Prioritization and Delegation - ML8

A male neonate has just been circumcised. Which nursing intervention is part of the initial care of a circumcised neonate? Apply petroleum jelly to the site for 24 to 48 hours. Change the diaper as needed. Wash the circumcised penis with warm water. Keep a bandage on the site for 24 to 48 hours.

ANSWER Petroleum jelly should be applied to the site for the first 24 to 48 hours to prevent the skin edges from sticking to the diaper. A gauze or other type of bandage may or may not be used. Washing the area with warm water is indicated, but is not part of the initial care.

A breastfeeding mother who is experiencing breast engorgement asks the nurse if there is anything she can do to get relief. What is the best intervention for the nurse to implement? applying a breast binder administering bromocriptine applying ice teaching how to express the breasts

ANSWER 4 Teaching the client how to express her breasts will facilitate let-down, and provide temporary relief. Ice can promote comfort by decreasing blood flow, numbing, and discouraging further let-down of milk. It is not recommended because it also causes the rebound reaction of more let-down once the ice is removed. Breast binders are not effective in relieving the discomforts of engorgement. Bromocriptine is no longer recommended for lactation suppression.

The nurse has just admitted a client with sickle cell crisis. What is the nurse's priority intervention? Preparing the client for a splenectomy Giving antibiotics and analgesics Giving blood transfusions Increasing fluid intake and giving analgesics

The primary therapy for sickle cell crisis is to increase fluid intake according to age and to give analgesics. Blood transfusions are given conservatively to avoid iron overload. Antibiotics are given to clients with fever. Routine splenectomy is controversial, and not recommended.

What is the priority nursing assessment of a client with an eating disorder? substance abuse history academic performance level of danger to self cultural needs

The priority assessment should be to determine if the client is a danger to self. Cultural needs, substance abuse history, and academic performance are an important part of assessment, but not the priority.

What is the nurse's initial action when preparing to insert a nasogastric (NG) tube? Apply a mask and gown. Open all necessary kits and tubing. Apply sterile gloves. Wash hands.

answer The first intervention before a procedure is hand washing. Clean gloves are used because the mouth and nasopharynx aren't considered sterile. A mask and gown aren't required. Opening all the equipment is the next step before inserting the NG tube.

A client experiencing alcohol withdrawal reports being upset about going through detoxification. Which goal is the priority for this client? drinking plenty of fluids on a daily basis making a personal inventory of strengths working with the nurse to remain safe committing to a drug-free lifestyle

ANSWER 3 The priority goal is for client safety. Symptoms of alcohol withdrawal syndrome can include delirium and seizures. Although drinking enough fluids, identifying personal strengths, and committing to a drug-free lifestyle are important goals, the nurse's priority at this time is to promote client safety.

A nurse is assigned to four clients. Which client should the nurse see first? A client who is being prepared for a major surgery receiving clopidogrel A client with a low white blood cell count receiving pegfilgrastim A client who had open reduction internal fixation (ORIF) receiving fondaparinux A client with acquired immunodeficiency syndrome receiving emtricitabine

Clopidogrel is an anti-platelet drug that should be stopped seven days prior to surgery because it can increase the risk of bleeding. All the other options are correct. Fondaparinux can be given to a client who had ORIF to prevent blood clot formation. Pegfilgrastim is given to a client with low white blood cell (WBC). Emtricitabine is a nucleoside-nucleotide reverse transcriptase inhibitor (NNRTI) drug used for clients with HIV/AIDS.

The nurse is planning care for an infant with bronchiolitis. What is the nurse's priority intervention for this child? Incorporate parents into the child's care. Assess respiratory status frequently. Monitor intake and output. Position the infant with the head elevated.

Infants with bronchiolitis will have impaired gas exchange related to bronchiolar obstruction, atelectasis, and hyperinflation. Changes in respiratory status may occur quickly as energy reserves are depleted; therefore, close monitoring is essential. Positioning the infant, monitoring fluid status, and including parents in care plan are necessary, but not the priority.

A client with acute renal failure has a serum potassium level of 7.0 mEq/L (mmol/L). What is the nurse's priority action for this client? Electrocardiogram (ECG) results Urine specific gravity Mental status Blood pressure

answer Acute renal failure can result in hyperkalemia, which can manifest in widening of the PR and QRS intervals on the ECG as well as irregular heartbeats, such as premature ventricular contractions. Urine specific gravity, mental status, and blood pressure are not a priority for this client.

A client is scheduled for amniocentesis. What priority intervention should the nurse implement? Have the client void. Tell the client to drink 34 oz (1 L) of water. Place the client on her left side. Instruct the client to fast for 12 hours.

answer 1 Before amniocentesis, the client should empty the bladder which reduces the risk of bladder perforation. This client doesn't need to drink fluids or fast before amniocentesis. A client would be placed in a supine position for an amniocentesis.

A multiparous client who has been in labor for 2 hours states that she feels the urge to move her bowels. What would the nurse do first? Check the fetal heart rate (FHR). Perform a pelvic examination. Allow the client to use a bedpan. Assist the client to get up to use the toilet.

ANSWER A report of rectal pressure usually indicates a low presenting fetal part, and imminent birth. The nurse should perform a pelvic examination to assess the dilation of the cervix and station of the presenting fetal part. Do not let the client use the toilet or a bedpan before she's examined because she could birth on the toilet or in the bedpan. Checking the FHR is important but comes after the nurse evaluates the client's report.

A 76-year-old woman, with a history of osteoporosis is 24-hours postoperative for a total right hip replacement. What is the priority nursing action for this client? Caring for the surgical wound Managing pain Ambulating 50 feet Promoting nutrition

ANSWER 2 Adequate pain relief will enable this client to engage in initial mobility exercises and prevent potential complications. Ambulating 50 feet is a longer-term goal. Wound care and nutrition are important post-surgical priorities over the longer term to ensure wound healing, but they are not the priority with this type of procedure.

A nurse caring for an infant with neonatal bronchopulmonary dysplasia (chronic lung disease) administers furosemide. What is the priority intervention following the administration of this medication? Obtain vital signs every 2 hours. Obtain a vision screen. Monitor electrolyte status. Obtain daily weights.

ANSWER 3 Furosemide is a potent diuretic. If given in excessive amounts it can lead to a profound diuresis of water and electrolyte depletion that could lead to life-threatening arrhythmias. Input and output should be monitored along with vital signs. Furosemide can be ototoxic; therefore, hearing should be evaluated.

The nurse is preparing to assess a child with a possible cardiac anomaly. What is the priority assessment for this nurse? Blood pressure in all four extremities Temperature Pupil size and reaction to light Skin turgor

Measuring blood pressure in all four extremities is necessary to document hypertension and the blood pressure gradient between the upper and lower extremities. Temperature, skin turgor, and pupillary assessment are also important, but are not as specific for cardiac assessment as the blood pressure.

The nurse is assigned to care for four clients. Which client should the nurse assess first? A client admitted two days ago with heart failure, blood pressure of 126/76 mmHg, and a respiratory rate of 22 breaths/min A client with end-stage, right-sided heart failure, with blood pressure of 78/50 mmHg, who is on hospice care A client admitted one day ago with thrombophlebitis who is receiving IV heparin A client admitted one hour ago with new-onset atrial fibrillation who is receiving IV diltiazem

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A client is admitted to the labor and delivery unit for birth of a known anencephalic fetus. What is the most appropriate intervention by the nurse? Assess fetal heart tones via external monitor. Reassure the client that she'll get pregnant again soon. Avoid talking about the baby. Provide privacy and emotional support.

answer Providing privacy and support is an appropriate therapeutic intervention for the client and family to grieve their loss. Fetal heart tones are rarely assessed in a client with an anencephalic fetus. Most fetuses will not survive due to a lack of cerebral function. Reassuring the client that she will get pregnant again dismisses how she feels about her current loss, and also provides false reassurance.

