants Explanation: High-pitched gurgles heard in four abdominal quadrants are a normal finding. Decreased bowel motility causes two or three bowel sounds per minute; increased bowel motility causes hyperactive bowel sounds. Abdominal cramping causes hyperactive, high-pitched tinkling bowel sounds and may indicate a bowel obstruction.

The nurse is performing a focused assessment on a client's gastrointestinal system. Which assessment is an expected finding? a)two to three bowel sounds per minute b)high pitched, tinkling bowel sounds c)high pitched gurgling noises in four abdominal quadrants d)sounds heard only in bilateral lower quadrants

2.4 mL X = (Dose Desired)/(Dose on Hand or Dose Available) × milliliters/grams X =(700 mg)/1000 × (3.4 ml)/(1 g)=2.4 ml

The nurse prepares to give penicillin to a client with osteomyelitis. The healthcare provider has ordered 700 mg IM. The vial is a mix-o-vial containing drug powder and sterile water for injection. When mixed together the vial contains 1 g/3.4 ml. How much should the nurse draw up to give this client? Record your answer using one decimal place. _______ mL

a)lying down. Explanation: Hiatal hernia produces symptoms of esophageal reflux as the sphincter slides up into the negative-pressure environment of the thorax. The symptoms typically occur when the client is in a recumbent position.

The nurse would expect a client with a hiatal hernia to report that the symptoms worsen when the client is: a)lying down. b)physically active. c)upset or angry. d)sitting.

c)Reposition the child every 1 to 2 hours. Explanation: The child in a wet hip spica cast should be turned every 1 to 2 hours to help dry all sides of the cast and prevent skin breakdown. The abductor bar shouldn't be used for turning the child, even after the cast is dry. A wet cast shouldn't be covered with plastic because this will impede drying, reduce air circulation, and allow heat to build up in the cast. A wet cast should be handled using the palms, because fingertips may cause indentations and pressure points.

What is the most important nursing intervention when caring for a child with a newly applied wet hip spica cast? a)Use the abductor bar to help move the child. b)Cover the cast in plastic to keep it clean. c)Reposition the child every 1 to 2 hours. d)Use the fingertips when handling the cast.

b)droplet precautions Explanation: Group-A beta-hemolytic streptococcal infections are spread through droplets. Standard and contact precautions would not be sufficient to decrease transmission. Group-A beta-hemolytic streptococcal infections do not require specialized masks.

What type of isolation precautions would the nurse request for a child diagnosed with group-A beta-hemolytic streptococcus? a)universal precautions b)droplet precautions c)contact precautions d)airborne precautions

c)it adds strength to the cast Explanation: The abduction bar is incorporated into the cast to increase the cast's strength and maintain the legs in alignment. The bar cannot be removed or adjusted, unless the cast is removed and a new cast is applied. The bar should never be used to lift or turn the client because doing so may weaken the cast.

When teaching the family of an older infant who has had a spica cast applied for developmental dysplasia of the hip, which information should the nurse include when describing the abduction stabilizer bar? a)It can be adjusted to a position of comfort. b)It is used to lift the child. c)It adds strength to the cast. d)It is necessary to turn the child.

a)pH: 7.55, PaCO2: 60 mm Hg, HCO3-: 28 Explanation: The client's ABG would likely demonstrate metabolic alkalosis. Metabolic alkalosis is a clinical disturbance characterized by a high pH (decreased H+ concentration) and a high plasma bicarbonate concentration. It can be produced by a gain of bicarbonate or a loss of H+. A common cause of metabolic alkalosis is vomiting or gastric suction with loss of hydrogen and chloride ions. The disorder also occurs in pyloric stenosis where only gastric fluid is lost. The other results do not represent metabolic alkalosis.

Which of the following arterial blood gas (ABG) results would the nurse anticipate for a client with a 3-day history of vomiting? a)pH: 7.55, PaCO2: 60 mm Hg, HCO3-: 28 b)pH: 7.45, PaCO2: 32 mm Hg, HCO3-: 21 c)pH: 7.28, PaCO2: 25 mm Hg, HCO3: 15 d)pH: 7.34, PaCO2: 60 mm Hg, HCO3: 34

240 calories Explanation: Eight feedings x 45 mL per feeding equals 360 mL. 360 mL x 20cal/30 mL = 240 calories.

Commercial formulas contain 20 calories per 30 mL. A 1-day-old infant was fed 45 mL at 0200, 0530, 0800, 1100, 1400, 1630, 2000, and 2230. What is the total amount of calories the infant received today? Record your answer using a whole number.

b)Instruct the client to take at least two rest breaks during the workday. Explanation: Fatigue and frequent urination are early signs and symptoms of pregnancy that may continue through the first trimester. For the working pregnant client, it is advisable to take two 10- to 15-minute breaks within an 8-hour workday. While at home the client should nap or rest if she feels sleepy or tired. People need different amounts of sleep to help them feel rested. Telling the client to get 9 hours is a good suggestion, but it isn't helpful or practical if the client needs normally needs significantly more or less than that. In general, 7-8 hours is adequate. Modifying work hours can be suggested, but many times this is not something within the client's control. Fatigue will most likely improve during the second trimester, but that does not address the client's immediate concerns.

A 10-week pregnant client tells the nurse she is worried about the fatigue that is causing difficulty with functioning at work. How can the nurse best instruct this client about the relief of fatigue? a)Explain that fatigue will improve during the second trimester. b)Instruct the client to take at least two rest breaks during the workday. c)Instruct the client to get at least 9 hours of sleep each night. d)Instruct the client to modify work hours during the first trimester.

d)dizziness Explanation: Signs and symptoms of early salicylate toxicity include tinnitus, disturbances in hearing and vision, and dizziness. Salicylate toxicity may cause nausea, vomiting, diarrhea, and bleeding from mucous membranes from long-term use.Pink-colored urine, a slowed pulse rate, and chest pain, rarely occurring in children, are not associated with salicylate toxicity.

A 10-year-old child is taking high doses of aspirin. Which finding indicates the child is experiencing early salicylate toxicity? a)chest pain b)pink-colored urine c)slowed pulse rate d)dizziness

a)what the child knows about the disease. Explanation: When discussing a child's wishes for future care, a nurse must first identify what the child knows about the disease. How severe the child perceives the illness to be will significantly affect the child's thoughts about realistic outcomes. A care plan proposed by a child who doesn't understand the disease process or prognosis won't effectively or realistically reflect the child's actual health status. A child who doesn't understand the disease process or prognosis might feel frightened or threatened by questions about what interventions the child would like to have implemented in the event of cardiac or respiratory arrest. Although exploring the child's experiences with death would be important, it shouldn't be the initial area of discussion.

A 12-year-old child has been receiving aggressive treatment for leukemia for the past year. The child's prognosis is poor and the parents would like to implement a do-not-resuscitate order. They ask the nurse to discuss their decision with their child because they can't bring themselves to talk with the child about it. When approaching this subject with the child, the nurse must first assess: a)what the child knows about the disease. b)how the child would like to handle the care plan. c)what interventions the child would like implemented in the event of cardiac or respiratory arrest. d)the child's experiences with death.

b)assessment of bowel sounds c)characteristics of the first stool d)measurement of gastric output Explanation: A postoperative ileus is a functional obstruction of the bowel. Assessment of bowel sounds, the first stool, and the amount of gastric output provide information about the return of gastric function. Measurement of urine specific gravity provides information about fluid and electrolyte status; bilirubin levels provide information about liver function, and neither of these tests need to be included in a focused assessment for ileus.

A 2-month-old infant is at risk for an ileus after surgery to correct intussusception. What should be included in a focused assessment for this complication? Select all that apply. a)measurement of urine specific gravity b)assessment of bowel sounds c)characteristics of the first stool d)measurement of gastric output e)bilirubin levels

d)apple juice e)lime gelatin f)chicken broth Explanation: Clear liquids include clear broth, gelatin, clear juices, water, and ice chips. The client can see through clear liquids. Cream of chicken soup, orange juice, and ice cream are not clear liquids. They are included in a full liquid diet because the cream soup and ice cream have milk products and the orange juice has pulp.

A 7-year-old client is prescribed a clear liquid diet by the healthcare provider after tonsillectomy. What nutrition will the nurse give the child? Select all that apply. a)cream of chicken soup b)orange juice c)ice cream d)apple juice e)lime gelatin f)chicken broth

a)providing fluids Explanation: During a vaso-occlusive crisis, sickle-shaped red blood cells (RBCs) clump together and obstruct blood vessels, causing ischemia and tissue damage. Therefore, the highest priority is providing I.V. and oral fluids, which promotes hemodilution and aids the free flow of RBCs through blood vessels. The client must be kept away from known infection sources but doesn't require protective isolation. Warm compresses may be applied to painful joints to promote comfort; cool compresses would cause vasoconstriction, which exacerbates sickling. Antipyretics may be administered to reduce fever but don't play a crucial role in resolving the crisis.

A child with sickle cell anemia is admitted to the healthcare facility in vaso-occlusive crisis after developing a fever and joint pain. What is the nurse's highest priority when caring for this child? a)providing fluids b)maintaining protective isolation c)applying cool compresses to affected joints d)administering antipyretics as ordered

d)"What exactly are these terrible voices saying to you?" Explanation: The nurse needs to collect additional information about the client's report about hearing voices. Assessing the content of hallucinations is essential to determine whether they are command hallucinations that the client might act on. Asking about what the neighbor has been doing or telling the client that the neighbor will not visit indirectly reinforces the delusion about the neighbor. Although determining the onset and duration of the voices is important, the nurse needs to assess the content of the hallucinations first.

A client admitted in an acute psychotic state hears terrible voices in the head and thinks a neighbor is upset with the client. What is the nurse's best response? a)"What has your neighbor been doing that bothers you?" b)"How long have you been hearing these terrible voices?" c)"We won't let your neighbor visit, so you'll be safe." d)"What exactly are these terrible voices saying to you?"

d)The cells could cause various conditions and help identify a problem early. Explanation: The Pap smear identifies atypical cervical cells that may be present for various reasons. Cancer is the most common possible reason, but not the only one. The Pap smear does not show abnormal viral cells unless specific gene typing is done for human papillomavirus. An adequate smear provides accurate diagnostic data; the false-positive rate is only about 5%.

A client asks the nurse to explain the meaning of her abnormal Papanicolaou (Pap) smear result of atypical squamous cells. The nurse should tell the client that an atypical Pap smear means that what has occurred? a)Abnormal viral cells were found in the smear. b)Cancer cells were found in the smear. c)The Pap smear alone is not very important diagnostically because there are many false-positive results. d)The cells could cause various conditions and help identify a problem early.

c)diphenhydramine Explanation: Using benzodiazepines with other central nervous system depressants such as diphenhydramine produces additive effects. Alprazolam doesn't cause clinically significant drug interactions with levodopa, famotidine, or hormonal contraceptives such as norgestrel.

A client enters the crisis unit complaining of increased stress from studies as a medical student. The client reports increasing anxiety for the past month. The physician orders alprazolam, 0.25 mg by mouth three times per day, along with professional counseling. Before administering alprazolam, the nurse reviews the client's medication history. Which drug can produce additive effects when taken concomitantly with alprazolam? a)levodopa b)famotidine c)diphenhydramine d)norgestrel

a)pain Explanation: The client's change in sexual behavior is directly attributable to the pain from the injury. There is no evidence of depression, sexual dysfunction, or self consciousness.

A client experienced a pelvic fracture in a motor vehicle collision several months ago. Recovery has been slow. Among the challenges presented by this event is that sexual activity causes a dull ache in the pelvis. What client problem is the priority? a)pain b)depression c)sexual dysfunction d)self-consciousness

a)respiratory acidosis Explanation: The client's respiratory drive is depressed, resulting in alveolar hypoventilation, progressive carbon dioxide retention, narcosis, and coma. These symptoms, along with cardiovascular collapse and shock, require aggressive and intensive therapy if the client is to survive.

A client has been hospitalized with myxedema coma. What acid-base imbalance would be expected in this client? a)respiratory acidosis b)respiratory alkalosis c)metabolic acidosis d)respiratory alkalosis

d)hypopituitarism Explanation: Most clients who undergo adenoma removal experience a gradual return of normal pituitary secretion and do not experience complications. However, hypopituitarism can cause growth hormone, gonadotropin, thyroid-stimulating hormone, and adrenocorticotropic hormone deficits. The client should be taught to monitor for change in mental status, energy level, muscle strength, and cognitive function. In adults, changes in sexual function, impotence, or decreased libido should be reported. Acromegaly and Cushing's disease are conditions of hypersecretion. Diabetes mellitus is related to the function of the pancreas and is not directly related to the function of the pituitary.

A client has had an hypophysectomy. What signs of a potential complication should the nurse teach the client to report? a)acromegaly b)Cushing's disease c)diabetes mellitus d)hypopituitarism

c)Level of consciousness, pain level, and wound dressing Explanation: Postoperatively vital signs are taken to ensure that vital systems are returning to normal after anesthesia. It is also important to check the level of consciousness, particularly postanesthesia and postanalgesia. Pain levels need to be monitored. Dressings need to be checked to detect abnormal increase in bleeding. The nurse would not check metabolic rate and reflexes, emotional response, or social support systems as an initial assessment after surgery.

A client has just been transferred to the postanesthesia recovery room following a laparotomy. In addition to vital signs, what are the most important initial assessments that need to be completed? a)Skin color, warmth of extremities, and mental status assessment b)Metabolic rate, orientation, and presence of reflexes c)Level of consciousness, pain level, and wound dressing d)Emotional status, response to anesthesia, and social support systems

b)blood pressure elevation Explanation: Albumin is a colloid that remains in the intravascular space, pulling fluid out of the intracellular and interstitial space. The client with nephrotic syndrome loses excessive amounts of protein, mainly albumin, in the urine. Because fluid is drawn into the intravascular space, blood pressure will increase. Crackles in the lung bases and cerebral edema are signs of circulatory overload or fluid volume excess. When edema is present in lower extremities, the skin feels cool to the touch unless an infection is present.

A client has nephrotic syndrome. To aid in the resolution of the client's edema, the health care provider prescribes 25% albumin. In addition to an absence of edema, the nurse should evaluate the client for which expected outcome? a)crackles in the lung bases b)blood pressure elevation c)cerebral edema d)cool skin temperature in lower extremities

d)Administer an opioid analgesic as prescribed. Explanation: If infection or blockage caused by calculi is present, a client can experience sudden severe pain in the flank area, known as renal colic. Pain from a kidney stone is considered an emergency situation and requires analgesic intervention. Withholding fluids will make urine more concentrated and stones more difficult to pass naturally. Forcing large quantities of fluid may cause hydronephrosis if urine is prevented from flowing past calculi. Straining urine for small stones is important, but does not take priority over pain management.

A client has renal colic due to renal lithiasis. What is the nurse's first priority in managing care for this client? a)Do not allow the client to ingest fluids. b)Encourage the client to drink at least 500 mL of water each hour. c)Request the central supply department to send supplies for straining urine. d)Administer an opioid analgesic as prescribed.

a)Ask the client to explain the treatment regimen. Explanation: It is important to first assess what the client knows about the treatment regimen. The nurse should then provide further teaching in terms that the client understands; this should be done after an assessment of what the client knows. The client should be using a cushion to sit on to reduce pressure, and the wound should be kept moist to promote healing. Care decisions can be made by the client; however, the nurse must ensure that the client has available knowledge to make an informed decision. Calling the family may be an option, but the client should be the first one to explore what is known about the treatment. Providing an in-depth explanation about the anatomy and physiology of pressure ulcer development is not necessary.

A client in a wheelchair comes to the clinic for a follow-up evaluation of pressure ulcers on the buttocks. The client reports that the family has been changing the hydrocolloid dressings every 3 to 5 days. During the past few weeks, the client has been spending less time in the wheelchair and, when in the wheelchair, uses a cushion. During the appointment the nurse notes that the client is not using a cushion, and that the wound is covered with a dry sterile dressing. How should the nurse initially approach the client about the treatment regimen? a)Ask the client to explain the treatment regimen. b)Call the family contact to ask about how the treatments have been done. c)Explain pressure ulcer development in terms that the client understands. d)Provide a brief anatomy and physiology lesson on how pressure ulcers develop.

b)a small amount of yellow drainage at the left pin insertion site Explanation: The nurse should report the presence of yellow drainage, which indicates the presence of infection, at the left pin insertion site. Crust formation around the pin site is a natural response to the trauma caused by the pin insertion. Redness at the insertion site may be an early sign of infection; the nurse should continue to monitor the area, but this finding doesn't need to be reported to the physician. The client may experience pain at the pin insertion sites; therefore, the nurse should administer pain medications as ordered. It's necessary to notify the physician only if the pain medication is ineffective.

A client in the surgical intensive care unit has skeletal tongs in place to stabilize a cervical fracture. Protocol dictates that pin care should be performed each shift. When providing pin care for the client, which finding should the nurse report to the physician? a)crust around the pin insertion site b)a small amount of yellow drainage at the left pin insertion site c)a slight reddening of the skin surrounding the insertion site d)pain at the insertion site

a)cirrhosis. Explanation: Muscle wasting, a decrease in chest and axillary hair, and increased bleeding tendencies are all symptoms of cirrhosis. The client may also have mild fever, edema, abdominal pain, and an enlarged liver. Clients with peptic ulcer disease complain of a dull, gnawing epigastric pain that's relieved by eating. Appendicitis is characterized by a periumbilical pain that moves to the right lower quadrant and rebound tenderness. Cholelithiasis is characterized by severe abdominal pain that presents several hours after a large meal.

A client is admitted for suspected GI disease. Assessment data reveal muscle wasting, a decrease in chest and axillary hair, and increased bleeding tendency. The nurse suspects the client has a)cirrhosis. b)peptic ulcer disease. c)appendicitis. d)cholelithiasis.

b)"You are not allowed anything by mouth so that your pancreas can rest." Explanation: The predominant clinical feature of acute pancreatitis is abdominal pain, which usually reaches peak intensity several hours after onset of the illness. Interventions include parenteral pain management preferably with an opioid, NPO status to decrease pancreatic activity, and bed rest to decrease body metabolism. Antibiotics are not usually indicated. The focus is on pain management and fluid replacement intraveneously. Because acute pancreatitis causes nausea and vomiting, the nurse should try to prevent fluid volume deficit, not overload. The nurse cannot help the client achieve adequate nutrition or understand the disease and its treatment until the client is comfortable and no longer in pain.

A client is admitted to the health care facility with abdominal pain, a low-grade fever, abdominal distention, and weight loss. Based on the diagnosis of acute pancreatitis the nurse will provide which explanation for the prescribed interventions? a)"I can offer you ibuprofen for pain with a small sip of water." b)"You are not allowed anything by mouth so that your pancreas can rest." c)"I will be starting antibiotic therapy once the blood cultures are obtained." d)"Activity is important, so you will be scheduled for physical therapy."

b)"I feel dizzy and light-headed when I get up." Explanation: The priority intervention, by the nurse, would be to assess the client's vital signs to note any alterations. A client stating "My life is over if I gain weight" is an example of catastrophizing. Dental erosion and caries are commonly found in a client with an eating disorder. Muscle weakness is also commonly found in a client with an eating disorder.

A client is admitted with an eating disorder. Which client response should the nurse address first? a)"My life is over if I gain weight." b)"I feel dizzy and light-headed when I get up." c)"I cannot eat because my teeth hurt." d)"I do not have the same energy that I used to have."

b)in 1 to 2 days. Explanation: Acute withdrawal symptoms from alcohol may begin 6 hours after the client has stopped drinking and peak 1 to 2 days later. Alcohol withdrawal delirium may occur 2 to 4 days — even up to 7 days — after the last drink.

A client is being admitted to the substance abuse unit for alcohol detoxification. As part of the intake interview, a nurse asks when the client had the last alcoholic drink. The client says that the last drink was 6 hours before admission. Based on this response, the nurse should expect early withdrawal symptoms to peak: a)immediately. b)in 1 to 2 days. c)within 2 to 7 days. d)after 7 days.

d)Bed rest with the affected extremity elevated Explanation: Elevation of the affected leg facilitates blood flow by the force of gravity and also decreases venous pressure, which in turn relieves edema and pain. Other answers are incorrect based on appropriate level of activity needed to assist the diagnosis. Bed rest with normal activity is incorrect because pain is not always experienced with a thrombophlebitis.

A client is diagnosed with thrombophlebitis. What nursing action would demonstrate the appropriate level of activity for this client? a)bed rest with the affected extremity in the dependent position b)bed rest with all normal activities as long as there no increased pain on the affected site c)bed rest with the affected extremity flat d)Bed rest with the affected extremity elevated

b)Raise the hips using trapeze. Explanation: The client in balanced suspension traction can raise the hips using a trapeze. The client can then use the bedpan. The client can be in a sitting position to eat. The client should not move side to side but can turn toward the affected side. The client should not flex or extend the ankle on the affected side.

A client is in balanced suspension traction to maintain alignment of a fractured tibia. Which activities are safe for the client? a)Eat while lying flat. b)Raise the hips using trapeze. c)Rotate side to side. d)Flex and extend the ankle on affected side.

Explanation: Carpal tunnel syndrome is compression of the median nerve in the wrist that supplies feeling and movement to parts of the hand. Tinel's sign may be used to help identify carpal tunnel syndrome. It is elicited by percussing lightly over the median nerve, located on the inner aspect of the wrist. If the client reports tingling, numbness, and pain, the test is considered positive.

A client is suspected of having carpal tunnel syndrome. The nurse assesses for Tinel's sign. Identify the area where the nurse would percuss in an attempt to elicit Tinel's sign.

c)Sucralfate should be taken on an empty stomach 1 hour before meals. Explanation: Sucralfate is taken on an empty stomach at least 1 hour before meals and at bedtime to allow a protective coating to form over the ulcer before high levels of gastric acidity occur. It is not to be taken every 4 hours. Aluminum hydroxide and sucralfate are effective when prescribed together. Aluminum hydroxide should be taken for 2 hours before or after taking sucralfate, not at the same time.

A client is taking aluminum hydroxide tablets along with sucralfate daily 1 hour before meals. The nurse should teach the client which of the following? a)Sucralfate should be taken every 4 hours to be effective. b)Aluminum hydroxide and sucralfate should not be taken together. c)Sucralfate should be taken on an empty stomach 1 hour before meals. d)Sucralfate and aluminum hydroxide should be taken early in the morning.

a)stores the unopened pens in the refrigerator b)injects the insulin in sites around the abdomen c)primes the pen by expelling any air Explanation: Insulin pens should be stored in the refrigerator before use; once opened they can be stored at a cool room temperature. The pen needs to be primed by expelling air before injecting the insulin. After the injection, the site can be patted, but not massaged. Needles cannot be reused; the client should remove the needle and place in a hard plastic container for disposal.

A client is to use an insulin pen. Which action indicates the client is using the pen correctly? Select all that apply. a)stores the unopened pens in the refrigerator b)injects the insulin in sites around the abdomen c)primes the pen by expelling any air d)massages the site after injection e)saves needle for reuse

d)metabolic alkalosis and hypokalemia Explanation: Gastric acid contains large amounts of potassium, chloride, and hydrogen ions. Excessive vomiting causes loss of these substances, which can lead to metabolic alkalosis and hypokalemia. Excessive vomiting doesn't cause metabolic acidosis or hyperkalemia.

A client presents to the emergency department, reporting that they have been vomiting every 30 to 40 minutes for the past 8 hours. Frequent vomiting puts this client at risk for which imbalances? a)metabolic acidosis and hyperkalemia b)metabolic acidosis and hypokalemia c)metabolic alkalosis and hyperkalemia d)metabolic alkalosis and hypokalemia

d) "Using stress management techniques will help you calm down and relax." Explanation: Stress management techniques are meant to reduce anxiety and promote calmness. The goal of using stress management techniques is not to challenge the validity of physical symptoms; this would promote more rumination on the source of the anxiety. Using stress management techniques should not help the client focus on what is causing the anxiety, but rather to distract the client. The client should not strain muscles to the point of numbness.

A client reports experiencing symptoms of stress including nasea, sweating, irritability, and some difficulty sleeping since getting married and becoming a step-parent. The client has always believed symptoms will go away on their own. The nurse is educating the client about stress managment. Which statement by the nurse is most approriate? a)"Using stress management techniques will help you challenge the validity of your physical symptoms." b)"Using stress management techniques will reduce your anxiety until you feel your legs go numb." c)"Using stress management techniques will help you focus on what is causing your anxiety." d) "Using stress management techniques will help you calm down and relax."

c)using a cooling mist humidifer and administering dextromethorphan Explanation: Dextromethorphan is the most widely used antitussive in Canada because it produces few adverse reactions while effectively suppressing a cough. A cool mist humidifier will help open nasal passages. Benzonatate is used for cough associated with respiratory conditions and chronic pulmonary diseases. Opioid antitussives, such as codeine and hydrocodone, are reserved for treating unruly coughs usually associated with lung cancer.

A client reports having a dry, hacking cough that disturbs sleep at night. Which antitussive agent and intervention are most appropriate for this client? a)decreasing the room temperature and b)administering a benzonatate increasing fluids to liquefy secretions and administering codeine c)using a cooling mist humidifer and administering dextromethorphan d)providing a heat vaporizer and administering hydrocodone

b)"I think these thoughts are frightening to you." Explanation: The client's disturbed thought process likely reflects this client's paranoid delusions. The nurse should acknowledge that the thoughts are frightening the client. Telling the client the nurse does not see any foreign agents is an appropriate nursing response if the client is having disturbed visual sensory perception and is having visual hallucinations. Telling the client the nurse does not understand what the client means is an appropriate response if the client has impaired verbal communication. Suggesting that a client participate in group activities would be appropriate if the client had a nursing diagnosis of social isolation and was staying in his room.

A client reports having thoughts of being followed by foreign agents who are after his secret papers. Which response by the nurse is most appropriate when responding to the client's disturbed thought process? a)"I don't see any foreign agents." b)"I think these thoughts are frightening to you." c)"I don't know what you mean." d)"I would like you to come to group with me right now."

b)participating in psychotherapy Explanation: Before having gender reassignment surgery, this client should have several years of psychotherapy. Though not a priority, family and friends should be told of the client's plans. Visiting transsexual clubs has no bearing on having gender reassignment surgery. A surgical consult typically isn't scheduled until after the completion of psychotherapy, so this is a premature action.

A client tells the nurse that he wants to undergo gender reassignment surgery because he feels trapped in his male body. What is the priority intervention for the client? a)telling his family and friends b)participating in psychotherapy c)visiting transsexual clubs d)scheduling a consult with a surgeon

d)declining level of consciousness (LOC) Explanation: With a brain injury such as an epidural hematoma (a likely diagnosis, based on this client's symptoms), the initial sign of increasing ICP is a change in LOC. As neurologic deterioration progresses, manifestations involving pupillary symmetry, breathing patterns, and posturing will occur.

A client was running along an ocean pier, tripped on an elevated area of the decking, and struck their head on the pier railing. According to friends, "The client was unconscious briefly and then became alert and behaved as though nothing had happened." Shortly afterward, the client began complaining of a headache and asked to be taken to the emergency department. If the client's intracranial pressure (ICP) is increasing, the nurse should expect to observe which sign first? a)pupillary asymmetry b)irregular breathing pattern c)involuntary posturing d)declining level of consciousness (LOC)

c)hypokalemia Explanation: Hypokalemia is the most expected laboratory finding owing to the diarrhea. Hypoalbuminemia can also occur in Crohn's disease; however, the client's potassium level is of greater importance at this time because a low potassium level can cause cardiac arrest. Anemia is an expected development, but thrombocytopenia is not. Calcium levels are not affected.

A client who has a history of Crohn's disease is admitted to the hospital with fever, diarrhea, cramping, abdominal pain, and weight loss. The nurse should review the client's laboratory reports to determine which potential complication of the client's symptoms? a)hyperalbuminemia b)thrombocytopenia c)hypokalemia d)hypercalcemia

a)Be aware of personal opinions and views. Explanation: The nurse must be aware of personal opinions and views when caring for clients with psychosexual disorders. The care plan for the client will be developed to manage both the depression and the pedophilia. It is not necessary to restrict the client's interactions with others on this adult mental health unit. The health care provider (HCP) will determine the type of therapy that will be most appropriate for this client.

A client who is admitted to the adult unit of a mental health care facility with depression tells the nurse that he has pedophilia. What should the nurse do? a)Be aware of personal opinions and views. b)Recognize that because the client is depressed, the client will not be able to discuss the pedophilia. c)Ensure that the client is never alone with other clients on the unit. d)Refer the client to group therapy.

a)"The radioactive material is controlled and stays with the source; once the material is removed, no radioactivity will remain." Explanation: The radioactivity comes from a radioactive material such as radium or cesium. Radioactivity affects tissues but does not make them radioactive. Once the radioactive source is removed, no radioactivity remains. Accurate information can help alleviate ungrounded fears.The time required for a radioactive substance to be half-dissipated is called its half-life, but this does not determine discharge time. The client receiving sealed internal radiotherapy is not discharged until the radioactive source is removed.While the radiation is necessary for treatment, telling the client this does not provide information to address her concerns.With cervical implants, there is no way to shield the area above the waist from radiation.

A client who is to have a vaginal radium implant tells the nurse she is concerned about being radioactive. The nurse should tell the client: a)"The radioactive material is controlled and stays with the source; once the material is removed, no radioactivity will remain." b)"The radioactivity will gradually decrease, and you will be discharged when the radioactive material reaches its half-life." c)"The radiation is necessary to treat your tumor." d)"Careful shielding prevents the area above your waist from radioactivity."