The nurse is caring for an 8-year-old child who arrived at the emergency department with chemical burns to both legs. What is the priority intervention for this child? diluting the chemicals applying topical antibiotics debriding and grafting the burns applying sterile dressings

answer 1 Diluting the chemical is the priority. It will help remove the chemical and stop the burning process. The remaining treatments are initiated after dilution.

Which client would benefit most from information explaining the importance of receiving an annual Papanicolaou (PAP) test? A client who had her first pregnancy before the age of 20 A client infected with the human papillomavirus (HPV) A client with a history of recurrent candidiasis A client who has used oral contraceptives for 27 years

answer 2 HPV causes genital warts, which are associated with an increased incidence of cervical cancer. Recurrent candidiasis, pregnancy before age 20, and the use of oral contraceptives have not been shown to increase the risk of cervical cancer.

The nurse is examining charts to identify clients at risk for developing multiple myeloma. Which client is most at risk? a 20-year-old Asian woman a 30-year-old White man a 60-year-old Black man a 50-year-old Hispanic woman

answer 3 Multiple myeloma is more common in middle-aged and older adult clients. The median age at diagnosis is 60 years. It is twice as common in Black clients as it is in White clients, and it occurs most often in Black men.

A client presents with acute onset chest pain rated as 7/10 radiating to left arm and mid-scapular region, blood pressure of 155/95 mm Hg, heart rate of 98 beats/min, respiratory rate of 22 breaths/min, and an oxygen saturation of 94%. What is the nurse's priority intervention? Establish intravenous access. Conduct a full cardiovascular assessment. Apply supplemental oxygen. Administer sublingual nitroglycerin.

answer 4 Current best practice guidelines recommend the application of supplemental oxygen in acute coronary syndrome only if the client has an oxygen saturation less than 90% or has other evidence of hypoxia. In this case, the client does not require supplemental oxygen but should receive sublingual nitroglycerin as a priority. Nitroglycerin is a potent vasodilator with its effects greater on veins than arteries. By creating venous pooling, preload is reduced, which decreases myocardial oxygen demand and helps reduce the ischemia and myocardial damage. Once the drug is administered, the nurse can continue with other interventions, such as establishing IV access or continuing to gather assessment data. The nurse will recheck the client's response and blood pressure 5 minutes after administering the nitroglycerin and base further actions on the client's response.

While performing the morning postpartum assessment, the nurse notices that a client's perineal pad is completely saturated with lochia rubra. What is the nurse's best action? Vigorously massage the fundus. Call the health care provider immediately. Have the charge nurse review the assessment. Ask the client when she last changed her perineal pad.

answer 4 If the morning assessment is done relatively early, it's possible that the client hasn't yet been to the bathroom, and the perineal pad may have been in place all night. In addition, her lochia may have pooled during the night, resulting in a heavy flow in the morning. Vigorous massage of the fundus isn't recommended if heavy bleeding or hemorrhage is present. If the nurse were uncertain, and wanted a second opinion, it would be appropriate to call the health care provider or ask another qualified nurse after doing a complete assessment of the client's status.

A client has just been diagnosed with pneumonia. What is the nurse's priority action? Reverse fluid volume excess. Provide information about how to avoid a recurrence. Incrementally increase activity tolerance. Maintain airway clearance.

answer 4 Pneumonia refers to inflammation of the lungs and can produce copious amounts of tracheobronchial secretions. These secretions interfere with airway patency and gas exchange. Airway clearance is a priority. The client may experience decreased fluid volume, not an excess, due to increased temperature and respiratory rate. The client may also experience activity intolerance and deficient knowledge, but neither is the priority diagnosis.

A client has received an infusion of antibiotics and is now experiencing an anaphylactic reaction. What is the most important intervention by the nurse? Administer a bolus of normal saline solution. Monitor vital signs. Administer epinephrine. Maintain a patent airway.

answer 4 The first priority is to maintain a patent airway. The client will then require an epinephrine injection. If hypotension develops, a saline bolus may be given. The client's vital signs should be monitored, but not as the first action.

A child is hospitalized with infective endocarditis. Which nursing intervention is most appropriate? increase fluids provide frequent toileting provide diversional activities give small, frequent meals

ANSWER Treatment for infective endocarditis requires long-term hospitalization or home care and I.V. antibiotics. During this time children may become bored or depressed, and need age-appropriate activities. Excessive fluid volume may be seen with infective endocarditis. Gastrointestinal upset and constipation may be adverse reactions related to the antibiotics. Overeating may occur due to boredom.

Which nursing assessment data would be given priority for a child with clinical findings related to tubercular meningitis? signs of increased intracranial pressure (ICP) degree and extent of nuchal rigidity onset and character of fever occurrence of urinary and fecal incontinence

ANSWER 1 Assessment of fever and evaluation of nuchal rigidity are important aspects of care, but assessing for signs of increasing ICP should be the highest priority due to the life-threatening implications. Urinary and fecal incontinence can occur in a child who is ill from nearly any cause. This doesn't pose a great danger to life.

A client is brought to the emergency department after a house fire. What is the priority assessment by the nurse? Assess the level of pain and medication allergies. Assess oxygen saturation and the client's ability to speak. Collect a full set of vital signs and spheres of orientation. Assess the depth and total surface area of burns.

ANSWER 2 The nurse's priority is to make sure the airway is open and that the client is breathing, which would be best accomplished by seeing if the client can speak and what the oxygen saturation is. Vital signs, degree of burns, and the client's pain can all be assessed once the nurse establishes that the client has a patent airway.

A nurse is planning preoperative care for a child diagnosed with Wilms' tumor. What is the nurse's most important intervention? Prepare the family for the initiation of chemotherapy and radiation. Avoid abdominal palpation or manipulation. Begin I.V. therapy of hyperalimentation and lipids. Insert a nasogastric tube for enteral feedings.

After a diagnosis of Wilms' tumor, the abdomen should not be palpated. Palpation of the tumor could lead to rupture, which would spread cancerous cells throughout the abdomen. If surgery is successful, long-term radiation and chemotherapy would not be required. Enteral feedings and total parenteral nutrition are not part of the preoperative treatment of Wilms' tumor. Radiation and chemotherapy are not started preoperatively.

The nurse is asked to assess a client prior to having an arterial blood gas (ABG) sample drawn to determine if the client can safely undergo this test. What assessment should the nurse conduct? Review the client's baseline ABG results. Perform an Allen's test. Gather a full set of vital signs. Palpate the radial artery for strength and rhythm.

An Allen's test to assess circulation should be performed first as this will determine if there is impaired radial artery circulation that would contraindicate having the ABG performed. The client can have a strong, regular radial pulse but still have impaired arterial blood flow to the region. Although the client's vital signs should be done, these are not directly related to the appropriateness of the ABG test. Previous ABG results will not have a bearing on whether this new test should be done.

The nurse is assessing a client who has been experiencing black stools for the past month. The client suddenly reports chest and stomach pain. What is the most important action by the nurse? Initiate cardiac monitoring Draw blood for laboratory analysis Assess the client's vital signs Administer oxygen via nasal cannula

answer 3 Assessing vital signs would determine this client's hemodynamic stability. Monitoring the heart rhythm may be indicated based on assessment findings. Administering oxygen and drawing blood require a health care provider's order, and would not be part of a screening evaluation.