141 Explanation: 1.5 mg/kg/dose X 94.1 kg = 141.15 mg/dose, which rounds to 141 mg/dose.

A client who weighs 207 lb (94.1 kg) is to receive 1.5 mg/kg of gentamicin sulfate IV three times each day. How many milligrams of medication should the nurse administer for each dose? Round to the nearest whole number. ___________

a)depression. Explanation: Agitation, irritability, poor memory, loss of appetite, and neglect of one's appearance may signal depression, which is common in clients with Cushing's syndrome. Neuropathy affects clients with diabetes mellitus — not Cushing's syndrome. Although hypoglycemia can cause irritability, it also produces increased appetite, rather than loss of appetite. Hyperthyroidism typically causes such signs as goiter, nervousness, heat intolerance, and weight loss despite increased appetite.

A client with Cushing's syndrome is admitted to the medical-surgical unit. During the admission assessment, the nurse notes that the client is agitated and irritable, has poor memory, reports loss of appetite, and appears disheveled. These findings are consistent with a)depression. b)neuropathy. c)hypoglycemia. d)hyperthyroidism.

a)"Your child is ill and can't make decisions about health care and safety right now, but this situation is temporary." Explanation: The client is temporarily unable to make decisions about health care and safety. After receiving emergency care and treatment, the client will probably be able to safely manage daily affairs. The nurse's reference to the client's constitutional rights isn't a therapeutic response. It's antagonistic to the parent's concern and could be a barrier to further nurse-parent interactions. The nurse shouldn't offer to help the client's parent contact the hospital's legal representative; a hospital's legal resources wouldn't be used to help a parent petition a court to declare a client incompetent. A guardian is responsible for making decisions about an individual's welfare and protecting civil rights. A guardian doesn't assume financial responsibility.

A client with a history of heroin addiction is admitted to the hospital intensive care unit with a diagnosis of opioid drug overdose. While talking with a nurse, the client's parent reports a plan to his child declared legally incompetent. Which response by the nurse is most therapeutic? a)"Your child is ill and can't make decisions about health care and safety right now, but this situation is temporary." b)"You don't have the right to declare your child incompetent. Your child has rights, too." c)"I'll help you contact the hospital legal representative for help with the paperwork." d)"If you become the guardian, you'll be responsible for your child's finances and paying for treatment."

b)Rapid phenytoin administration can cause cardiac arrhythmias. Explanation: Intravenous phenytoin should not exceed 50 mg/min, as rapid administration can depress the myocardium, causing lethal dysrhythmias. Therapeutic drug levels range from 10 to 20 mg/ml. Phenytoin is only compatible with normal saline, not dextrose in water. Phenytoin is very irritating to the blood vessels, and may cause purple glove syndrome when administered I.V. into a hand.

A client with a subarachnoid hemorrhage is prescribed a 1,000 mg loading dose of I.V. phenytoin. What information is most important when administering this dose? a)Therapeutic drug levels should be maintained between 20 and 30 mg/ml. b)Rapid phenytoin administration can cause cardiac arrhythmias. c)Phenytoin should be mixed in dextrose in water before administration. d)Phenytoin should be administered through an I.V. catheter in the client's hand.

a)Explore other ways to control symptoms and address the family's concerns more effectively. Explanation: Trying other nursing measures may more effectively relieve the client's distress. These need to be explored. It is important to examine other ways to alleviate the other symptoms by ensuring rest periods just prior to eating and better pain management. In addition, it is the nurse's role to advocate for and support the client while explaining what is happening to the family. The client would need to request restriction of visits, and the client is the person who needs the most support, then the family. Right now is not the right time to discuss stages of dying; addressing breathing problems is the priority.

A client with a terminal diagnosis is anxious and concerned about the fact that breathing is taking so much energy and eating is very difficult. Most of the client's time is spent in bed, and the family is very concerned about recuperation. What is the best action by the nurse? a)Explore other ways to control symptoms and address the family's concerns more effectively. b)Reinforce the meaning of supportive care to the family and restrict their visits so the client has more rest time. c)Provide support for the family and encourage the client to become more actively involved in the care. d)Determine where the client is regarding the stages of dying and discuss the findings with the family.

b)The oxygen tubing is pinched. Explanation: Pinching of the tubing used to deliver oxygen causes a high-pitched whistling sound. When the water level in the humidifier reservoir is too low, the oxygen tubing appears dry but doesn't make noise. A client with a nasal obstruction becomes more uncomfortable with nasal prongs in place and doesn't experience relief from oxygen therapy; the client's complaints, not an abnormal sound, would alert the nurse to this problem. A nasal cannula can't deliver oxygen concentrations above 44%.

A client with acute bronchitis is admitted to the healthcare facility and is receiving supplemental oxygen via nasal cannula. When monitoring this client, the nurse suddenly hears a high-pitched whistling sound. What is the most likely cause of this sound? a)The water level in the humidifier reservoir is too low. b)The oxygen tubing is pinched. c)The client has a nasal obstruction. d)The oxygen concentration is above 44%.

b)Place an intravenous line. Explanation: Grey Turner's sign is a bluish discoloration in the flank area caused by retroperitoneal bleeding. The vital signs are showing hemodynamic instability. IV access should be obtained to provide immediate volume replacement. The urine output will provide information on the fluid status. A nasogastric tube is indicated for clients with uncontrolled nausea and vomiting or gastric distension. Repositioning the client may be considered for pain management once the client's vital signs are stable.

A client with acute pancreatitis has a blood pressure of 88/40 mm Hg, heart rate of 128 bpm, respirations of 28 breaths/min, and Grey Turner's sign. What prescription should the nurse implement first? a)Initiate intake/output record. b)Place an intravenous line. c)Position on the left side. d)Insert a nasogastric tube.

c)frontal and maxillary sinuses. Explanation: After detecting tenderness of the paranasal sinuses, the nurse should transilluminate both the frontal and maxillary sinuses; lack of illumination may indicate sinus congestion and pus accumulation. The sphenoidal and ethmoidal sinuses can't be transilluminated because of their location.

A client with chronic sinusitis comes to the outpatient department complaining of headache, malaise, and a nonproductive cough. When examining the client's paranasal sinuses, the nurse detects tenderness. To evaluate this finding further, the nurse should transilluminate the a)frontal sinuses only. b)sphenoidal sinuses only. c)frontal and maxillary sinuses. d)sphenoidal and ethmoidal sinuses.

b)It determines the average blood glucose level in the previous 2-3 months. Explanation: Blood glucose levels can be monitored with a glucometer and indicate the present state of blood glucose. Glycosylated hemoglobin gives a measure of blood glucose controls over the previous 3 months. This is a better indicator for how effectively the diabetes is being controlled. This diagnostic test is a longer-term monitor of diabetes control compared to the fasting glucose levels. It does not compare levels of glucose to hemoglobin or measure reduced hemoglobin.

A client with diabetes is being tested for glycosylated hemoglobin. How would the nurse explain the reason for this diagnostic test? a)It determines the fasting blood glucose level. b)It determines the average blood glucose level in the previous 2-3 months. c)It determines the ratio of glucose to hemoglobin. d)It is used to identify a reduction in hemoglobin because of high glucose levels.

b)The isophane (NPH) insulin is peaking. Explanation: Headache, sweating, tremor, pallor, and nervousness typically result from hypoglycemia, an insulin reaction in which serum glucose level drops below 70 mg/dl (3.88 mmol/L). Isophane (NPH) insulin typically peaks at 4-12 hours after administration. However, hypoglycemia may occur 4 to 18 hours after administration of isophane (NPH) insulin suspension or insulin zinc suspension, both of which are intermediate-acting insulins. Although hypoglycemia may occur at any time, it usually precedes meals. Hyperglycemia, in which serum glucose level is above 180 mg/dl (10 mmol/L), causes such early manifestations as fatigue, malaise, and drowsiness. Intravenous insulin can cause an acute shift in potassium levels leading to hypokalemia, but these signs and symptoms would include muscle weakness and muscle cramps.

A client with diabetes mellitus has a prescription for 5 units of U-100 regular insulin and 25 units of U-100 isophane (NPH) insulin to be taken before breakfast. At about 4:30 p.m. (1630), the client experiences headache, sweating, tremor, pallor, and nervousness. What is the most probable cause of these signs and symptoms? a)The regular insulin is at the end of its duration. b)The isophane (NPH) insulin is peaking. c)The client's potassium level is below 3.5 mEq/L d)The client is experiencing hyperglycemia.

b)enteric precautions must be continued. Explanation: The nurse must continue enteric precautions for a client with gastroenteritis caused by the Norwalk virus because this virus is transmitted by the fecal-oral route. No safe and effective antiviral agent is available specifically for treating viral gastroenteritis. The Norwalk virus isn't transmitted by droplets.

A client with gastroenteritis is admitted to an acute care facility and presents with severe dehydration and electrolyte imbalances. Diagnostic tests reveal the Norwalk virus as the cause of gastroenteritis. Based on this information, the nurse knows that a)the client requires an antiviral agent. b)enteric precautions must be continued. c)enteric precautions can be discontinued. d)the client's infection may be caused by droplet transmission.

a)decreased cardiac output Explanation: Decreased cardiac output is an appropriate nursing diagnosis for a client with HCM because the hypertrophied cardiac muscle decreases the effectiveness of the heart's contraction, decreasing cardiac output. Heart failure may complicate HCM, causing fluid volume excess; therefore, the nursing diagnosis of risk for deficient fluid volume is not applicable. Ineffective peripheral tissue perfusion would be applicable if the client is experiencing an alteration in peripheral pulses, capillary refill time greater than 3 seconds, or a change in skin characteristics. Although it might seem that the diagnosis of risk for activity intolerance would be applicable because of dyspnea and fatigue, addressing cardiac output will help reduce these symptoms.

A client with hypertrophic cardiomyopathy (HCM) is experiencing dyspnea, chest pain, syncope, fatigue, and palpitations and has an apical systolic thrill and heave, fourth heart sound (S4), and systolic murmur. Which nursing diagnosis should the nurse use to guide this client's care? a)decreased cardiac output b)risk for deficient fluid volume c)ineffective peripheral tissue perfusion d)risk for activity intolerance

b)Wake the client an hour earlier to perform his ritual. Explanation: The nurse should wake the client an hour earlier to perform his ritual so that he can be on time for breakfast with the other clients. The nurse provides the client with time needed to perform rituals because the client needs to keep his anxiety in check. The nurse should never take away a ritual, because panic will ensue. The nurse should work with the client later to slowly set limits on the frequency of the action.

A client with obsessive-compulsive disorder, who was admitted early yesterday morning, must make his bed 22 times before he can have breakfast. Because of his behavior, the client missed having breakfast yesterday with the other clients. Which action should the nurse institute to help the client be on time for breakfast? a)Tell the client to make his bed one time only. b)Wake the client an hour earlier to perform his ritual. c)Insist that the client stop his activity when it is time for breakfast. d)Advise the client to have breakfast first before making his bed

c)risk for infection Explanation: The peritoneal dialysis catheter and regular exchanges of the dialysis bag provide a direct portal for bacteria to enter the body. If the client experiences repeated peritoneal infections, continuous ambulatory peritoneal dialysis may no longer be effective in clearing waste products. Impaired urinary elimination, toileting self-care deficit, and activity intolerance may be pertinent but are secondary to the risk of infection.

A client with renal failure is undergoing continuous ambulatory peritoneal dialysis. Which nursing diagnosis is the most appropriate for this client? a)impaired urinary elimination b)toileting self-care deficit c)risk for infection d)activity intolerance

a)serum creatinine Explanation: The nurse monitors the blood levels of antibiotics, white blood cells, serum creatinine, and blood urea nitrogen because of the decreased perfusion to the kidneys, which are responsible for filtering out the ceftriaxone sodium. It is possible that the clearance of the antibiotic has been decreased enough to cause toxicity. Increased levels of these laboratory values should be reported to the health care provider (HCP) immediately. A spinal fluid analysis is done to examine cerebral spinal fluid, but there is no indication of central nervous system involvement in this case. Arterial blood gases are used to determine actual blood gas levels and assess acid-base balance. Serum osmolality is used to monitor fluid and electrolyte balance.

A client with toxic shock has been receiving ceftriaxone sodium, 1 g every 12 hours. In addition to culture and sensitivity studies, which other laboratory finding does the nurse monitor? a)serum creatinine b)spinal fluid analysis c)arterial blood gases d)serum osmolality

d)Tell a nursing assistant to stay with the client during the infusion. Explanation: The client needs the medication to combat the protozoal infection. Because the client has been dislodging the I.V. access devices, a staff member should remain with with the client during the infusion. Bilateral wrist restraints are a poor choice for managing this situation, and using them doesn't ensure that the client will receive the medication. Giving sedation to a confused client is risky, and it's a poor alternative to having a staff member remain with the client. Administering the drug shouldn't be delayed; appropriate nursing action allows for the drug's administration.

A client with toxoplasmosis and cytomegalovirus is confused and has been dislodging the I.V. access device. The client's scheduled to receive amphotericin B I.V. Which action would be most appropriate for the nurse to take? a)Place bilateral wrist restraints on the client. b)Ask the physician to order sedation for the client. c)Delay giving the drug until the client's confusion disappears. d)Tell a nursing assistant to stay with the client during the infusion.

c)Elevate the feet several times a day. Explanation: Elevating the feet will promote venous return and decrease foot and ankle edema. Limiting fluid intake is not recommended unless there are additional medical complications such as heart failure; limiting fluids after 8 pm can help with nocturia but time is irrelevant to edema prevention. Buying walking shoes will not necessarily decrease edema. Over-the-counter knee-high "support hose" are not the same as medical-grade graduated compression stockings, and there are some contraindications to compression that should first be ruled out. Therefore, the nurse should not recommend this intervention unless the elevation of legs fails to solve the edema, at which time the client should consult the health care provider about the use of medically approved compression stockings.

A client with venous insufficiency reports swelling in the feet and ankles. What is the most appropriate intervention for the nurse to recommend? a)Limit fluid intake after 8 pm. b)Buy well-fitting walking shoes. c)Elevate the feet several times a day. d)Wear a pair of knee-high support hose.

b)"Do you have a digital rectal examination and prostate-specific antigen tests yearly?" Explanation: Prostate-specific antigen (PSA) and digital rectal examinations, although not specific for prostate cancer, will indicate possible changes in the prostate gland. The transrectal ultrasound would be performed as a follow-up for an increased PSA and/or an enlarged prostate gland. Testicular exams will not reveal changes in the prostate. The client already told the nurse he has nocturia, so this question is gathering more information about symptoms, not detection of the disease.

A middle-aged male client comes to the clinic for an evaluation of difficulty urinating and nocturia. His father died from prostate cancer. He asks the nurse what he can do to ensure early detection of this disease. What question will the nurse ask next? a)"Do you perform monthly testicular self-examinations?" b)"Do you have a digital rectal examination and prostate-specific antigen tests yearly?" c)"Have you had a transrectal ultrasound within the last 10 years?" d)"How many times a night do you get up to void?"

a)current medications Explanation: St. John's wort, an herbal supplement commonly used to treat mild depression, interacts with many medications, making them less effective. If the client is already taking a prescription antidepressant, she can be at risk for serotonin syndrome. St. John's wort is not known to cause fetal growth or liver problems. It would be important to assess the client's mood after determining if the client is at risk for medication interactions.

A multigravida prenatal client with a history of postpartum depression tells the nurse that she is taking measures to make sure that she does not suffer that complication, including taking St. John's wort. What is the most important assessment for the nurse to make? a)current medications b)fetal growth c)liver functions d)mood status

d)The neonate may need a more calorie-dense formula. Explanation: Neonates with heart failure may need calorie-dense formula to provide extra calories for growth. Fluids should not be restricted because the nutritional requirements are based on calories per ounce of formula. Decreasing fluid intake will decrease calories needed for growth. These neonates may have limited energy due to their heart condition but have a high caloric need to stimulate proper growth and development. The sodium level should be at a normal level to ensure adequate fluid and electrolyte balance unless prescribed by the health care provider (HCP) .

A neonate with heart failure is being discharged home. When teaching the parents about the neonate's nutritional needs, what should the nurse explain? a)Fluids must be restricted. b)Decreased activity level should reduce the need for additional calories. c)The formula should be low in sodium. d)The neonate may need a more calorie-dense formula.

a)contacting the physician Explanation: The nurse should immediately contact the physician as these are concerning findings and may be indicative of serious critical events such as hypovolemic shock and hemorrhaging. Waiting to reassess the vital signs in 15 minutes can delay critical treatment, as would inserting a Foley catheter to monitor urine output.

A nurse caring for a child notes that the child begins to experience decreased urinary output, drop in blood pressure, and rapid thready pulse. Which is the appropriate nursing intervention? a)contacting the physician b)increasing the rate of IV fluids c)reassessing vital signs in 15 minutes d)inserting a Foley catheter to monitor urine output

c)adduction and flexion of the extremities with gently rounded shoulders Explanation: The goal of neonatal positioning is to gently round shoulders and flex elbows and to avoid abduction of the shoulders and hips. This positioning enhances physiologic stability and developmental progress. Hyperabduction and external rotation in a preterm neonate may result in contractures. Neck extension, back arching, flattened shoulders, and abduction should be avoided in neonates.

A nurse caring for a preterm neonate knows that positioning can benefit high-risk neonates. Which position is appropriate for a preterm neonate? a)hyperabduction and extension of the arms with external rotation of the hips b)neck extension and back arching with flattened shoulders c)adduction and flexion of the extremities with gently rounded shoulders d)abduction and flexion of the arms with flattened shoulders

b)The nurse must start the process to warn the client's husband. Explanation: Confidentiality must be broken if there are credible threats made against another person's safety. Confidentiality does not override the safety of other persons.

A nurse hears a client state, "I've had it with this marriage. It would be so much easier to just hire someone to kill my husband!" What action should the nurse take? a)Since the client is still admitted to the hospital, the nurse must hold the statement in confidence. b)The nurse must start the process to warn the client's husband. c)An assessment of the client's response to treatment must be performed. d)The comment must be held in confidence because the client did not report the statement directly to the nurse.

b)massive proteinuria Explanation: Nephrotic syndrome is characterized by massive proteinuria caused by increased glomerular membrane permeability. Other symptoms include peripheral edema, hyperlipidemia, and hypoalbuminemia. Because of the edema, clients retain fluid and may gain weight. Hematuria is not a symptom related to nephrotic syndrome.

A nurse is assessing a client with nephrotic syndrome. The nurse should assess the client for which condition? a)hematuria b)massive proteinuria c)increased serum albumin level d)weight loss

d)Consult the health care provider. Explanation: Petechiae are tiny, purplish, hemorrhagic spots visible under the skin. Petechiae usually appear when platelets are depleted. Bleeding gums or oozing of blood may accompany the petechiae, and the client should seek medical assistance immediately. Increasing iron in the diet will not improve the platelet count. Lotion will not treat the petechiae. Elevating the legs will not cause the petechiae to disappear.

A nurse is assessing an adult who has been receiving chemotherapy. The client has a platelet count of 22,000 cells/mm3 (22 × 109/L) and has petechiae on the lower extremities. What should the nurse should instruct the client to do? a)Increase the amount of iron in the client's diet. b)Apply lotion to the lower extremities. c)Elevate the legs. d)Consult the health care provider.

a)altered nutrition (less than body requirements) related to difficulty sucking Explanation: The nurse's initial priority should be to address the caloric intake of the baby through health teaching and support of the parents to ensure that the baby will meet age-appropriate growth and development milestones.

A nurse is assessing the family of an infant and observes that the parents are argumentative and appear fatigued. They indicate that the baby is not breastfeeding well and cries through the night. What would be the nurse's priority nursing diagnosis for this infant? a)altered nutrition (less than body requirements) related to difficulty sucking b)parental sleep pattern disturbance related to the baby's feeding schedule c)knowledge deficit related to normal infant growth and development d)altered role performance related to new responsibilities within the family

c)Provide an early opportunity for the couple to see the child if desired. d)Offer to stay with the grieving parents. e)Answer the parents' questions accurately. Explanation: Seeing the fetus/baby helps parents face the reality of the loss, reduces painful fantasies, and offers an opportunity for closure. Wishes of the parents should be respected either way. Not showing any emotion in front of the parents may not let the parents know that the nurse has also been affected by the loss. Trying to provide a reason for the death of the baby tends to invoke anger in parents who wonder what the reason was and why it had to be them. Some parents are quite anxious about being left alone with the baby and prefer not to have the nurse leave the room. Allowing the parents to ask questions and answering accurately will help the grieving parents understand their loss at their pace.

A nurse is assisting a grieving client and spouse to deal with the loss of their 24-week-old infant. Which of the following actions would be most appropriate from the nurse? Select all that apply. a)The nurse should control emotions so as to not upset the parents. b)Remind the parents that there must have been something wrong with the baby. c)Provide an early opportunity for the couple to see the child if desired. d)Offer to stay with the grieving parents. e)Answer the parents' questions accurately.

b)Tell the physician to stop the procedure immediately because an informed consent form hasn't been signed. Explanation: Parents have the legal right to decide whether their son is circumcised. The nurse and physician should always check the medical record for a signed informed consent form before beginning any procedure. It's unacceptable for the nurse to ask for consent after the procedure. Quickly completing the circumcision is also unacceptable because an informed consent form wasn't signed. Both the nurse and physician were negligent for not checking for a signed informed consent form.

A nurse is assisting with a circumcision. After the physician has started the procedure, the nurse reviews the neonate's medical record and notices that an informed consent form hasn't been signed. What should the nurse do? a)Continue assisting with the circumcision and ask the mother to sign the consent form after the procedure. b)Tell the physician to stop the procedure immediately because an informed consent form hasn't been signed. c)Inform the physician and ask the physician to quickly complete the procedure. d)Notify the medical director of the physician's negligence.

c)irrigate the NG tube gently with normal saline solution if ordered. Explanation: The nurse can gently irrigate the tube if ordered, but must be careful not to reposition it. Repositioning can cause bleeding. The nurse should apply suction continuously — not every hour. The nurse shouldn't clamp the NG tube postoperatively because secretions and gas will accumulate, stressing the suture line.

A nurse is caring for a client who underwent a subtotal gastrectomy 24 hours ago. The client has a nasogastric (NG) tube. The nurse should a)apply suction to the NG tube every hour. b)clamp the NG tube if the client complains of nausea. c)irrigate the NG tube gently with normal saline solution if ordered. d)reposition the NG tube if pulled out.

c)a client with a nasogastric tube Explanation: Nasogastric, orogastric, and endotracheal tubes increase the risk of pneumonia because of the risk of aspiration from improperly placed tubes. Frequent oral hygiene and checking tube placement help prevent aspiration and pneumonia. Although a client who smokes is at increased risk for pneumonia, the risk decreases if the client has stopped smoking. Ambulation helps prevent pneumonia. A client who receives opioids, not acetaminophen, has a risk of developing pneumonia because respiratory depression may occur.

A nurse is caring for a group of clients on a medical-surgical floor. Which client is at greatest risk for developing pneumonia? a)a client with a history of smoking two packs of cigarettes per day until quitting 2 years ago b)a client who ambulates in the hallway daily c)a client with a nasogastric tube d)a client who has an order for acetaminophen with codeine for pain but has not requested it

a)Include the child in the teaching process. Explanation: The nurse should include the preschooler in any discharge teaching performed. Preschoolers have developed reasoning skills and are beginning to understand the concepts of right and wrong and cause and effect, but verbalizing the reason for the accident is not the most important focus. It isn't necessary for both parents to be present during teaching, although it is desirable.

A nurse is caring for a preschooler who sustained deep partial-thickness burns on the hands as a result of touching a hot pot on the stove. What is most important for the nurse to consider in discharge teaching? a)Include the child in the teaching process. b)Provide teaching to the parents in the treatment room. c)Ask the child to verbalize why the accident occurred. d)Delay the teaching until both parents are present.

c)Develop a written, individual turning schedule. Explanation: A turning schedule sheet helps ensure that the client gets turned and, thus, helps prevent pressure ulcers. Turning should occur every 1 to 2 hours — not every 4 hours — for clients who are in bed for prolonged periods. The nurse should apply lotion to keep the skin moist, but should avoid vigorous massage, which could damage capillaries. When moving the client, the nurse should lift — rather than slide — the client to avoid shearing, despite the amount of helpers.

A nurse is caring for an elderly bedridden adult in the long term care facility. To prevent pressure ulcers, which intervention should the nurse include in the care plan? a)Turn and reposition the client every 4 hours. b)Massage lotion over bony prominences when turning. c)Develop a written, individual turning schedule. d)Use two people when sliding the client up in bed.

a)prostate problems b)urinary tract infection (UTI) Explanation: An elevated PSA level and lower urinary tract symptoms may indicate a prostate problem. A urine specimen positive for leukocytes, nitrites, and bacteriuria indicates UTI. The client's signs and symptoms don't indicate acute renal failure, liver failure, or a vitamin K deficiency.

A nurse is caring for an elderly male client who complains that he can't pass urine. A bladder scan reveals 600 ml of urine present in the bladder. The nurse attempts to place the indwelling catheter the physician ordered, but resistance prevents the nurse from placing it. A serum prostate-specific antigen (PSA) test indicates a level of 29 g/L. The physician places an indwelling catheter and the urine specimen returns positive for nitrites, leukocytes, and bacteriuria. Which conditions should the nurse suspect? Select all that apply. a)prostate problems b)urinary tract infection (UTI) c)acute renal failure d)vitamin K deficiency e)liver failure

a)adverse effects. Explanation: When developing a drug therapy regimen that won't interfere with a client's lifestyle, the nurse must consider the drug's adverse effects because these may result in noncompliance. A drug's excretion route, peak concentration time, and steady-state duration of action are important considerations when developing a drug therapy regimen; however, they're related to the drug's physiologic effects and don't affect the client's lifestyle.

A nurse is developing a drug therapy regimen that won't interfere with a client's lifestyle. When doing this, the nurse must consider the drug's a)adverse effects. b)route of excretion. c)peak concentration time. d)steady-state duration of action.

b)The weights are allowed to hang freely over the end of the bed. Explanation: In Buck's traction, the weights should hang freely without touching the bed or floor. Lifting the weights would break the traction. The client should be moved up in bed, allowing the weight to move freely along with the client. The leg should be kept in straight alignment. Performing ankle rotation exercises could cause the leg to go out of alignment.

A nurse is instructing an unlicensed assistive personnel (UAP) on the proper care of a client in Buck's extension traction following a fracture of the left fibula. Which observation would indicate that teaching has been effective? a)The leg in traction is kept externally rotated. b)The weights are allowed to hang freely over the end of the bed. c)The UAP instructs the client to perform ankle rotation exercises. d)The UAP lifts the weights while assisting the client as he moves up in bed.

b)pouring solution onto a sterile field cloth Explanation: Pouring solution onto a sterile field cloth contaminates the sterile field because moisture penetrating the cloth can carry microorganisms to the sterile field via capillary action. Holding sterile objects above the waist, leaving a 1″ edge around the sterile field, and opening the outermost flap of a sterile package away from the body maintain the sterile field.

A nurse is performing a sterile dressing change. Which action contaminates the sterile field? a)holding sterile objects above the waist b)pouring solution onto a sterile field cloth c)leaving a 1″ (2.5-cm) edge around the sterile field d)opening the outermost flap of a sterile package away from the body

d)"Don't eat for 6 hours prior to the procedure." Explanation: Bronchoscopy involves visualization of the trachea and bronchial tree. To prevent aspiration of stomach contents into the lungs, the nurse should instruct the client not to eat or drink anything for approximately 6 hours before the procedure. The client will need to be in a semi-Fowler's position after the procedure. It isn't necessary for the client to avoid talking or coughing.

A nurse is preparing a client for bronchoscopy. Which instruction is appropriate for the nurse to give to the client? a)"You will need to stay flat after the procedure." b)"Don't cough after the procedure." c)"You will not be able to talk for 4 hours following the procedure." d)"Don't eat for 6 hours prior to the procedure."

c)4 hours. Explanation: Refrigeration delays the growth of bacteria in the blood. After the blood is removed from the refrigerator, it must be administered within 4 hours. If the blood is administered too rapidly, within 1 or 2 hours, the client could experience fluid overload. Six hours is too long because the extended time out of refrigeration increases the risk of contamination and growth of bacteria.

A nurse is preparing to administer a unit of blood to a client with anemia. After its removal from the refrigerator, the blood should be administered within: a)1 hour. b)2 hours. c)4 hours. d)6 hours.

a)chickenpox Explanation: Reye's syndrome commonly occurs about 1 week after a child has had a viral infection, such as chickenpox (varicella) or influenza. Children with flulike symptoms or chickenpox who receive aspirin are at increased risk for Reye's syndrome. Bacterial meningitis and strep throat are caused by bacteria and don't lead to Reye's syndrome. Lyme disease is caused by a spirochete and isn't implicated in Reye's syndrome.

A nurse is taking a history from the parents of a 11-year-old child admitted with Reye's syndrome. Which illness should the nurse expect the parents to report their child having the previous week? a)chickenpox b)bacterial meningitis c)strep throat d)Lyme disease

d)"I should drink more water when feeling thirsty or becoming irritable." Explanation: Early signs and symptoms of dehydration include thirst, irritability, dry mucous membranes, and dizziness. Coma, seizures, sunken eyeballs, poor skin turgor, and increased heart rate with hypotension are all later signs. Dehydration is a problem at all times, not just when it's hot outside. Lotion helps dry skin, but will not help hydration.