A child diagnosed with bacterial meningitis has been admitted to the unit. What is the priority nursing action? administering intravenous antibiotics reducing environmental stimuli avoiding lifting the client's head providing pain control

ANSWER Bacterial meningitis is a medical emergency that requires immediate treatment with antibiotics. If not treated rapidly, it may lead to brain damage, deafness, stroke, and death. All the other actions are important but only secondary to administering antibiotics.

A child has ingested poisonous hydrocarbons. What is the most important nursing intervention? Keep the child calm and relaxed. Administer activated charcoal. Induce vomiting. Monitor the parent-child interactions for possible child abuse.

ANSWER 1 Keeping the child calm and relaxed will help prevent vomiting. If vomiting is induced, the esophagus will be damaged from regurgitation of the gastric poison. The risk of chemical pneumonitis exists if vomiting occurs. Activated charcoal poorly absorbs hydrocarbons, and it tends to distend the stomach and cause vomiting. The parents should remain with the child to help keep the child calm. It is not necessary to monitor parent-child interactions for possible child abuse.

During a routine prenatal examination, a client who is at 32 weeks' gestation becomes dizzy, lightheaded, and pale. After placing the client in a supine position, what is the priority nursing action? Ask the client to breathe deeply. Take the client's blood pressure. Turn the client on her left side. Listen to fetal heart tones.

answer As the uterus gets larger, it increases pressure on the inferior vena cava. This inhibits venous return causing dizziness, lightheadedness, and pallor when the client is supine. Turning the client on her left side relieves the pressure on the vena cava and restores venous return. Although they're valuable assessments, listening to fetal heart tone and measuring maternal blood pressure don't alleviate the symptoms. Deep breathing has no effect on venous return, and will not relieve this client's symptoms.

A client, who underwent femoral-popliteal (fem-pop) bypass surgery, is scheduled to return from the post-anesthesia care unit. Which staff member should receive this client? Registered nurse with one year of experience Nursing assistant with 15 years of experience Charge nurse with 10 years of experience Licensed practical nurse (LPN) with five years of experience

answer Because this client requires frequent neurovascular assessments, a registered nurse should receive him. Although experienced and able to collect data, an LPN doesn't have the education to assess this client. The nursing assistant lacks the necessary assessment skills. The charge nurse needs to be available to direct the care of other clients.

The nurse is caring for a client with terminal lung cancer. What is the priority nursing intervention for this client? Provide nutritional support. Provide education about end-of-life. Provide emotional support. Provide pain control.

answer A client with terminal lung cancer may have extreme pleuritic pain and should be treated to reduce this discomfort. Preparing the client and their family for impending death and providing emotional support are also important, but shouldn't be the primary focus until the pain is under control. Nutritional support may be provided, but as the terminal phase advances, the client's nutritional needs greatly decrease.

A parent reports that the school-age child has been reprimanded for daydreaming during class. The parent is concerned because the child's sibling has been diagnosed with absence seizures. This behavior is new, and the child's grades are dropping. What is the most appropriate action by the nurse? Refer the child to the primary care provider to assess for attention deficit hyperactivity disorder (ADHD). Refer the child to an audiologist for a hearing assessment. Refer the child to the special education department to assess for a learning disability. Refer the child to the primary health care provider to assess for absence seizures.

answer Absence seizures are commonly misinterpreted as daydreaming. The child loses awareness, but no alteration in motor activity is exhibited. A mild hearing problem usually presents as leaning forward, talking loudly, increasing the volume of the TV and radio, and continually asking, "What?" There isn't enough information to indicate a learning disability. ADHD isn't characterized by episodes of daydreaming.

A 19-month-old child with croup is crying as a nurse tries to auscultate breath sounds. What is the nurse's most appropriate intervention? tell the parents that they are upsetting the child and to wait outside the room hand the stethoscope to the child to examine before auscultating the lungs ignore the crying and listen to breath sounds as best as possible tell the child, in a loud and firm voice, that they must sit still and cooperate

answer Children at this age are very curious. Encouraging the child to play with the stethoscope will distract them and help gain trust so that the nurse will be able to auscultate the lungs. Ignoring the child's crying may only upset them more, and will not help the nurse gain their trust. The nurse should ask the parents to help quiet and comfort the child. Asking the parents to leave may only upset the child more. The nurse should speak to the child in a soft, comforting tone of voice.

What is the nurse's priority to regulate the temperature of a neonate? Block radiant, convective, conductive, and evaporative losses. Minimize the energy needed for the neonate to produce heat. Supply extra heat sources to the neonate. Keep the ambient room temperature less than 100° F (37.8° C).

answer 1 Prevention of heat loss is always the first goal in thermoregulation to avoid hypothermia. The second goal is to minimize the energy necessary for neonates to produce heat. Adding extra heat sources is a means of correcting hypothermia. The ambient room temperature should be kept at approximately 100° F (37.8° C).

A nurse walks into the room of a client diagnosed with congestive heart failure (CHF). The client is lying supine and is diaphoretic, anxious, and dyspneic. What is the nurse's priority action? Raise the head of the bed to 45°. Draw arterial blood gases. Administer oxygen at 4/l/min. Administer 0.5 mg of lorazepam.

answer 1 Raising the head of the bed will help the client's lungs expand and allow for deeper breaths. The nurse would need a provider's order for oxygen, and it may not be most beneficial if the head of the bed is not elevated. Lorazepam may decrease the client's anxiety, but it may also diminish respirations and increase dyspnea. Arterial blood gases are not a priority.

The nurse is caring for a client with terminal lung cancer. What is the priority nursing intervention for this client? Provide emotional support. Provide pain control. Provide education about end-of-life. Provide nutritional support.

answer 2 A client with terminal lung cancer may have extreme pleuritic pain and should be treated to reduce this discomfort. Preparing the client and their family for impending death and providing emotional support are also important, but shouldn't be the primary focus until the pain is under control. Nutritional support may be provided, but as the terminal phase advances, the client's nutritional needs greatly decrease.

The nurse is concerned that a client admitted with major depressive disorder may be suicidal. What is the most important action by the nurse? Talk to the client to determine whether the client is an attention seeker Speak to family members to ascertain whether the client is suicidal Ask a direct question such as, "Do you ever think about killing yourself?" Arrange for the client to be placed on immediate suicidal precautions

answer 2 The best approach is to ask about thoughts of suicide in a direct and caring manner. Assessing for attention-seeking behaviors doesn't deal directly with the problem. The client should be assessed directly, not through family members. Assessment must be performed before determining whether suicide precautions are necessary.

The nurse is caring for a client in the post anesthesia care unit (PACU) following an adrenalectomy. What is the nurse's priority action? Assessing serum potassium Administering dextrose in water Assessing blood pressure Administering opioids

answer 3 Removing a major source of adrenal hormones may cause a state of temporary adrenal insufficiency. After an adrenalectomy, the patient is usually sent to a critical care unit. Immediately after surgery, the patient should be assessed every 15 minutes for shock due to possible insufficient glucocorticoid replacement. Assessment is a priority over interventions. Assess the blood pressure, then electrolytes, and finally assess the client for fluid replacement and pain management needs.