A nurse is teaching a client about the importance of increasing fluids when experiencing the early stages of dehydration. Which statement by the client would express understanding? a)"Dehydration is only a problem in the summer months when it's hot outside." b)"If my skin becomes dry and itchy I can apply extra lotion." c)"Vitamin hydration drinks would be good when I feel my heart pounding and become lightheaded." d)"I should drink more water when feeling thirsty or becoming irritable."

c)"I need to have my blood counts checked periodically." Explanation: The most dangerous adverse effect of carbamazepine is bone marrow depression. Other medications may be taken with carbamazepine. Hair loss doesn't occur in clients taking carbamazepine. Clients who take lithium, not carbamazepine, must be closely monitored for nephrogenic diabetes insipidus. The interactions of all drugs must be monitored because some can either increase or decrease the blood level of carbamazepine.

A nurse is teaching a client with bipolar disorder about the drug carbamazepine. The nurse determines teaching was effective when the client states a)"My hair will fall out after I take this drug for a few months." b)"I will drink plenty of water so I don't develop kidney problems." c)"I need to have my blood counts checked periodically." d)"I can't take any other drugs while I am taking this one."

d)enhances protein synthesis. Explanation: The client should be encouraged to consume foods high in vitamin C because vitamin C is essential for protein synthesis, an important part of wound healing. Hemostasis is responsible for the inflammatory response and reducing edema. Hemoglobin is responsible for oxygen transport.

A nurse should encourage a client with a wound to consume foods high in vitamin C because this vitamin a)restores the inflammatory response. b)enhances oxygen transport to tissues. c)reduces edema. d)enhances protein synthesis.

c)Explain that the client's physical changes are a result of excessive corticosteroids. Explanation: The nurse should explain to the client that Cushing's syndrome causes physical changes related to excessive corticosteroids. Clients with hyperthyroidism, not Cushing's syndrome, are heat intolerant and must have cool clothing and bedding. Clients with Cushing's syndrome should have a high-protein, not low-protein, diet. Clients with Addison's disease must increase sodium intake and fluid intake in times of stress of prevent hypotension.

A nurse should perform which intervention for a client with Cushing's syndrome? a)Offer clothing or bedding that's cool and comfortable. b)Suggest a high-carbohydrate, low-protein diet. c)Explain that the client's physical changes are a result of excessive corticosteroids. d)Explain the rationale for increasing salt and fluid intake in times of illness, increased stress, and very hot weather.

d)shearing forces Explanation: Friction, impaired circulation, localized pressure, and shearing forces are all risk factors of pressure ulcer development; trapeze use reduces shearing forces. Shearing forces (opposing forces that cause layers of skin to move over each other, stretching and tearing capillaries and, eventually, resulting in necrosis) can occur as clients slide down in bed or are pulled up in bed. Subcutaneous skin layers adhere to the sheets while deeper layers, muscle, and bone slide in the direction of movement. To reduce shearing forces, the nurse should instruct the client to use an overbed trapeze, place a draw sheet under the client to move him up in bed, and keep the head of the bed no higher than 30 degrees.

A nurse who is preparing to boost a client up in bed instructs the client to use the overbed trapeze. Which risk factor for pressure ulcer development is the nurse reducing by instructing the client to move in this manner? a)friction b)impaired circulation c)localized pressure d)shearing forces

a)activity limited to bed rest Explanation: Treatment of partial placenta previa includes bed rest, hydration, and careful monitoring of the client's bleeding.Placenta previa involves an abnormal implantation of the placenta. Platelets are not affected. Therefore, a platelet infusion is not necessary.Vaginal birth is the preferred method of birth. An immediate cesarean section is not warranted unless fetal distress occurs or the client begins to hemorrhage.Induction of labor should be initiated with caution and only if birth is indicated because of the risk for possible hemorrhage or fetal distress.

A pregnant client is diagnosed with partial placenta previa. The nurse should prepare the client for which intervention? a)activity limited to bed rest b)platelet infusion c)cesarean birth d)labor induction with oxytocin

a)a 2-year-old child who nearly drowned 2 days earlier Explanation: The nurse can delegate care of the near-drowning victim to an LPN. Children recover quite quickly from near-drowning experiences; acute care isn't necessary. The infant who has undergone surgery is still under the effects of anesthesia and requires close observation for dehydration, pain, and signs of adverse reactions. The infant with gastroenteritis also requires close monitoring for signs of dehydration. The infant who lost consciousness will need to be monitored most closely. The child's status could quickly become very critical.

A registered nurse (RN) has been paired with a licensed practical nurse (LPN) for the shift. Whose care should the RN delegate to the LPN? a)a 2-year-old child who nearly drowned 2 days earlier b)a 19-month-old infant who had surgery for a fractured tibia 12 hours ago c)a 6-month-old infant who has gastroenteritis and vomits every 30 minutes d)a 17-month-old infant who lost consciousness 2 hours earlier because of a head injury

d)Assess the child beginning at 1230 for shakiness, feelings of anxiety, or decreased level of consciousness. Explanation: The onset of the action of regular insulin is 30 minutes to 1 hour. The peak action occurs in 2 to 4 hours. The child needs to be checked for a hypoglycemic reaction (shaking, feelings of anxiety, and decreased level of consciousness) 2 hours after the insulin is given.NPH insulin is not given in an IV solution. Only regular insulin is given through the IV route.It is not necessary to force fluids on the child.Because there is no information that indicates the child is unable to take fluids and foods by mouth, it is not necessary to give a dextrose solution at this time.

A school-age child is admitted to the hospital with newly diagnosed insulin-dependent diabetes mellitus. On admission at 1000, his blood glucose is 180 mg/dL (10 mmol/L). He receives 2 units of regular insulin subcutaneously at 1030. What should the nurse include in the plan of care? a)Carefully regulate an IV solution of normal saline and NPH insulin at 1230. b)Encourage the child to drink at least 500 mL of a sugar-free clear liquid by 1130. c)Begin IV administration of 5% dextrose in water at 1100. d)Assess the child beginning at 1230 for shakiness, feelings of anxiety, or decreased level of consciousness.

b)Assess chest sounds and oxygen saturation. Explanation: It is relatively common for children to experience delayed hypersensitivity reactions to penicillin that are isolated to cutaneous eruptions. Often, it is safe for these children to receive penicillins in the future. However, the nurse must ensure this current reaction is not more serious than it appears. Because a toddler cannot adequately communicate symptoms, the nurse assesses the client's respiratory status to ensure there is no evidence of bronchoconstriction that could suggest anaphylaxis. Once a full assessment has been completed, the nurse can then request the appropriate treatments be initiated.

A toddler taking penicillin for acute otitis media developed a maculopapular rash 24 hours ago after 3 days of therapy. The parents report no other abnormal symptoms. The nurse takes what initial action? a)Administer epinephrine intramuscularly. b)Assess chest sounds and oxygen saturation. c)Administer albuterol (salbutamol) nebulizer. d)Reassure the parents that this is a mild reaction.

d)infection control Explanation: The risk of becoming neutropenic during chemotherapy is very high. Therefore, an inserted foreign object such as a diaphragm may be a nidus for infection. Although the nurse may wish to inform the client about the ease with which various contraceptive modalities may be used, the focus of this discussion should be on preventing an infection, which can be fatal for the neutropenic client. There are no data to suggest the client is at risk for acquiring a sexually transmitted disease. The client will not be experiencing body changes directly related to hormonal changes.

A young female client is receiving chemotherapy and mentions to the nurse that she and her husband are using a diaphragm for birth control. Which information is most important for the nurse to discuss? a)inconvenience of the diaphragm b)transmission of sexually transmitted diseases c)body changes related to hormones d)infection control

b)it usually lasts a day or two before resolving Explanation: Molding occurs with vaginal births and is commonly seen in newborns. This is especially true with primigravid clients experiencing a lengthy labor process. Parents need to be reassured that it is not permanent and that it typically lasts a day or two before resolving. Molding rarely is present if the fetus is in a breech or brow presentation. Surgical intervention is not necessary.

After a lengthy labor, a primigravid client gives birth to a healthy newborn boy with a moderate amount of skull molding. What information would the nurse include when explaining to the parents about this condition? a)It is typically seen with breech births. b)It usually lasts a day or two before resolving. c)It is unusual when the brow is the presenting part. d)Surgical intervention may be necessary to alleviate pressure.

c)presence of maternal antibodies Explanation: A direct Coombs test is also known as a direct antiglobulin test (DAT). The test is done on umbilical cord blood to detect maternal antibodies coating the neonate's red blood cells. Rho(D) immune globulin doses are determined by amount of Rh-positive neonatal blood found in the mother after birth. Hematocrit is used to detect anemia. A direct Coombs test does not measure bilirubin but may help explain the underlying cause of increased bilirubin levels.

After birth, a direct Coombs test is performed on the umbilical cord blood of a neonate with Rh-positive blood born to a mother with Rh-negative blood. The nurse explains to the client that this test is done to detect which information? a)degree of anemia in the neonate b)initial bilirubin level c)presence of maternal antibodies d)appropriate dose of Rho(D) immune globulin

b)Direct-acting beta-active agent Explanation: Adrenergic agents are classified according to their method of action and the type of receptor on which they act. Direct-acting agents act on the sympathetically innervated organ or tissue, whereas indirect-acting agents trigger the release of a neurotransmitter, usually norepinephrine. Dual-acting agents combine direct and indirect actions. Adrenergic agents act on alpha, beta, and dopamine receptors. Dobutamine acts directly on beta receptors. Thus, the drug can be described as a direct-acting beta-active agent.

After extensive cardiac bypass surgery, a client returns to the intensive care unit on dobutamine, 5 mcg/kg/minute I.V. Which classification best describes dobutamine? a)Indirect-acting dual-active agent b)Direct-acting beta-active agent c)Indirect-acting beta-active agent d)Direct-acting alpha-active agent

a)"an enlarged muscle below the stomach" Explanation: Pyloric stenosis involves hypertrophy of the pylorus muscle distal to the stomach and obstruction of the gastric outlet resulting in vomiting, metabolic acidosis, and dehydration. Telescoping of the bowel is called intussusception. Overfeeding, feeding too quickly, or underfeeding is not associated with pyloric stenosis. The stomach is obstructed, but it is not smaller than normal.

After the nurse teaches the parent of an infant with pyloric stenosis about the condition, which cause, if stated by the parent, indicates effective teaching? a)"an enlarged muscle below the stomach" b)"a telescoping of the large bowel into the smaller bowel" c)"a result of giving the baby more formula than is necessary" d)"a genetically smaller stomach than normal"

b)Educate the client about the accompanying risk of cervical cancer. Explanation: This client's external lesions should be treated, and she should receive education regarding the relationship between HPV and cervical cancer. Antibiotics would be ineffective because of the viral etiology of HPV. Hormonal contraceptives are of no benefit, and HPV is not normally the cause of systemic infection.

An adolescent girl is being treated for anogenital warts caused by the human papillomavirus (HPV). What is the nurse's priority intervention for this client? a)Educate the client about the need to adhere to antibiotic therapy. b)Educate the client about the accompanying risk of cervical cancer. c)Assess the client's knowledge of hormonal contraceptives. d)Assess the client for signs and symptoms of systemic infection.

a)Do nothing as this is normal behavior for a toddler. Explanation: Toddlers participate in parallel play. They play beside each other but not together. They are not ready to "share" their toys. No intervention is needed for this normal developmental behavior

As two toddlers play side by side, their parents note that they are not sharing their toys with each other and one cries when a toy is taken by the other child. The nurse hears the parents telling their children to share. Which is the nurse's best response? a)Do nothing as this is normal behavior for a toddler. b)Encourage the parents to teach their children to share. c)Separate the children so that they cannot fight. d)Sit between the children and encourage them to play together.

c)assess vital signs. Explanation: Because the client in addisonian crisis is unstable, vital signs and fluid and electrolyte balance should be assessed every 30 minutes until the client is stable. Daily weights are sufficient when assessing the client's condition. The client shouldn't have ketones in their urine, so there is no need to assess the urine for their presence. Oral hydrocortisone isn't administered during the first 24 hours in severe adrenal insufficiency.

During the first 24 hours after a client is diagnosed with addisonian crisis, which intervention should the nurse perform frequently? a)weigh the client. b)test urine for ketones. c)assess vital signs. d)administer oral hydrocortisone.

c)replying to the client with feedback about reality and the client's behaviors Explanation: The client falsely believes that they are responsible for catastrophic events that are unrelated to them. The nurse must present reality in a nonjudgmental manner and validate the part of the delusion that is real. The nurse must also present that the client does not observe the part of the delusion the client is seeing. Reduction of environmental stimuli is important but is not central in the care of the delusional client. The priority would also not include preparing for escalation of behaviors because, if handled properly, the client should not escalate. The nurse should not invade the client's personal space and should use touch judiciously.

During the initial assessment, a client exhibits pressured speech. The client points to certain patterns on the wallpaper and says, "This is the writing about the tsunami. Thousands of people died because I read the writing. I should never have read the writing; it was my fault." Which would be central to the nurse's interventions? a)reduction of environmental stimuli b)challenging the client's personal space c)replying to the client with feedback about reality and the client's behaviors d)preparing the staff and the environment for escalation of behaviors

b)The nurse dries from forearms up toward fingers. Explanation: Hand hygiene procedures involve drying from the fingers toward the forearm and discarding the paper towel. The other options should be included in hand hygiene practices.

Following an education session on proper hand hygiene, the nurse educator observes a nurse washing hands before entering a client's room. Which observation would alert the nurse educator to the need for further education? a)The nurse dries from finger tips down toward elbows. b)The nurse dries from forearms up toward fingers. c)The nurse keeps hands lower than elbows while washing. d)The nurse uses at least 3 to 5 mL of liquid soap.

b)can persist for several months Explanation: Dribbling of urine can occur for several months after TURP. The client should be informed that this is expected and is not an abnormal sign. The nurse should teach the client perineal exercises to strengthen sphincter tone. The client may need to use pads for temporary incontinence. The client should be reassured that continence will return in a few months and will not be a chronic problem. Dribbling is not a sign of healing, but is related to the trauma of surgery.

In discussing home care with a client after transurethral resection of the prostate (TURP), what should the nurse tell the male client about dribbling of urine after this surgery? Dribbling of urine: a)can be a chronic problem. b)can persist for several months. c)is an abnormal sign that requires intervention. d)is a sign of healing within the prostate.

b)inner-city areas

In which areas of the United States and Canada is the incidence of tuberculosis highest? a)rural farming areas b)inner-city areas c)areas where clean water standards are low d)suburban areas with significant industrial pollution

a)heart rate of 150 bpm Explanation: A heart rate of 150 bpm is very high for a 7-year-old child and may indicate carditis. For this age group, the normal heart rate while awake is 70 to 110 bpm.Swollen and painful joints (e.g., the knee), twitching in the extremities (chorea), and a red rash on the trunk are characteristic findings in the child with rheumatic fever and do not require immediate primary care provider notification.