A breastfeeding mother who is experiencing breast engorgement asks the nurse if there is anything she can do to get relief. What is the best intervention for the nurse to implement? administering bromocriptine applying a breast binder teaching how to express the breasts applying ice

answer 3 Teaching the client how to express her breasts will facilitate let-down, and provide temporary relief. Ice can promote comfort by decreasing blood flow, numbing, and discouraging further let-down of milk. It is not recommended because it also causes the rebound reaction of more let-down once the ice is removed. Breast binders are not effective in relieving the discomforts of engorgement. Bromocriptine is no longer recommended for lactation suppression.

The nurse is caring for a client who has just undergone electroconvulsive therapy (ECT) for the treatment of severe depression that is unresponsive to medication. What is the nurse's most important intervention immediately postprocedure? Provide oral fluids. Reorient the client to the environment. Assess vital signs. Administer analgesics.

ANSWER ECT is performed under sedation, so vital signs are monitored carefully for approximately one hour after the procedure or until the client is stable. The client should not have anything by mouth and will take time to awaken enough to require orientation to the environment. Analgesia should not be needed immediately postprocedure, because the client will not yet be conscious.

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? The UAP instructs the client to perform ankle rotation exercises. The UAP lifts the weights while assisting the client as he moves up in bed. The leg in traction is kept externally rotated. The weights are allowed to hang freely over the end of the bed.

ANSWER 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.

The parent of a 2-year-old with epiglottitis states a need to pick up the older child from school. The 2-year-old child begins to cry and appears more stridorous. What is the nurse's priority action? Tell the 2-year-old child everything will be all right. Ask the parent if there's anyone else who can meet the older child. Ask how long the parent will be gone. Tell the 2-year-old child the nurse will stay.

ANSWER Increased anxiety and agitation should be avoided to prevent airway obstruction. A 2-year-old child fears separation from parents, and the parent should be encouraged to stay. Other means of picking up the older child should be found. Telling the child that everything will be all right may not decrease agitation. The parent is the primary caregiver and important to the child for emotional and security reasons.

A client has received an infusion of antibiotics and is now experiencing an anaphylactic reaction. What is the most important intervention by the nurse? Maintain a patent airway. Administer a bolus of normal saline solution. Administer epinephrine. Monitor vital signs.

ANSWER The first priority is to maintain a patent airway. The client will then require an epinephrine injection. If hypotension develops, a saline bolus may be given. The client's vital signs should be monitored, but not as the first action.

Parents bring a preschool-age client to the emergency department with suspected ingestion of an unknown toxic substance. What intervention should the nurse perform first? Ask the parents what they think the child ingested. Assess the child's vital signs and neurological status. Establish intravenous access, and provide supplemental oxygen. Interview the parents about the initial onset of symptoms.

ANSWER The nurse must assess the child to determine if life-saving intervention such as cardiopulmonary resuscitation is needed. This assessment will direct all the subsequent actions, such as the application of oxygen and intravenous fluids. The parents have indicated the source of suspected poisoning is unknown, so although interviewing them to try to determine the possible source and the initial symptoms should be done, the nurse must first assess and stabilize the child.

A 46-year-old female client is diagnosed with anorgasmia. Which nursing intervention takes priority when planning care for this client? assessing the client's role in her sexual relationship determining the nurse's own attitudes about this issue interviewing the client with her sexual partner clarifying changes in her sexual functioning

ANSWER The nurse must first identify her own beliefs and feelings about this issue and remain nonjudgmental. The other actions may be relevant in assessing and planning interventions, but risk being unconsciously influenced by the nurse's comfort level with this intimate topic.

A client, who underwent femoral-popliteal (fem-pop) bypass surgery, is scheduled to return from the post-anesthesia care unit. Which staff member should receive this client? Registered nurse with one year of experience Charge nurse with 10 years of experience Licensed practical nurse (LPN) with five years of experience Nursing assistant with 15 years of experience

ANSWER 1 Because this client requires frequent neurovascular assessments, a registered nurse should receive him. Although experienced and able to collect data, an LPN doesn't have the education to assess this client. The nursing assistant lacks the necessary assessment skills. The charge nurse needs to be available to direct the care of other clients.

What is the most important intervention for the nurse to include in the care plan for a male infant following surgical repair of hypospadias? frequent assessment of the tip of the penis urethral catheterization if voiding doesn't occur over an 8-hour period sterile dressing changes every 4 hours removal of the suprapubic catheter on the second postoperative day

ANSWER 1 Following hypospadias repair, a pressure dressing is applied to the penis to reduce bleeding and tissue swelling. The tip of the penis should then be assessed frequently for signs of circulatory impairment. The dressing around the penis is initially changed by the surgeon, and shouldn't be changed every 4 hours thereafter. The provider will determine when the suprapubic catheter will be removed. Urethral catheterization should be avoided after repair of hypospadias to prevent trauma to the repaired urethra.

What is the nurse's priority to regulate the temperature of a neonate? Block radiant, convective, conductive, and evaporative losses. Supply extra heat sources to the neonate. Keep the ambient room temperature less than 100° F (37.8° C). Minimize the energy needed for the neonate to produce heat.

ANSWER 1 Prevention of heat loss is always the first goal in thermoregulation to avoid hypothermia. The second goal is to minimize the energy necessary for neonates to produce heat. Adding extra heat sources is a means of correcting hypothermia. The ambient room temperature should be kept at approximately 100° F (37.8° C).

A nurse is assigned to four clients. Which client should the nurse see first? A client who is being prepared for a major surgery receiving clopidogrel A client who had open reduction internal fixation (ORIF) receiving fondaparinux A client with acquired immunodeficiency syndrome receiving emtricitabine A client with a low white blood cell count receiving pegfilgrastim

ANSWER 1Clopidogrel is an anti-platelet drug that should be stopped seven days prior to surgery because it can increase the risk of bleeding. All the other options are correct. Fondaparinux can be given to a client who had ORIF to prevent blood clot formation. Pegfilgrastim is given to a client with low white blood cell (WBC). Emtricitabine is a nucleoside-nucleotide reverse transcriptase inhibitor (NNRTI) drug used for clients with HIV/AIDS.

Which nursing intervention is a priority for a pregnant adolescent during her first trimester? Schedule the client for a screening glucose tolerance test. Refer the client to a dietitian for nutritional counseling. Assess the client for signs and symptoms of placenta previa. Tell the client that she will most likely need a cesarean birth due to the head size of the fetus.

ANSWER 2 Adolescents are at risk for delivering low-birth-weight neonates. Nutritional counseling should be a priority for these clients to ensure proper fetal development. A pregnant adolescent is not likely to deliver a macrosomic neonate. The final head size of the fetus is unknown at this time. Adolescents are not at increased risk for developing gestational diabetes or placenta previa.

A client is scheduled for amniocentesis. What priority intervention should the nurse implement? Place the client on her left side. Have the client void. Instruct the client to fast for 12 hours. Tell the client to drink 34 oz (1 L) of water.

ANSWER 2 Before amniocentesis, the client should empty the bladder which reduces the risk of bladder perforation. This client doesn't need to drink fluids or fast before amniocentesis. A client would be placed in a supine position for an amniocentesis.

The nurse is caring for an 8-year-old child who arrived at the emergency department with chemical burns to both legs. What is the priority intervention for this child? applying topical antibiotics diluting the chemicals debriding and grafting the burns applying sterile dressings

ANSWER 2 Diluting the chemical is the priority. It will help remove the chemical and stop the burning process. The remaining treatments are initiated after dilution.

The nurse is caring for a client who has just undergone electroconvulsive therapy (ECT) for the treatment of severe depression that is unresponsive to medication. What is the nurse's most important intervention immediately postprocedure? Provide oral fluids. Assess vital signs. Administer analgesics. Reorient the client to the environment.