On initial assessment of a 7-year-old child with rheumatic fever, which finding would require contacting the primary care provider immediately? a)heart rate of 150 bpm b)swollen and painful knee joints c)twitching in the extremities d)red rash on the trunk

d)orange juice Explanation: A serum potassium level of 3.3 is low for a child; the normal range is 3.5 to 5.0. Orange juice is an excellent source of potassium, and the nurse should encourage its consumption. Additional sources of potassium are bananas, cantaloupe, grapefruit juice, tomato juice, honeydew melon, nectarines, and boiled or baked potatoes.Cranberry juice, apple juice, and grape juice all contain less potassium than orange juice does.

On reviewing a child's laboratory results, the nurse notes a serum potassium level of 3.3. What should the nurse encourage the child to drink? a)cranberry juice b)apple juice c)grape juice d)orange juice

b)wearing gloves when handling the client's urine c)disposing of chemotherapy waste as hazardous material Explanation: Nurses preparing and administering chemotherapy wear gloves and a disposable, long-sleeved gown. Antineoplastic agents are disposed of as hazardous material and gloves are always worn when handling the excretions of clients who have received chemotherapy. It is not appropriate to tape IV tubing connections; antineoplastic agents are administered using Luer lock fittings on all intravenous tubing to minimize the risk of exposure from needle stick injury.

The RN is administering intravenous chemotherapy to a client with cancer. Which precautions are necessary when administering chemotherapy? Select all that apply. a)taping all IV tubing connections b)wearing gloves when handling the client's urine c)disposing of chemotherapy waste as hazardous material d)wearing a long-sleeved gown when administering chemotherapy

a)a nurse who was reassigned from another ward at the beginning of the shift Explanation: The nurse's work load would be low because she was reassigned to the ward at the beginning of the shift. The client with asthma requires constant monitoring by the nurse until the situation is resolved. Simple tasks and procedures are commonly more time-consuming when clients with paralysis are involved because these clients can't directly aid in their own care. Additional time must also be allotted for the nurse about to undertake a complicated procedure, such as a wet-to-damp dressing change

The charge nurse on the adolescent unit must decide which nurse should admit a new client. Based on the present client care assignments, who is the best candidate to admit the client? a)a nurse who was reassigned from another ward at the beginning of the shift b)a nurse whose patient with asthma has decreasing oxygen saturation levels c)a nurse caring for a client who is paralyzed and has no visiting family d)a nurse who is about to start a complicated wet-to-damp dressing change

c)spaghetti with tomato sauce, salad, and coffee Pasta, tomato sauce, salad, and coffee would be the best selection for the client following a low-cholesterol diet. Hamburgers, milkshakes, liver, and fried foods tend to be high in cholesterol.

The client who experiences angina has been told to follow a low-cholesterol diet. Which meal would be best? a)hamburger, salad, and milkshake b)baked liver, green beans, and coffee c)spaghetti with tomato sauce, salad, and coffee d)fried chicken, green beans, and skim milk

a)low sodium Explanation: A low-sodium diet is frequently an effective mechanism for reducing the frequency and severity of the disease episodes. About three-quarters of clients with Ménière's disease respond to treatment with a low-salt diet. A diuretic may also be prescribed. Other dietary changes, such as high protein, low carbohydrate, and low fat, do not have an effect on Ménière's disease.

The client with Ménière's disease is instructed to modify the diet. The nurse should explain that what is the most frequently recommended diet modification for Ménière's disease? a)low sodium b)high protein c)low carbohydrate d)low fat

a)lateral Explanation: An unconscious client is best positioned in a lateral or semiprone position because these positions allow the jaw and tongue to fall forward, facilitate drainage of secretions, and prevent aspiration.Positioning the client supine carries a major risk of airway obstruction from the tongue, vomitus, or nasopharyngeal secretions.Trendelenburg's position, with the head lower than the heart, decreases effective lung volume and increases the risk of cerebral edema.The lithotomy position has no purpose in this situation.

The comatose victim of a car accident is to have a gastric lavage. Which position would be most appropriate for the client during this procedure? a)lateral b)supine c)Trendelenburg's d)lithotomy

c)Ask the client to sign the consent form. Explanation: Preparation for cesarean birth is similar to preparation for any abdominal surgery. The client must give informed consent. Another person may not sign for the client unless the client is unable to sign the form. If this is the case, only certain designated people can do so legally. The husband does not need to sign the form unless his wife is unable to do so. In an emergency, surgery may be performed without a written consent if it is done to save the life of the mother or the child, or both.

The health care provider (HCP) who elects to perform a cesarean birth on a primigravid client for fetal distress has informed the client of possible risks during the procedure. When the nurse asks the client to sign the consent form, the client's husband says, "I will sign it for her. She is too upset by what is happening to make this decision." What should the nurse do? a)Ask the client if this is acceptable to her. b)Have the client and her husband both sign the consent form. c)Ask the client to sign the consent form. d)Ask the HCP to witness the consent form.

c)work with radiation on an ongoing basis, while visitors have infrequent exposure to radiation Explanation: The three factors related to radiation safety are time, distance, and shielding. Nurses on radiation oncology units work with radiation frequently and so must limit their contact. Nurses are physically closer to clients than are visitors, who are often asked to sit 6 feet (182.9 cm) away from the client. Touching the client does not increase the amount of radiation exposure. Aseptic technique and isolation prevent the spread of infection. Age is a risk factor for people in their reproductive years.

The mother of a client who has a radium implant asks why so many nurses are involved in her daughter's care. She states, "The doctor said I can be in the room for up to 2 hours each day, but the nurses say they are restricted to being here for 30 minutes." What should the nurse explain to the client? a)touch the client, which increases their exposure to radiation. b)work with many clients and could carry infection to a client receiving radiation therapy, if exposure is prolonged. c)work with radiation on an ongoing basis, while visitors have infrequent exposure to radiation. d)are at greater risk from the radiation because they are younger than the mother.

b)ambulate as tolerated Explanation: The client has a low risk score (0-2) and therefore should be encouraged to ambulate as desired during labor and birth. Bathroom privileges only or complete bed rest imply that the client should be in bed for the majority of the laboring process which is contradictory to associated health promotion practices during the labor process for a client with a low risk score.

The nurse determines that a client has an antenatal or intrapartum risk score of 2. Based on this information, which activity level should the nurse recommend to the client during labor? a)bathroom privileges only b)ambulate as tolerated c)up in the chair at the side of the bed d)complete bed rest with IV hydration

c)"I should report any skin irritation to the healthcare provider." Explanation: Because transdermal nitroglycerin can cause skin irritation, this should be reported to the healthcare provider. The site to apply the patch should be rotated every day to prevent sensitization and tolerance. The medication pad should not be touched, because this could cause the drug to be absorbed through the fingers. The medication should be stored away from temperature and humidity extremes because this may inactivate the drug.

The nurse instructs a client on the use of transdermal nitroglycerin 0.2 mg/hour patch for angina pectoris. Which client statement indicates that teaching was effective? a)"I should apply the patch to the same area every day." b)"I should touch the medication pad before applying to my skin." c)"I should report any skin irritation to the healthcare provider." d)"I should store the supply of transdermal pads in the refrigerator."

b)the 6-month-old does not normally have a pincer grasp yet. Explanation: The nurse would be incorrect to inform the parent that the infant could be at risk for developmental disabilities, because the pincer grasp does not present itself until around 9 months of age. Deferring the question to the physician is ignoring the mother's concern, and the nurse can manage this question. There is no need to ask the physician about the infant's other sibilings.

The nurse is assessing a 6-month-old and notices no pincer grasp on either hand. The parent asks the nurse if this is abnormal. The nurse correctly responds that: a)the infant may be at risk for developmental disabilities. b)the 6-month-old does not normally have a pincer grasp yet. c)the physician will be in to check the child and the parent can ask the physician. d)the physician will need to ask questions about the infant's siblings and their development.

b)A chest tube will be inserted into the left pleural space and attached to a pleural evacuation device. Explanation: Shortness of breath and decreased breath sounds will be present if there is collapse of the lung because of loss of integrity of the pleural space. The chest tube will need to be inserted because of the rib fractures that have resulted in air and blood in the pleural space. The chest tubes will be removed when the hemopneumothorax has resolved. A thoracentesis will not be enough to resolve the hemopneumothorax; splinting of the ribs will not resolve the hemopneumothorax. Oxygen would be indicated, but a bronchoscopy will not confirm the area of damage if the lung is collapsed.

The nurse is assessing a client who has been in a car accident. The client reports sore ribs and painful breathing on the left side of the chest wall. A chest X-ray confirms fracture of two ribs and left-sided hemopneumothorax. What can the nurse anticipate? a)Aspirational thoracentesis will be performed to remove the accumulated bloody fluid. b)A chest tube will be inserted into the left pleural space and attached to a pleural evacuation device. c)Splinting of the affected ribs will be initiated and limitation of upper body activity recommended. d)Oxygen will be initiated and a bronchoscopy will be performed to identify the area of damage.

d)back arched, rigid extension of all four extremities Explanation: Decerebrate posturing occurs in clients with damage to the upper brain stem, midbrain, or pons and is demonstrated clinically by arching of the back, rigid extension of the extremities, pronation of the arms, and plantar flexion of the feet. Internal rotation and adduction of arms with flexion of elbows, wrists, and fingers describes decorticate posturing, which indicates damage to corticospinal tracts and cerebral hemispheres.

The nurse is assessing with a head injury a client for decerebrate posturing. Which position indicates the client has decerebrate posturing? a)internal rotation and adduction of arms with flexion of elbows, wrists, and fingers b)back hunched over, rigid flexion of all four extremities with supination of arms and plantar flexion of feet c)supination of arms, dorsiflexion of the feet d)back arched, rigid extension of all four extremities

b)Dispose of the plastic basin. Explanation: The plastic basin would be disposed of. Hot water causes the protein materials to stick to the basin. The basin does not need to be disinfected. An antiseptic is used to limit bacteria on the skin. Plastic emesis basins are disposable. The nurse would obtain a new one for the room.

The nurse is assisting a healthcare provider in debriding a necrotic skin wound. The healthcare provider is using a plastic basin to collect the bloody supplies. When cleaning the area on completion of debridement, which nursing action is done after placing the supplies in a hazardous material bag? a)Wash the basin in hot, soapy water. b)Dispose of the plastic basin. c)Spray the basin with a disinfectant agent. d)Clean the basin with an antiseptic agent.

a)Ask an unlicensed assistive personnel to assist with the application of the antiembolism stockings. Explanation: When a client is confused and is kicking at the nurse, the next action would be to ask a nursing assistant to assist with stabilizing the legs for the application of the stockings. Medicating the client with ordered lorazepam would only be done after attempting the application with additional assistance. Contacting the health care provider would be done after all options for the application of the stockings had been attempted. It is important to have the correct size antiembolism stocking; therefore, the client's legs would need to be measured before applying the stockings.

The nurse is caring for a client who has a prescription for antiembolism stockings. The client is confused and begins kicking at the nurse during the measurement of the client's legs. What is the next action by the nurse? a)Ask an unlicensed assistive personnel to assist with the application of the antiembolism stockings. b)Administer prescribed lorazepam 1 mg by mouth. c)Contact the health care provider to make aware that the antiembolism stockings cannot be applied. d)Place the antiembolism stockings without measuring the client's legs.

d)obtaining a wound culture during a dressing change Explanation: A LPN/VN's scope of practice includes obtaining wound cultures and changing dressings. Teaching, assessment, and planning of care are complex actions that should be carried out only by the RN.

The nurse is caring for a client who has been admitted to the hospital with a leg ulcer that is infected with vancomycin-resistant s. aureus (VRSA). Which nursing actions can be delegated to a licensed practical/vocational nurse (LPN/VN)? a)teaching the client about the care of the leg ulcer b)planning the client's diet to improve protein intake c)assessing the risk of further skin breakdown d)obtaining a wound culture during a dressing change

b)Provide gentle support to the fetal head. Explanation: During a precipitous birth, after calling for assistance and helping the client lie down, the nurse should provide support to the fetal head to prevent too rapid of emergence leading to injury. It is not appropriate to tell the client to push between contractions because this may lead to lacerations. The shoulder should be delivered by applying downward traction until the anterior shoulder appears fully at the introitus, then upward pressure to lift out the other shoulder. Priority should be given to safe birth of the infant over protecting the perineum by massage.

The nurse is caring for a multigravid client and observes the woman squatting on the bed and the fetal head crowning. After calling for assistance and helping the client lie down, the nurse should perform which action next? a)Tell the client to push between contractions. b)Provide gentle support to the fetal head. c)Apply gentle upward traction on the neonate's anterior shoulder. d)Massage the perineum to stretch the perineal tissues.

a)autonomy Explanation: The principle of autonomy informs decisions when conflicts arise between maternal and fetal rights. The woman has the right to choose for herself what she believes to be in her best interest versus the well-being of the fetus. This is the concept of self-determination, of being in charge of one's person rather than another person determining what behavior or decision represents justice. Nonmaleficence refers to doing no harm. The client has the right to make choices that align with her belief system. Jurisprudence is the actual theory or study of law.

The nurse is caring for an expectant mother who asks how decisions are made if complications place both the mother and fetus at risk. What ethical principle will the nurse cite when responding to the client's question? a)autonomy b)justice c)nonmaleficence d)jurisprudence

c)Assess the client to determine why she wants to sit up. Explanation: The nurse should first determine why the client wants to sit up and then, if needed delegate someone to assist the client. Loosening the restraints will not keep the client safe in bed. Raising the side rails and elevating the head of the bed do not address the client's needs.

The nurse is conducting walking rounds and observes the client (see figure). What should the nurse do? a)Loosen the bed restraints so the client can sit up. b)Raise the side rails to full upright position. c)Assess the client to determine why she wants to sit up. d)Elevate the head of the bed.

a)The spouse places soiled dressing supplies in the kitchen garbage can. d)Sheets with wound drainage are washed in lukewarm water. Explanation: Methicillin resistant Staphylococcus aureus (MRSA) is a bacterium that causes infections in different parts of the body and is resistant to some commonly used antibiotics. Infection control practices prevent the spread of the infection. Further teaching is needed if a nurse notes that soiled dressing supplies are placed in a community garbage can such as one located in the kitchen. Soiled sheets need to be wash in hot water and dried in a clothes dryer. It is correct to clean and disinfect the area where dressing supplies are prepared. Routine hand hygiene followed by wearing clean gloves is appropriate when removing the dressing. Sterile gloves may be needed when completing

The nurse is evaluating infection control practices performed by a spouse on a loved one who has methicillin resistant Staphylococcus aureus (MRSA) in a right leg wound. Which actions indicate that the spouse requires further teaching? Select all that apply. a)The spouse places soiled dressing supplies in the kitchen garbage can. b)Disinfectant spray is used on the table where dressing supplies are prepared. c)Clean gloves are used for wound dressing removal. d)Sheets with wound drainage are washed in lukewarm water. e)Dressing supplies are placed in a clean, dry location. f)Routine hand hygiene is performed before and after care.

c)low-protein, low-sodium, low-potassium Explanation: Dietary management for clients with chronic renal failure is usually designed to restrict protein, sodium, and potassium intake. Protein intake is reduced because the kidney can no longer excrete the byproducts of protein metabolism. The degree of dietary restriction depends on the degree of renal impairment. The client should also receive a high-carbohydrate diet along with appropriate vitamin and mineral supplements. Calcium requirements remain 1,000 to 2,000 mg/day.