ANSWER 2 ECT is performed under sedation, so vital signs are monitored carefully for approximately one hour after the procedure or until the client is stable. The client should not have anything by mouth and will take time to awaken enough to require orientation to the environment. Analgesia should not be needed immediately postprocedure, because the client will not yet be conscious.

A client is receiving CPR from paramedics as he arrives in the emergency department (ED). The paramedics are ventilating the client through an endotracheal tube placed prior to transport. During a pause in compressions, the cardiac monitor shows narrow QRS complexes and a heart rate of 55 bpm with a palpable pulse. Which action should the nurse take first? Start an IV line and administer amiodarone Administer 1 mg atropine IV Check ET tube placement Obtain an arterial blood gas (ABG) sample

ANSWER 3 Endotracheal tube placement should be confirmed as soon as the client arrives in the ED. Once the airway is verified, oxygenation and ventilation should be confirmed using an end-tidal carbon dioxide monitor and pulse oximetry. Next, the nurse should establish IV access. If the client experiences symptomatic bradycardia, atropine should be administered as ordered. The ABG sample would verify effectiveness of CPR ventilations. Amiodarone is indicated for ventricular tachycardia, ventricular fibrillation, and atrial flutter.

A nurse is teaching a group of parents about urinary tract infections (UTIs) in children. What is the priority educational topic for this group of parents? risk factors for UTIs in children how to identify symptoms of UTI interventions to prevent UTIs how to collect a midstream urine sample

ANSWER 3 Prevention is the most important goal of teaching about a preventable condition such as UTIs. The most preventive measures are simple hygienic practices that should be a routine part of daily care. While some of the teaching about prevention will overlap with risk factor discussion, some risk factors, such as female gender, are not something that can be targeted for prevention. Teaching about treatment, detection, and testing is important, but this is not the priority and will not be relevant if the UTI is successfully prevented.

A nurse suspects an infant may have a tracheoesophageal fistula or esophageal atresia. What is the most important intervention by the nurse? Give oxygen. Tell the parents. Report the suspicion to the health care provider. Put the neonate in an isolette or on a radiant warmer.

ANSWER 3 The provider needs to be told so that immediate diagnostic tests can be done to determine a definitive diagnosis with surgical correction. Oxygen should be given only after notifying the provider, except in an emergency; a need for oxygen is based on the infant's oxygen saturation levels or arterial blood gas results. It is not the nurse's responsibility to inform the parents of the suspected finding. By the time tracheoesophageal fistula or esophageal atresia is suspected, the neonate would have already been placed in an isolette or a radiant warmer.

The nurse is caring for a client who has an endotracheal tube (ETT). What is the nurse's priority intervention to prevent oral ulceration related to an ETT? Use water-based lubricant on the lips every 8 hours. Suction the oral cavity with a flexible catheter every 4 hours. Provide oral care twice a day with a soft, moist oral swab. Reposition the tube from one side of mouth to the other per protocol frequency.

ANSWER 4 Pressure causes skin breakdown or ulceration, so repositioning the ET tube can best decrease this risk for oral ulcers. Extreme care must be taken to move the tube only laterally; it must not be pushed in or pulled out. The tape securing the tube must be changed daily. Oral care, suctioning, and lubricant will help keep skin clean, intact, and reduce the risk of further infection but will not reduce the risk for ulcers like tube repositioning will.

A postpartum mother is concerned about a noted decrease in her breast milk production. Which response by the nurse best addresses this mother's concern? Have several alcoholic beverages for relaxation. Suggest the mother consume a diet high in vitamin C. Feed the infant less frequently. Decrease supplemental feedings with formula.

ANSWER 4 Routine formula supplementation may interfere with establishing an adequate milk volume because suckling the breast stimulates prolactin production. Prolactin is the hormone responsible for milk production. Vitamin C levels haven't been shown to influence milk volume. One alcoholic beverage generally tends to relax the mother, and facilitate the milk let-down reflex. Excessive consumption of alcohol may block milk let-down, though supply isn't necessarily affected. Frequent feedings are likely to increase milk production.

What is the nurse's priority intervention for a client diagnosed with a pulmonary embolism? Determining need for a ventilation-perfusion scan Monitoring for other sources of clots Monitoring the oxygen delivery device Assessing oxygenation status

An Allen's test to assess circulation should be performed first as this will determine if there is impaired radial artery circulation that would contraindicate having the ABG performed. The client can have a strong, regular radial pulse but still have impaired arterial blood flow to the region. Although the client's vital signs should be done, these are not directly related to the appropriateness of the ABG test. Previous ABG results will not have a bearing on whether this new test should be done.

After undergoing a cardiac catheterization, a client has a large puddle of blood under his buttocks. What is the nurse's priority action? Assess the groin site Call for help Ask the client to "lift up" Obtain vital signs

Assessment of the groin site is the priority. This establishes the source of the blood, and determines how much blood has been lost. The goal is to stop the bleeding. The nurse would call for help if needed after the assessment of the situation. After determining the extent of the bleeding, vital sign assessment is important. The nurse should never move the client, in case a clot has formed. Moving can disturb the clot and cause re-bleeding.

While performing the morning postpartum assessment, the nurse notices that a client's perineal pad is completely saturated with lochia rubra. What is the nurse's best action? Have the charge nurse review the assessment. Ask the client when she last changed her perineal pad. Vigorously massage the fundus. Call the health care provider immediately.

If the morning assessment is done relatively early, it's possible that the client hasn't yet been to the bathroom, and the perineal pad may have been in place all night. In addition, her lochia may have pooled during the night, resulting in a heavy flow in the morning. Vigorous massage of the fundus isn't recommended if heavy bleeding or hemorrhage is present. If the nurse were uncertain, and wanted a second opinion, it would be appropriate to call the health care provider or ask another qualified nurse after doing a complete assessment of the client's status.

A two-year-old child comes to the emergency department with inspiratory stridor and a barking cough. A preliminary diagnosis of croup has been made. What is the nurse's most important intervention? ask the parent to go to the waiting room administer I.V. antibiotics provide oxygen by face mask establish and maintain the airway

The initial priority is to establish and maintain the airway. Edema and an accumulation of secretions may contribute to airway obstruction. Antibiotics are not indicated for viral illnesses. Oxygen should be administered as soon as possible to decrease the child's distress. Allowing the child to stay with the parent reduces anxiety and distress.

While performing an assessment of a 75-year-old client in the emergency department, a nurse notes several areas of ecchymosis in various stages of healing on the client's body. What is the nurse's priority action? Notify the nursing supervisor. Inquire how these bruises occurred. Document the findings. Notify the health care provider.

The nurse should obtain more information from the client first, in order to complete the initial assessment. The nurse should not assume that the bruises are a result of abuse, and she should not notify the nursing supervisor until additional facts are obtained. The nurse should inform the provider so an examination can be completed. She should follow the facility's policy and procedure for reporting abuse and document the findings.

An older adult client with pneumonia is admitted with prescriptions for intravenous antibiotics, supplemental oxygen as needed, and antipyretics. The nurse should immediately notify the health care provider for which assessment finding? temperature of 101.3°F (38.5°C) acute onset delirium respiratory rate of 24 breaths/minute pleuritic chest pain and cough

answer The acute change in client cognition (i.e., delirium) is considered a medical emergency and should be investigated immediately. This acute change could be evidence of sepsis, electrolyte imbalances, or other organic causes that should be diagnosed and treated as soon as possible. The nurse should assess for the common symptoms of pneumonia such as fever, chills, dyspnea, pleuritic chest pain, and a productive cough. These symptoms should be monitored, but the nurse has treatments prescribed by the health care provider to address these findings.

The nurse is delegating activities to a recently graduated licensed practical/vocational nurse (LPN/VN) at a skilled nursing facility. Which activities are appropriate to delegate to the LPN/VN? Select all that apply. Cleansing a leg wound and applying antibiotic ointment. Administering intravenous sedation. Assisting an unlicensed assistive personnel (UAP) with a weight. Completing an admission body assessment. Recording percentage of meal completion.

answer According to the LPN/VN scope of practice, the LPN/VN can cleanse a leg wound and apply antibiotic ointment, record percentage of meal completion, and assist a UAP with weighing a client. The scope of practice of a LPN/VN varies by state, but it usually does not include administering an intravenous medication unless the nurse has obtained a certification establishing competency with IV medication administration. Even then, administering a sedative may be outside the scope of practice. An admission body assessment must be performed by an RN.

A client is admitted to the labor and delivery unit for birth of a known anencephalic fetus. What is the most appropriate intervention by the nurse? Reassure the client that she'll get pregnant again soon. Avoid talking about the baby. Assess fetal heart tones via external monitor. Provide privacy and emotional support.

answer Providing privacy and support is an appropriate therapeutic intervention for the client and family to grieve their loss. Fetal heart tones are rarely assessed in a client with an anencephalic fetus. Most fetuses will not survive due to a lack of cerebral function. Reassuring the client that she will get pregnant again dismisses how she feels about her current loss, and also provides false reassurance.

A 30-year-old multiparous client in active labor is admitted to the labor and delivery unit. She has received no prenatal care for this pregnancy. Which data would the nurse obtain first? family history of sexually transmitted infection (STIs) number of and ages of previous children date of last menstrual period (LMP) name of insurance provider

answer The date of the LMP is essential to estimate the date of birth, and should be obtained first. The nursing history would also include subjective information, such as personal history of STIs, gravidity, and parity. Although beneficial to the hospital for financial reimbursement, the insurance provider has no bearing on the nursing history. The number of siblings is not pertinent to the assessment.

The nurse is caring for a 3-year-old with acute lymphocytic leukemia and notes that the child has a decreased appetite. What is the priority nursing intervention? Encourage the child to eat all of the meal to get adequate nutrition. Provide oral hygiene after eating. Have the dietician meet with the child and family to provide foods the child will eat. Refrain from serving snacks as requested.

answer The dietician should be involved to help determine foods appropriate for children in different age groups. The child and family should help select preferred foods and identify cultural beliefs and dining habits. Take advantage of a hungry period and serve small snacks. Encourage parents to relax pressures placed on eating by stressing the legitimate nature of loss of appetite. The other responses do not help to stimulate the child's appetite.

What is the nurse's most important intervention for a client having a tonic-clonic seizure? Protect the client from further injury Time the duration of the seizure Note the origin of seizure activity Insert a padded tongue blade to prevent the client from biting his tongue

answer The priority during and after a seizure is to protect the person from injury by keeping them from falling to the floor. Furniture or other objects that be a source of injury during the seizure should be moved out of the client's way. Timing the seizure, and noting the origin of the seizure are important, but are not the priority. Nothing should be placed in the client's mouth during a seizure because teeth may be dislodged or the tongue pushed back, further obstructing the airway.

A multiparous client who has been in labor for 2 hours states that she feels the urge to move her bowels. What would the nurse do first? Perform a pelvic examination. Allow the client to use a bedpan. Assist the client to get up to use the toilet. Check the fetal heart rate (FHR).

answer 1 A report of rectal pressure usually indicates a low presenting fetal part, and imminent birth. The nurse should perform a pelvic examination to assess the dilation of the cervix and station of the presenting fetal part. Do not let the client use the toilet or a bedpan before she's examined because she could birth on the toilet or in the bedpan. Checking the FHR is important but comes after the nurse evaluates the client's report.

Which nursing intervention is a priority for a pregnant adolescent during her first trimester? Refer the client to a dietitian for nutritional counseling. Tell the client that she will most likely need a cesarean birth due to the head size of the fetus. Assess the client for signs and symptoms of placenta previa. Schedule the client for a screening glucose tolerance test.

answer 1 Adolescents are at risk for delivering low-birth-weight neonates. Nutritional counseling should be a priority for these clients to ensure proper fetal development. A pregnant adolescent is not likely to deliver a macrosomic neonate. The final head size of the fetus is unknown at this time. Adolescents are not at increased risk for developing gestational diabetes or placenta previa.

During a routine prenatal examination, a client who is at 32 weeks' gestation becomes dizzy, lightheaded, and pale. After placing the client in a supine position, what is the priority nursing action? Turn the client on her left side. Listen to fetal heart tones. Ask the client to breathe deeply. Take the client's blood pressure.

answer 1 As the uterus gets larger, it increases pressure on the inferior vena cava. This inhibits venous return causing dizziness, lightheadedness, and pallor when the client is supine. Turning the client on her left side relieves the pressure on the vena cava and restores venous return. Although they're valuable assessments, listening to fetal heart tone and measuring maternal blood pressure don't alleviate the symptoms. Deep breathing has no effect on venous return, and will not relieve this client's symptoms.

The nurse is caring for a client with type 1 diabetes mellitus. At 0300, the nurse finds the client disoriented to time and place, diaphoretic, and reports palpitations. What is the nurse's priority intervention? Check blood glucose level. Call the healthcare provider for additional insulin order. Administer 1 mg of glucagon subcutaneously. Give 10 to15 g of carbohydrate orally.

answer 1 Check the blood glucose level first when symptoms arise, then proceed with treatment according to the results. If the client is hypoglycemic, administration of a simple carbohydrate is appropriate. If the client is conscious, the carbohydrate may be given orally. If consciousness is altered, subcutaneous or intramuscular glucagon is appropriate. This client is showing symptoms of hypoglycemia, additional insulin would further lower the blood glucose.

A nurse is assigned four clients. Which client should the nurse see first? A 33-year-old client with a recent diagnosis of Guillain-Barré syndrome A 17-year-old client 24 hours post appendectomy A 50-year-old client with diverticulitis A 50-year-old client three days post myocardial infarction

answer 1 Guillain-Barré syndrome is characterized by ascending paralysis and potential respiratory failure. The order of client assessment should follow client priorities, with disorders of airway, breathing, and then circulation seen first. There is no information to suggest that the client with post myocardial infarction has an arrhythmia or other complication. There is no evidence to suggest hemorrhage or perforation for the remaining clients as a priority of care.

A postpartum mother is concerned about a noted decrease in her breast milk production. Which response by the nurse best addresses this mother's concern? Decrease supplemental feedings with formula. Feed the infant less frequently. Have several alcoholic beverages for relaxation. Suggest the mother consume a diet high in vitamin C.

answer 1 Routine formula supplementation may interfere with establishing an adequate milk volume because suckling the breast stimulates prolactin production. Prolactin is the hormone responsible for milk production. Vitamin C levels haven't been shown to influence milk volume. One alcoholic beverage generally tends to relax the mother, and facilitate the milk let-down reflex. Excessive consumption of alcohol may block milk let-down, though supply isn't necessarily affected. Frequent feedings are likely to increase milk production.