The nurse is instructing the client with chronic renal failure to maintain adequate nutritional intake. Which diet would be most appropriate? a)high-carbohydrate, high-protein b)high-calcium, high-potassium, high-protein c)low-protein, low-sodium, low-potassium d)low-protein, high-potassium

d)The nurse should instill mineral oil 30 minutes before irrigation to soften the cerumen. Explanation: The nurse can use mineral oil to soften the cerumen before irrigation of the ear. Using warm water, not cool water, is best for irrigation for client comfort and loosening of the cerumen. The client would need gentle, not forceful, irrigation in order to prevent perforation of the tympanic membrane. Irrigation would be completed before attempting to mechanically remove the cerumen.

The nurse is irrigating a client's ear due to impacted cerumen. Which nursing action is correct for this procedure? a)The nurse should push fluid forcefully into the ear to remove the cerumen. b)The nurse should use cool water with the irrigation for client comfort. c)The nurse should irrigate as a last resort after trying to mechanically remove the cerumen. d)The nurse should instill mineral oil 30 minutes before irrigation to soften the cerumen.

c)inspect the skin at pressure points from the back-lying position. Explanation: The client is positioned correctly in the side-lying position. The pillows support the client's joints and do not cause unnecessary pressure on the joints or skin. It is not necessary to add another pillow under the arm or to elevate the head of the bed. The nurse should assess the client's skin for signs of breakdown, particularly at the elbows, back, hips, and heels where there were pressure points from the position in which the client was previously lying.

The nurse is making rounds and observes a client who is unconscious (see figure). The unlicensed assistive personnel (UAP) has just turned the client from lying on her back and raised the side rail next to the bedside stand. Before raising the side rail on the opposite side, the nurse should: a)elevate the head of the bed to 30 degrees. b)ask the UAP to add a pillow under the right arm. c)inspect the skin at pressure points from the back-lying position. d)assistthe UAP in moving the client closer to the head of the bed.

a)Have the client void before the procedure. Explanation: Before paracentesis, the client is asked to void. This is done to collapse the bladder and decrease the risk of accidental bladder perforation. The abdomen is not prepared with an antiseptic cleansing solution. The client is placed in a Fowler's position. The client does not need to be put on NPO status before the procedure.

The nurse is preparing a client for paracentesis. What should the nurse do? a)Have the client void before the procedure. b)Scrub the client's abdomen with povidone-iodine solution. c)Position the client supine. d)Put the client on nothing-by-mouth (NPO) status 4 hours before the procedure.

2 Explanation: To calculate the number of tablets to give, use the formula Amount to give = (Desired dose/dose on hand) Amount to give = 1200 mg divided by 600 mg/tablet = 2 tablets.

The nurse is teaching a client with asthma to administer Zyflo CR 1200 mg orally twice a day. The drug is available in 600-mg tablets. How many tablets will the nurse teach the client to take at each dose? __________

c)extent of overdistention of the stomach Explanation: The primary reason for evaluating gastric residual is to determine whether gastric emptying has been delayed and the stomach is becoming overdistended from the feeding. With delayed gastric emptying, the possibility of aspiration of the feeding into the lungs is increased. It is not possible to determine how well the client's body is absorbing nutrients or whether the client is receiving enough feeding by checking the gastric residual. It is not necessary to keep partially digested formula separate from undigested formula.

The nurse is to administer an enteral feeding to an adult client. Prior to initiating the feeding, the nurse evaluates the gastric residual. What should the nurse determine from evaluating the gastric residual? a)how well nutrients are being absorbed b)if the client is receiving enough feeding c)extent of overdistention of the stomach d)presence of undigested formula

a)Ask the client to state name and birthdate. Explanation: The nurse should ask the client to state name and birthdate and compare it to the client's records. The nurse does not need to provide a pencil and paper for the client to write his or her name and birthdate as a client has ataxia, not apraxia. Ataxia involves muscle movement, typically in the arms and legs. Apraxia involves speech. Recalling the client's facial features to verify identity is prone to errors. Asking two staff members which client is in the room does not verify identity.

The nurse is verifying the identity of a client prior to administering medication. The client has had a stroke and has ataxia. What is the best action by the nurse? a)Ask the client to state name and birthdate. b)Give client paper and pencil with which to write name and birthdate. c)Recall the client's facial features to verify the client's identity. d)Ask two staff members to state the name of the client in the room.

b)Administering a medication. c)Delivering a breakfast tray. d)Beginning an enteral feeding. Explanation: The nurse will need to use two identifiers with administering a medication, delivering a breakfast tray, and beginning an enteral feeding. Changing the bed linens and directing visitors are not identification safety issues.

The nurse is working with a client assignment on the medical-surgical unit. Which client encounters require client identification with two identifiers? Select all that apply. a)Directing visitors to a client room. b)Administering a medication. c)Delivering a breakfast tray. d)Beginning an enteral feeding. e)Changing bed linens.

a)Encourage motivation and confidence so that the clients can better deal with the triggers that cause them to repeat their behaviors. Explanation: Provide confidence so that the clients have the ability to deal with the triggers that cause them to repeat their behaviors. Clients with multiple episodic occurrences of relapse are unable to adapt to the stressors but need support. Zero tolerance to relapse demonstrates an authoritarian attitude that the clients have a weakness in character. Providing reassurance that the problem will resolve itself in time does not motivate change. Providing coping strategies for the clients does not instill personal commitment to change.

The nurse is working with a highly culturally diverse group of mostly young adult clients who have substance abuse issues. Many clients in the group have had difficult social circumstances and experience relapses. What would be the most appropriate nursing intervention in dealing with these clients? a)Encourage motivation and confidence so that the clients can better deal with the triggers that cause them to repeat their behaviors. b)Demonstrate zero tolerance to relapse and provide a firm approach so the clients can repair character weaknesses now, while they are still young. c)Brainstorm and develop new coping strategies to share with the young adults weekly to keep a constant supply of options. d)Provide reassurance that the problem will resolve itself in time.

a)The clients are accepted although their behavior may not be. Explanation: The most basic and important idea to convey to a client is that, as a person, he or she is accepted, although his or her behavior may not be. Empathy is conveyed for emotional pain regardless of the client's behavior. Although some clients need limits placed on their behavior, not all clients require limit setting. That the staff members are the primary ones left to care about these clients is not necessarily true, nor is it true that the staff should use very little humor with these clients. Clients who are rigid and perfectionists and who have a restricted affect may need help with displaying humor.

The nurse orients an unlicensed assistive personnel (UAP) new to the mental health unit about the principles for the care of a client diagnosed with a personality disorder. What information should the nurse include? a)The clients are accepted although their behavior may not be. b)The clients need limits on their behavior. c)The staff members are the primary ones left to care about these clients. d)The staff should use minimal humor when working with these clients.

c)an x-ray for gastric tube placement Explanation: The drooling and excessive mucus production is highly suggestive of a tracheoesophageal fistula (TEF). The initial diagnosis is made when a gastric tube cannot be passed to the stomach. A lactation consult would be warranted only after determining feedings were safe to continue. While cyanosis can be a sign of sepsis and hypoglycemia, the cyanosis is most likely related to the excessive secretions and airway patency. A blood gas may be needed, but only after ruling out a TEF.

The parents report that their 1-day-old is drooling and having choking episodes with excessive amounts of mucus and color changes, especially during feedings. The nurse should contact the health care provider (HCP) to further assess the baby and request which prescription? a)a lactation consultation b)an arterial blood gas c)an x-ray for gastric tube placement d)a serum blood glucose level

d)Use hot water throughout wash cycle. Explanation: The nurse instructs to use hot water throughout the wash cycle. Using hot water kills scabies and infectious agents on the laundry. If using the correct wash settings, the client does not need to use commercial grade laundry detergent and the clothing does not need pretreated or washed through two cycles. The family would also be instructed to dry the articles in a dryer. The family would clean all belongings thoroughly due to the ease of transmission.

The registered nurse (RN) is referred to a client's home when spouses have been confirmed to have scabies. The family asks, "How will we get rid of this?" When instructing on the proper procedure to wash contaminated clothing and sheets, which nursing instruction is a priority? a)Use commercial grade laundry detergent. b)Pretreat clothing where scabies contact existed. c)Wash clothes through two laundry cycles. d)Use hot water throughout wash cycle.

a)The LPN/VN assists a child to the bathroom 2 hours after a cardiac catheterization. Explanation: Because the femoral artery is usually used as the access site during a cardiac catheterization, children are required to remain on bed rest (with the head only slightly elevated) for several hours after the procedure to avoid arterial bleeding at the site. A knee chest position is the correct position for an infant during a cyanotic episode as it will create peripheral resistance to the extremities, shunting blood to the heart. The apical heart rate is assessed prior to administering this medication; administration can be performed by an experienced LPN/VN, although medication is checked with the RN prior to administration. Because echocardiography is noninvasive, there is no need to withhold meals before this procedure.

The registered nurse (RN) is teamed with a licensed practical/vocational nurse (LPN/VN) in caring for a group of cardiac clients on a pediatric unit. Which action by the LPN/VN indicates the nurse should intervene immediately? a)The LPN/VN assists a child to the bathroom 2 hours after a cardiac catheterization. b)The LPN/VN places an infant having a cyanotic episode in a knee-chest position. c)The LPN/VN checks a child's apical heart rate prior to administering digoxin. d)The LPN/VN brings breakfast to a child who is scheduled for an electrocardiogram.

b)considering all body substances potentially infectious Explanation: Standard precautions are based on the concept that all body substances are potentially infectious and that direct contact with them must be avoided. The nurse should wear gloves when contact with body substances — not unsoiled articles or intact skin — is anticipated. Because all body substances from all clients are considered potentially infectious, signs on doors are unnecessary. Gloves and gowns are inappropriate when caring for a client in respiratory isolation because they don't prevent transmission of airborne respiratory infections. The nurse should wear a mask as a barrier to such infections.

The student nurse is admitting an elderly patient with congestive heart failure and sets up the room with standard precautions. Which is noted by the nursing instructor as the best action? a)wearing gloves for all client contact b)considering all body substances potentially infectious c)placing a body substance isolation sign on the client's door d)wearing a gown if the client is in respiratory isolation

d)"Soft and seedy unformed stools with each feeding are normal for this age and will continue through breastfeeding." Explanation: A soft seedy unformed stool is the norm for a 4-day-old infant. It may surprise the mother as it is a change from the meconium the infant had since birth. This stool is not diarrhea even though it has no form. There is no need for the infant to be seen for this. As long as the infant is breastfeeding, the stools will remain of this color and consistency. Brown and formed stool is common for an infant who is bottle-fed or after the breastfeeding infant has begun eating food.

The triage nurse in the pediatrician's office returns a call to a mother who is breastfeeding her 4-day-old infant. The mother is concerned about the yellow seedy stool that has developed since discharge home. What is the best reply by the nurse? a)"This type of stool indicates the infant may have diarrhea and should be seen in the office today." b)"The stool will transition into a soft, brown, formed stool within a few days and is appropriate for breastfeeding." c)"The stool results from the gassy food eaten by the mother. Refrain from eating these foods while breastfeeding." d)"Soft and seedy unformed stools with each feeding are normal for this age and will continue through breastfeeding."

d)perineal lacerations Explanation: A small, constant trickle of blood and a firm fundus are usually indicative of a vaginal tear or cervical laceration. If the client had retained placental tissue, the fundus would fail to contract fully (uterine atony), exhibiting as a soft or boggy fundus. Also, vaginal bleeding would be evident. Uterine inversion occurs when the uterus is displaced outside of the vagina and is obvious on inspection. Bladder distention may result in uterine atony because the pressure of the bladder displaces the fundus, preventing it from fully contracting. In this case the fundus would be soft, possibly boggy, and displaced from midline.

Three hours postpartum, a primiparous client's fundus is firm and midline. On perineal inspection, the nurse observes a small, constant trickle of blood. Which condition should the nurse assess further? a)retained placental tissue b)uterine inversion c)bladder distention d)perineal lacerations

c)Monitor patient blood pressure. Explanation: Blood pressure control is a priority assessment in clients with poststreptococcal glomerulonephritis. The blood pressure can be increased for up to 6 weeks after treatment. The nurse must provide a low-protein diet during the acute phase. The nurse must also closely monitor the client's fluid intake and output. Clients should be placed on bed rest to control hypertension and workload on the kidney. Although providing comfort measures (such as placing the client on a sheepskin) are important, this action isn't a priority.

Two weeks after being diagnosed with a streptococcal infection, a client develops fatigue, a low-grade fever, and shortness of breath. The nurse auscultates bilateral crackles and observes jugular vein distention. Urinalysis reveals red and white blood cells and protein. After the physician diagnoses poststreptococcal glomerulonephritis, the client is admitted to the medical-surgical unit. Which immediate action should the nurse take? a)Encourage activity as tolerated. b)Provide a high-protein, fluid-monitored diet. c)Monitor patient blood pressure. d)Place the client on a sheepskin, and monitor for increasing edema.

c)Place transcutaneous pads on the client. Explanation: Transcutaneous pads should be placed on the client with third-degree heart block. For a client who is symptomatic, transcutaneous pacing is the treatment of choice. The hemodynamic stability and pulse should be assessed prior to calling a code or initiating CPR. Defibrillation is performed for ventricular fibrillation or ventricular tachycardia with no pulse.

Upon assessment of third-degree heart block on the monitor, what should the nurse do first? a)Call a code. b)Begin cardiopulmonary resuscitation (CPR). c)Place transcutaneous pads on the client. d)Prepare for defibrillation.

b)Assess the client, call the physician, and then hang the ordered solution Explanation: This scenario is the same as any medication error. The client must be assessed, the physician must be notified, and the correct solution should be given to the client. The other answers are incorrect because they do not ensure that the client will receive appropriate follow-up care for a medication error.

Upon initial assessment of a postoperative client, the nurse identifies that the I.V. infusion is different from the solution ordered by the physician. What is the first action the nurse should take? a)Discontinue the I.V. at the insertion site. b)Assess the client, call the physician, and then hang the ordered solution. c)Let the current IV. bag infuse while calling the physician to confirm the order. d)Replace the current I.V. with the ordered IV after the current I.V. finishes.

b) The client's receipt of information about status and rights should be charted. Explanation: Nurses are required to document that clients have been given information about their status and rights. Seclusion is not related to people becoming involuntary or certified clients. Including details contained within the certificates, such as a healthcare provider (HCP) signing the certificates, is not required.