The nurse is preparing to discharge a school-age child with asthma. Which intervention is most important for the nurse to perform prior to discharge? Obtain additional equipment and medication that can be provided at the school. Arrange for a thorough, deep cleaning of the home. Discuss limitations on the child's participation in sports activities. Counsel the family in making arrangements to remove the family pet.

answer 1 The child needs to have equipment and medication available at school to treat and prevent asthma attacks. This is the priority intervention at this time. Discussions should be held with the child and family to motivate the child to be involved in as many normal activities as possible; the emphasis is on the options rather than the limitations. The nurse should teach the parents that the house should be kept as clean as possible on an ongoing basis to prevent exacerbations due to dust and pet dander, but it is not the nurse's responsibility to arrange for this cleaning. If the child is allergic to the family pet, the nurse should provide counseling on ways to minimize the risks, but this does not necessarily mean removal of the pet.

The nurse is delegating activities to a recently graduated licensed practical/vocational nurse (LPN/VN) at a skilled nursing facility. Which activities are appropriate to delegate to the LPN/VN? Select all that apply. Cleansing a leg wound and applying antibiotic ointment. Recording percentage of meal completion. Administering intravenous sedation. Assisting an unlicensed assistive personnel (UAP) with a weight. Completing an admission body assessment.

answer 1-2-4 According to the LPN/VN scope of practice, the LPN/VN can cleanse a leg wound and apply antibiotic ointment, record percentage of meal completion, and assist a UAP with weighing a client. The scope of practice of a LPN/VN varies by state, but it usually does not include administering an intravenous medication unless the nurse has obtained a certification establishing competency with IV medication administration. Even then, administering a sedative may be outside the scope of practice. An admission body assessment must be performed by an RN.

A preschool-age child has just been admitted to the pediatric unit with a diagnosis of bacterial meningitis. What is the nurse's priority intervention? Encourage the parents to hold the child. Decrease environmental stimulation. Assess LOC every 12 hours. Monitor temperature every 4 hours.

answer 2 A child with the diagnosis of meningitis is more comfortable in an environment with decreased stimuli. Noise and bright lights would stimulate this child and cause the child to cry, in turn, increasing intracranial pressure. Vital signs should be assessed initially every hour and temperature monitored every 2 hours. Neurological signs should be assessed according to the child's condition, but more frequently that every 12 hours. Children are usually much more comfortable if allowed to lie flat because this position reduces meningeal irritation.

A client in early labor tells the nurse that she has a thick, yellow discharge from both of her breasts. What is the nurse's most appropriate intervention? Perform a culture on the discharge, and inform the client that she might have mastitis. Inform the client that the discharge is colostrum, and a normal finding. Complete a thorough breast examination and document the results in the chart. Tell her that her milk is starting to come in because she's in labor.

answer 2 After the fourth month, colostrum may be expressed. The breasts normally produce colostrum for the first few days after birth. Milk production begins one to three days postpartum. A clinical breast examination isn't usually indicated in the intrapartum setting. Although a culture may be indicated, it requires advanced assessment as well as a medical order.

A client is admitted to the labor and delivery unit in labor with blood flowing down her legs. What would be the priority nursing intervention? Perform a cervical examination. Monitor fetal heart tones. Place an indwelling catheter. Prepare the client for cesarean birth.

answer 2 Monitoring fetal heart tones would be the priority, due to a possible placenta previa or abruptio placentae. Although an indwelling catheter may be placed, it is not a priority intervention. Performing a cervical examination would be contraindicated because any agitation of the cervix with a previa can result in hemorrhage and death for the mother or fetus. Preparing the client for a cesarean birth may not be indicated. A sonogram will need to be performed to determine the cause of bleeding. If the diagnosis is a partial placenta previa, the client may still be able to deliver vaginally.

A primiparous client arrives for her first prenatal visit at 10 weeks' gestation. The client seems nervous and has many questions. What is the most important intervention by the nurse? Ask the client to undress to prepare for the physical examination. Reassure the client that all her questions will be answered during the visit. Provide the client with reading material for newly expectant mothers. Tell the client not to worry, because the health care provider will take good care of her.

answer 2 The nurse has made the observation that the client requires reassurance and should attempt to establish a positive nurse-client relationship. Providing initial reassurance helps set the client's mind at ease. Offering reading materials will not help develop this relationship. Asking this client to immediately disrobe does not address her concerns and could make the client more nervous. Telling a client "not to worry" is dismissive. The client should be treated as a partner in her care rather than being told that her health care provider will take care of everything.

A nurse is caring for a client exhibiting mild contractions and a cervical dilation of 4 cm. Using an external fetal monitor, the nurse observes variable decelerations. Which action should the nurse take first? Administer oxygen by face mask. Place the client on her left side. Prepare for imminent birth. Increase the I.V. rate.

answer 2 Variable decelerations in fetal heart rate are caused by compression of the umbilical cord. Typically, variable decelerations are corrected by placing the client in a left lateral position to alleviate cord pressure. Since variable decelerations are usually transient and correctable, the nurse would not prepare for an imminent birth. Increasing the I.V. rate is not needed or ordered. If other measures have been ineffective in correcting the variable deceleration, oxygen may be administered.

A parent reports that the school-age child has been reprimanded for daydreaming during class. The parent is concerned because the child's sibling has been diagnosed with absence seizures. This behavior is new, and the child's grades are dropping. What is the most appropriate action by the nurse? Refer the child to an audiologist for a hearing assessment. Refer the child to the special education department to assess for a learning disability. Refer the child to the primary health care provider to assess for absence seizures. Refer the child to the primary care provider to assess for attention deficit hyperactivity disorder (ADHD).

answer 3 Absence seizures are commonly misinterpreted as daydreaming. The child loses awareness, but no alteration in motor activity is exhibited. A mild hearing problem usually presents as leaning forward, talking loudly, increasing the volume of the TV and radio, and continually asking, "What?" There isn't enough information to indicate a learning disability. ADHD isn't characterized by episodes of daydreaming.

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

answer 3 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 nurse's initial client assessment indicates probable opioid overdose complicated by alcohol ingestion. What intervention should the nurse perform first? Administer IV fluids Continue monitoring of vital signs Administer IV naloxone Draw blood for a drug screen

answer 3 If a client has ingested opioids, naloxone would reverse the effects and rouse the client, confirming the assessment of opioid overdose. Intravenous fluids would most likely be administered, but giving IV fluids is not the first action the nurse should take. This client would be closely monitored over a period of several hours to several days. The client should be screened for drugs, but there is not as much urgency around drawing the blood for the drug screen as for administering the naloxone.

What is the nurse's priority action in caring for a client who has just had a liver biopsy? Assess the level of pain. Instruct the client to avoid alcohol in the future. Monitor vital signs. Assess for feelings about body image.

answer 3 Internal bleeding is a potential complication following a liver biopsy. Elevated pulse and decreased blood pressure are indications that the client may be developing shock, which results in altered circulation. Physiologic needs take priority over psychological needs, Assessing feelings and teaching should be addressed after immediate needs. Pain is considered a psychological reaction unless the client is experiencing an acute episode that is causing physiologic response.

A male neonate has just been circumcised. Which nursing intervention is part of the initial care of a circumcised neonate? Wash the circumcised penis with warm water. Change the diaper as needed. Apply petroleum jelly to the site for 24 to 48 hours. Keep a bandage on the site for 24 to 48 hours.

answer 3 Petroleum jelly should be applied to the site for the first 24 to 48 hours to prevent the skin edges from sticking to the diaper. A gauze or other type of bandage may or may not be used. Washing the area with warm water is indicated, but is not part of the initial care.