What should be charted by the nurse when the client has an involuntary commitment or formal admission status? a)Nothing should be charted. The forms are in the chart; there is no need to duplicate. b) The client's receipt of information about status and rights should be charted. c)The client's willingness to cooperate with seclusion should be charted. d)The name of the physician officially signing the certificates should be charted.

a)Assess but not disturb the epidural dressing Explanation: The nurse should assess but not disturb the epidural dressing because the catheter can be easily dislodged and organisms can easily be transmitted into the central nervous system. The nurse should not have to change the dressing at all if a waterproof dressing is applied over the epidural site. Even with strict aseptic technique, a drain into a sterile cavity is a direct route for transmission of organisms and places a client at increased risk of infection, and the nurse should not handle the dressing or the catheter.

When an epidural catheter is used for postoperative pain management, what should the nurse do? a)Assess but not disturb the epidural dressing. b)Change the epidural dressing daily. c)Change the epidural dressing daily only if it is wet. d)Use strict aseptic technique when handling the epidural catheter.

a)restraining a school-age child at risk for self-harm because the nursing assistant had to leave the room Explanation: The nurse supervising a nursing assistant will need to intervene when a nursing assistant restrains a client requiring one-on-one observation to leave the room. It should be reinforced with the nursing assistant to call for a replacement for the time needed to leave the client. Assisting a preschooler in a bathroom is appropriate for that age group. Transporting an infant in a bassinet is appropriate and within the scope of the nursing assistant's job. Removing the toddler from the mother's bed to the crib is appropriate. Cosleeping is dangerous for the child, and the mother should be educated on the risks.

Which action by the nursing assistant would require immediate intervention by the nurse? a)restraining a school-age child at risk for self-harm because the nursing assistant had to leave the room b)assisting a preschool-age child in the bathroom with the door closed c)transporting a newborn in a bassinet from the mother's room to the newborn nursery d)removing a toddler from a sleeping mother's bed to the crib

c)test the fluid for glucose Explanation: Glucose in this clear, colorless fluid indicates the presence of cerebrospinal fluid. Excessive fluid leakage should be reported to the HCP. The nurse should not change the dressing of a postoperative craniotomy client unless instructed to do so by the surgeon. Ordinarily, the head of the bed would not be elevated because this would put pressure on the sutures. The nurse should notify the HCP after testing the fluid for glucose.

Which action should the nurse do first when noting clear drainage on the child's dressing and bed linen after a craniotomy for a brain tumor? a)Change the dressing. b)Elevate the head of the bed. c)Test the fluid for glucose. d)Notify the health care provider (HCP).

c)hemoglobin level, hematocrit, and platelet count Explanation: The baseline laboratory data that are established before a client is started on tissue plasminogen activator or alteplase recombinant include hematocrit, hemoglobin level, and platelet count.

Which baseline laboratory data should be established before a client is started on tissue plasminogen activator or alteplase recombinant? a)potassium level b)lee-White clotting time c)hemoglobin level, hematocrit, and platelet count d)blood glucose level

a)a client being treated for chronic stable angina who reports a recent increase in chest pain frequency Explanation: A report of increasing frequency of chest pain suggests that the client may have developed unstable angina that can lead to an acute coronary syndrome. It requires additional testing and immediate assessment. The diabetic client's A1C level is within normal limits. Pitting edema and weight gain are expected findings with right side heart failure exacerbations—this client is not unstable. The hypertensive client is not in any acute distress.

Which client should the nurse assess first? a)a client being treated for chronic stable angina who reports a recent increase in chest pain frequency b)a client with type 2 diabetes requesting medication refills whose A1C level is 5 mg/dL c)a client being treated for right side heart failure who has 1+ pitting edema to lower extremities bilaterally and reports a 2 lb (0.9 kg) weight gain in the last week d)a client with chronic hypertension whose blood pressure today is 182/98 mm Hg

c)"Don't flex your hip more than 90 degrees, don't cross your legs, and have someone help you put your shoes on." Explanation: Falls in the home cause most injuries among the elderly. Elderly clients should take measures to decrease the clutter that can contribute to falls, such as removing objects such as throw rugs from the floor. Elderly clients should also install grab bars in the shower and next to the toilet. The threat of fire makes burglar bars on every window impractical.

Which discharge instruction should a nurse give a client who's had surgery to repair a hip fracture? a)"Don't flex your hip more than 30 degrees, don't cross your legs, and have someone help you put your shoes on." b)"Don't flex your hip more than 60 degrees, don't cross your legs, and have someone help you put your shoes on." c)"Don't flex your hip more than 90 degrees, don't cross your legs, and have someone help you put your shoes on." d)"Don't flex your hip more than 120 degrees, don't cross your legs, and have someone help you put your shoes on."

d)long-term hospitals Explanation: For a community-based program, the need for long-term hospitalization is least needed if the other services, such as partial hospitalization programs, psychiatric home care, and residential services, are available and accessible.

Which facility would the nurse rank as the lowest priority to expand when developing a community-based service program for clients with chronic mental illnesses? a)partial hospitalization programs b)psychiatric home care c)residential services d)long-term hospitals

a)vertex presentation Explanation: Vertex presentation (flexion of the fetal head) is the optimal presentation for passage through the birth canal. Transverse lie presentation (when the neonate is in a horizontal position across the birth canal) requires a cesarean birth. Frank breech presentation, in which the buttocks present first, can make for a difficult vaginal delivery. Posterior positioning of the fetal head can make it difficult for the fetal head to pass under the maternal symphysis pubis bone.

Which fetal presentation is most favorable for birth? a)vertex presentation b)transverse lie c)frank breech presentation d)posterior position of the fetal head

a)Cleanse the mouth three times a day. Explanation: Oral hygiene is an important aspect of self-care for the laryngectomy client, who is less able to detect mouth odor. Additionally, the mouth harbors bacteria. Good mouth care reduces the risk of infection.The client is able to take tub baths with careful instruction on ways to avoid slipping, the need to make sure the water is no more than 6 inches (15 cm) deep, and other safety measures that will prevent water from entering the laryngectomy site.Moderate exercise may be beneficial, but an aggressive exercise program is not usually part of the plan of care.Air should be humidified to enhance comfort.

Which health-promoting activity should the nurse teach the client who recently underwent a laryngectomy? a)Cleanse the mouth three times a day. b)Avoid taking tub baths. c)Develop an aggressive program of exercise to increase airway functioning. d)Dehumidify the air for comfort.

d)supine with the head midline Explanation: The best initial position for a person with a cervical fracture is supine with the head immobilized and midline. This position prevents flexion, rotation, and extension of the neck. The other choices are incorrect because they don't create alignment.

Which is the best positioning for a client who has a fractured spine as a result of a diving accident? a)prone with head to the side b)side-lying with the head midline c)high Fowler's position with the head to the side d)supine with the head midline

b)cleaning the teeth with a toothbrush Explanation: The oral mucous membranes are easily damaged and are commonly ulcerated in the client with leukemia. It is better to provide oral hygiene without using a toothbrush, which can easily damage sensitive oral mucosa. Applying petroleum jelly to the lips, swabbing the mouth with moistened cotton swabs, and rinsing the mouth with a nonirritating mouthwash are appropriate oral care measures for a child with leukemia.

Which measure is contraindicated when the nurse assists a child who has leukemia with oral hygiene? a)applying petroleum jelly to the lips b)cleaning the teeth with a toothbrush c)swabbing the mouth with moistened cotton swabs d)rinsing the mouth with a nonirritating mouthwash

b)Have the parents stay at the bedside. Explanation: A toddler has a short attention span and is energetic. Thus, keeping a 2-year-old child quiet is a challenge. Because the parents know their child well, the parents have a better chance of helping the child stay quiet. Therefore, they should be encouraged to stay with the child at the bedside.Allowing the child to go to the playroom would most likely encourage the child to be active rather than quiet.A 2-year-old child engages in parallel play but does not know how to play with others.A 2-year-old child's attention span is short, so watching television would keep the child quiet for only a short time.

Which nursing intervention would be most effective in helping a 2-year-old child stay quiet after a bronchoscopy? a)Allow the child to go to the playroom. b)Have the parents stay at the bedside. c)Have the child play with another child in the room. d)Turn on the television so the child can watch cartoons.

a)"Do you have any pets?" Explanation: An infected pet may be the source of this infection. The other questions are appropriate to ask when obtaining a health history related to skin disorders but are not the priority question.

Which question is most important for a nurse to ask when taking a history from a client diagnosed with tinea corporis? a)"Do you have any pets?" b)"Have you recently consumed alcohol?" c)"What is your occupation?" d)"How has this affected you?"

b)"How is this illness impacting you and your family?" Explanation: This question helps address how illness affects the client as well as the family. This question seeks to assess the impact of the stressor and coping abilities. It also examines how the support system, the family, is responding. It is too late to address prevention issues. Taking away worries is not realistic because the client needs to work through concerns. Asking about worst challenges changes the topic of what the client is experiencing right now.

Which question would the nurse ask to determine a client's coping abilities during a lengthy hospital stay? a)"What could you have done to prevent this illness?" b)"How is this illness impacting you and your family?" c)"How can we take away your worries while you are in the hospital?" d)"What are the worst challenges that you have faced?"

c)Dullness. Explanation: A distended bladder produces dullness when percussed because of the presence of urine. Hyperresonance is a percussion sound that is present in hyperinflated lungs. Tympany, a loud drumlike sound, occurs over gas-filled areas such as the intestines. Flat sounds occur over very dense tissue that has no air present.

Which sound should the nurse expect to hear when percussing a distended bladder? a)Hyperresonance. b)Tympany. c)Dullness. d)Flatness.

b)It is noninvasive using real-time ultrasound. Explanation: The fetal biophysical profile, a noninvasive test using real-time ultrasound, assesses five parameters: fetal heart rate reactivity, fetal breathing movements, gross fetal body movements, fetal tone, and amniotic fluid volume. Fetal heart rate reactivity is determined by a nonstress test; the other four parameters are determined by ultrasound scanning. The results are available as soon as the test is completed and interpreted. The lecithin-sphingomyelin ratio is used to determine fetal lung maturity. Although the fetal biophysical profile is useful in predicting which fetuses may be at greater risk for compromise, there is no correlation with the newborn's Apgar score. The biophysical score is sometimes referred to as the fetal Apgar score. A score of 8 to 10 indicates fetal well-being. Use of an ultrasound requires the mother to have a full bladder.

Which statement about a fetal biophysical profile would be incorporated into the teaching plan for a primigravid client with insulin-dependent diabetes? a)It determines fetal lung maturity. b)It is noninvasive using real-time ultrasound. c)It will correlate with the newborn's Apgar score. d)It requires the client to have an empty bladder.

b)Gargle with warm salt water. e)Give acetaminophen for sore throat. f)Offer lots of fluids. Explanation: Treatment for viral tonsillitis consists of supportive care, gargles, administering acetaminophen for fever and sore throat, and encouraging fluids. Aspirin is not used to control fever, because of its associated risk of Reye's syndrome. The child's throat is sore, so a regular diet would probably irritate it further. Viral tonsillitis usually does not cause coughing, so cough medicine would not be indicated.

Which suggestions should the nurse include when teaching the parents of a child who has viral tonsillitis? Select all that apply. a)Administer aspirin for fever control. b)Gargle with warm salt water. c)Supply a regular diet. d)Offer cough medicine every 4 hours. e)Give acetaminophen for sore throat. f)Offer lots of fluids.

b)shock Explanation: After a neonate is diagnosed with a birth defect, parents often go through stages of grief similar to those they would have if they had lost the child. The physical appearance of the anomaly and the life-threatening nature of the disorder may result in shock to the parents. The parents may hesitate to form a bond with the neonate because of the guarded prognosis. Denial would be evidenced if the parents acted as if nothing were wrong. Bargaining would be evidenced by parental statements involving "if-then" phrasing, such as, "If the surgery is successful, I will go to church every Sunday." Anger would be evidenced if the parents attempted to blame someone, such as health care personnel, for the neonate's condition.

While caring for a male neonate diagnosed with gastroschisis, the nurse observes that the parents seem hesitant to touch the neonate because of his appearance. The nurse determines that the parents are most likely experiencing which stage of grief? a)denial b)shock c)bargaining d)anger

a)Walk away from the item. b)Notify the radiation department. Explanation: A radiation seed that is outside of the body will continue to emit radiation particles. Moving away from the object should be done immediately and the radiation department notified so that appropriate personnel can remove the object. The object should not be touched to place on the bedside table, on the sink, or placed in the trash.

While changing bed linens the nurse notices a metal object on the bottom sheet of a client with radiation seeds implanted in the bladder. Which action should the nurse take? Select all that apply. a)Walk away from the item. b)Notify the radiation department. c)Place the object on the bedside table. d)Place the object on the sink in the bathroom. e)Scoop the item with a tissue and place in the trash.

a)report this to the nursing supervisor immediately. Explanation: This situation should be reported immediately to the nursing supervisor or manager at the time. The nurse is liable to report a suspicious situation that could create an unsafe situation for the clients. Reporting a suspicious situation does not imply actual guilt; it implies identification of a high-risk situation. The supervisor will then follow the correct procedure for management and follow-up of the situation. This situation requires immediate attention and cannot be delayed until the head nurse is available on the day shift. The charge nurse, or another staff nurse, should not confront the nurse; this is the responsibility of the nursing supervisor. Assessment of the nurse's behavior is not the nurse's responsibility; reporting the potentially unsafe situation is.

While giving report to the oncoming night shift, the charge nurse smells alcohol on the breath of one of the nurses. The charge nurse should: a)report this to the nursing supervisor immediately. b)report this to the head nurse in the morning. c)ask the nurse if she has been drinking. d)assess the nurse's behavior for signs of intoxication.

a)football hold Explanation: After a cesarean birth, most mothers have the greatest comfort when the neonate is positioned in the football hold with the mother in semi-Fowler's position, supporting the neonate's head in her hand and resting the neonate's body on pillows alongside her hip. This position prevents pressure on the uterine incision yet allows the neonate easy access to the mother's breast. The scissors hold, where the mother places her hand well back on the breast to prevent touching the areola and interfering with the neonate's mouth placement, is used by the mother to hold the breast and support it during breastfeeding. The cross-cradle hold is done when the mother holds the neonate's head in the hand opposite from the breast on which the neonate will feed and the mother's arm supports the neonate's body across her lap. This position can be uncomfortable because of the pressure placed on the client's incision line. For the cradle hold, the mother cradles the infant alongside the arm at the breast on which the neonate will feed. This position also can be uncomfortable because of the pressure placed on the incision line.

While the nurse is caring for a primiparous client with cephalopelvic disproportion 4 hours after a cesarean birth, the client requests assistance in breastfeeding. To promote maximum maternal comfort, which position would be most appropriate for the nurse to suggest? a)football hold b)scissors hold c)cross-cradle hold d)cradle hold