An older adult client with pneumonia is admitted with prescriptions for intravenous antibiotics, supplemental oxygen as needed, and antipyretics. The nurse should immediately notify the health care provider for which assessment finding? pleuritic chest pain and cough temperature of 101.3°F (38.5°C) acute onset delirium respiratory rate of 24 breaths/minute

answer 3 The acute change in client cognition (i.e., delirium) is considered a medical emergency and should be investigated immediately. This acute change could be evidence of sepsis, electrolyte imbalances, or other organic causes that should be diagnosed and treated as soon as possible. The nurse should assess for the common symptoms of pneumonia such as fever, chills, dyspnea, pleuritic chest pain, and a productive cough. These symptoms should be monitored, but the nurse has treatments prescribed by the health care provider to address these findings.

A nurse is caring for clients on a medical/surgical unit. Which client should the nurse see first? a 65-year-old client 2 days postoperative for a coronary artery bypass graft (CABG) with a temperature of 100.2° F (37.9° C) a 50-year-old client admitted for dizziness and hypertension with a blood pressure of 160/90 mm Hg a 60-year-old client admitted with partial-thickness (second-degree) burns covering the arms, chest, neck, and face a 35-year-old client scheduled for a laparoscopic cholecystectomy with chills

answer 3 The client with partial-thickness (second-degree) burns covering the upper body is the most at risk for airway complications and should be assessed first. The postoperative client with low-grade temperature should be assessed next. Although temperature elevations are common postoperatively, the fact that this client is only 48 hours post-CABG makes this assessment the next highest priority. Third, the nurse should assess the client awaiting cholecystectomy. Chills are common when cholecystitis is present, but because the client has a procedure pending the next day, the nurse needs to ensure the client has no acute changes that need to be addressed. Finally, the client with hypertension and dizziness would be assessed. An elevated blood pressure in this range is not urgent.

A six-week-old infant is brought to the emergency department not breathing. A preliminary finding of sudden infant death syndrome (SIDS) is made to the parents. Which initial intervention should the nurse take? collect the infant's belongings and give them to the parents call their spiritual advisor allow them to see their infant explain the etiology of SIDS

answer 3 The parents need time with their infant to assist with the grieving process. Calling their pastor and collecting the infant's belongings are also important steps in the plan of care, but are not priorities. The parents may be too upset to understand an explanation of SIDS at this time.

A school-age client with a diagnosis of epilepsy is admitted to the pediatric unit of a local hospital for evaluation of anticonvulsant medications. As the nurse enters the client's room, the client begins to have a seizure. What is the priority nursing action? Push the call light and ask for help. Hold the child down to prevent injury. Loosen any restrictive clothing. Force the jaw open to maintain an open airway.

answer 3 The primary nursing goal during a seizure is to protect the client from physical injury and maintain a patent airway. Loosening clothing, especially around the neck, will allow free movement and aid in keeping the airway open. Other priority interventions to prevent injury are raising bed rails if the client is in bed or easing the client to the floor and place a soft object under the head. After making sure the client is safe from injury, the nurse should push the call light if further assistance is needed. The nurse should never forcibly hold a client down, since the force of the child's movements against restraint could cause muscle strain or even joint dislocation. The nurse also should not force the jaw open.

What is the most important intervention for the nurse to implement while caring for a neonate with an omphalocele? Cover the omphalocele when parents visit. Gently palpate the omphalocele to assess for changes. Keep the omphalocele dry. Carefully position and handle the omphalocele.

answer 4 Careful positioning and handling prevents infection and rupture of the omphalocele. The omphalocele should be kept moist until the neonate is taken to the operating room. The parents can see the defect if they so choose. Palpation of the omphalocele increases the risk of rupture and infection.

A 40-year-old client with schizophrenia lives in a rooming house. The client scratches vigorously and reports creatures eating at the skin. Which intervention should be done first? Administer an anticholinergic medication. Call the healthcare provider. Encourage the client to discuss the delusions. Assess the physical problems.

answer 4 Clients with schizophrenia generally have poor visceral recognition because they live so fully in their fantasy world. They need to have an in-depth assessment of physical complaints that may spill over into their delusional symptoms. Talking with the client won't provide an assessment of the itching, and itching isn't an adverse reaction of antipsychotic drugs. The client's provider should be called if the assessment warrants.

A child has ingested a bottle of over-the-counter medication and is brought into the emergency department by the parents. The nurse expedites rapid first aid for poisoning by immediately accessing what resource? reviewing the emergency department poison control guidelines consulting the current Compendium of Pharmaceuticals and Specialties (CPS) reviewing the treatment for overdose on the medication bottle contacting the Poison Control Center by phone

answer 4 Despite having directions on the bottle or in the CPS about what to do in the event of overdose of medications, best practice dictates the nurse contact the Poison Control Center for directions. Often, medication labels are outdated and should not be followed. Written hospital guidelines may also be out of date. Although making the call takes time, it guarantees the best treatment for the poisoning.

The nurse is preparing discharge plans for the parents of an infant born at 24 weeks' gestation. What priority information should the nurse tell these parents regarding vaccinations for their child? Routine vaccines should occur for all babies, regardless of prematurity. There are some specific contraindications to vaccines for preterm infants. An extra dose of certain vaccines will need to be given to preterm infants. Palivizumab should be given to prevent RSV infection in preterm infants.

answer 4 Palivizumab is a monoclonal antibody against the RSV F glycoprotein. It can help to prevent serious lower respiratory tract infections caused by RSV. The first dose is given before RSV season, with monthly doses given throughout the season for protection. This agent is indicated for children with neonatal bronchopulmonary dysplasia (chronic lung disease), who are younger than 24 months of age, who have a history of prematurity (less than 35 weeks), or who have hemodynamically significant congenital heart disease. Routine vaccines are given based on chronological age not corrected age. There are no specific contraindications based on prematurity alone. Certain vaccines such as Hepatitis B may need an extra dose depending on the age or weight of the child at the time of the vaccine. While all the answers are correct, the answer discussing palivizumab is the priority to include in parent teaching.

A client with type 1 diabetes mellitus is conscious but confused, weak, diaphoretic, and having heart palpitations. What is the nurse's priority action? Give an intravenous (IV) bolus of dextrose 50%. Inject 10 units of fast-acting insulin subcutaneously. Administer glucagon intramuscularly (IM) or subcutaneously. Provide 15 to 20 grams of a fast-acting oral carbohydrate.

answer 4 The client is exhibiting signs of hypoglycemia. Since the client is conscious, the first intervention is to give a fast-acting oral carbohydrate, such as orange juice, hard candy, or honey. If the client becomes unconscious, the nurse would administer IM or subcutaneous glucagon or dextrose 50% IV if access is available. Administering insulin wouldn't be appropriate because the client is experiencing hypoglycemia.

While performing a cervical examination on a client in labor, a nurse's fingertips feel pulsating tissue. What is the most appropriate nursing intervention? Put the client in a semi-Fowler's position. Leave the client and call the provider. Ask the client to push with the next contraction. Leave the fingers in place and press the nurse call light.

answer 4 When the umbilical cord precedes the fetal presenting part, it's known as a prolapsed cord. Leaving the fingers in place and calling for assistance is the safest intervention for the fetus. The nurse will need to keep the fetus off the cord to reduce cord compression. The nursing staff will contact the provider, and the client will probably require a cesarean birth to decrease the risk of fetal demise during birth. Placing the client in the semi-Fowler's position would increase the pressure of the fetus on the umbilical cord. Asking the client to push with the next contraction would force the presenting part against the cord, causing severe bradycardia and possible fetal demise.