PTB 106-120

A client is admitted to a voluntary hospital mental health unit with the diagnosis of suicidal ideation. The client has been on the unit for two days and now states, "I demand to be released now!" The appropriate response from the nurse should be which of these statements? "You can be released only if you sign a no suicide contract before you leave." "You cannot be released because you are still at risk of being suicidal." "You have a right to sign out as soon as we get the health care provider's discharge order." "Let's discuss your decision to leave and then we can prepare you for discharge."

"Let's discuss your decision to leave and then we can prepare you for discharge." Clients who are voluntarily admitted to the hospital have a right to demand and obtain release. By discussing the decision to leave the nurse has an opportunity to suggest or implement interventions other than discharge. The client may just need to talk through thoughts or feelings.

The parents of a newborn male with hypospadias want their child circumcised. Which of the following statements made by the nurse would provide the best information to the parents? "There is no medical indication for performing a circumcision on any child." "The procedure should be performed as soon as the newborn is stable." "This procedure is contraindicated because of the permanent defect." "Circumcision is delayed so the foreskin can be used for the surgical repair."

"Circumcision is delayed so the foreskin can be used for the surgical repair." With the birth of a healthy baby boy, parents need to decide what is best for their son, based on their religious, cultural and personal preferences. However, even if only mild hypospadias is suspected, a circumcision is not done in order to save the foreskin for surgical repair if needed.

The nurse is preparing a client for a myelogram scheduled at 9 am. Which statement made by a client indicates a contraindication for this test? "I think I may be allergic to shellfish." "I took my regular dose of enoxaparin this morning." "I suffer from claustrophobia and hate loud noises." "I had a severe headache after a spinal tap last year."

"I took my regular dose of enoxaparin this morning." The nurse should review any allergies with the client, especially a reaction to previous tests using contrast media. However, recent studies indicate that people who have a seafood allergy are not at risk for reaction to contrast media. Spinal procedures must be delayed for at least 12 hours from the last dose of any low molecular weight heparin, such as enoxaparin (Lovenox). A headache after a spinal tap is often caused by lack of fluids after the procedure. Claustrophobia and an aversion to loud noises would be an issue for someone undergoing a MRI.

After talking with her partner, a client voluntarily admits herself to the substance abuse unit. The next day the client states to the nurse, "My partner told me to get treatment or we would have to get divorced. I don't believe I really need treatment, but I don't want my partner to leave me." Which response by the nurse would be of assistance to the client? "In early recovery it's quite common to have mixed feelings. Let's discuss the benefits of sobriety for you." "In early recovery it's quite common to have mixed feelings. Perhaps it would be best to seek treatment on an outpatient basis." "In early recovery it's quite common to have mixed feelings. I didn't know you had been pressured to come." "In early recovery it's quite common to have mixed feelings. Unmotivated people can't get well."

"In early recovery it's quite common to have mixed feelings. Let's discuss the benefits of sobriety for you." Only the correct option focuses on the client and the client's problem (alcohol). This is the best response because it gives the client the opportunity to decrease ambivalent feelings by focusing on the benefits of sobriety. The other options are not therapeutic and do not have the client's best interests at heart. The option about being pressured to come might encourage clients to project blame for their behavior on someone else. The option of outpatient care might be a goal for this client, but it is inappropriate to suggest outpatient counseling at this time. To label the client's behavior as "unmotivated" might simply reinforce the client's ambivalence about treatment.

A client who is recovering from addiction to alcohol asks a nurse, "Will it be OK for me to just drink at special family gatherings?" Which response by the nurse is appropriate? "In the recovery phase, as well as for the rest of your life, you cannot return to drinking without starting the addiction process over." "At your next Alcoholic Anonymous meeting discuss the possibility of limited drinking with your sponsor." "Since you are in recovery, you need to get in touch with your feelings. Do you want a drink?" "At this phase you have to be very careful not to lose control. Therefore, confine your drinking only to family gatherings."

"In the recovery phase, as well as for the rest of your life, you cannot return to drinking without starting the addiction process over." Recovery from alcohol, as well as recovery from other substance addictions, requires total abstinence from the desired substance. To take one drink or one puff on a cigarette has a high potential for the return to addictive behaviors.

During a staff meeting, the nurse manager is using the technique of brainstorming to help solve a problem. One nurse criticizes another nurse's contribution and begins to find objections to the suggestion. The nurse manager's best response is which one of these approaches? "Let's move on to a new action that deals with the problem." "I think you need to reserve judgment until after all suggestions are offered." "Very well thought out. Your analytic skills and interest are incredible." "Let's move to the 'what if...' as related to these objections and explore ideas related to this situation."

"Let's move to the 'what if...' as related to these objections and explore ideas related to this situation." The goal of brainstorming is to gather as many ideas as possible without judgment that slows the creative process and may discourage innovative ideas. Exploration of the nurse's objections would encourage the generation of new ideas.

A nurse is caring for a child receiving albuterol inhaled (AccuNeb, ProAir HFA, Proventil HFA, Ventolin HFA) for asthma. The parents ask the nurse why their child is receiving this medication. Which explanation by the nurse is correct? "The respiratory center in the brain that controls respirations will be stimulated." "It will decrease the swelling in the airways." "The medication is given to reduce the secretions that block the airways." "Proventil will relax the smooth muscles in the airways."

"Proventil will relax the smooth muscles in the airways." Albuterol (a short acting beta-adrenergic agonist) is the drug of choice to treat asthma. It is used to prevent and treat wheezing, difficulty breathing and chest tightness. It works by relaxing and opening the airways to make breathing easier (which is why it is categorized as a bronchodilator). Albuterol comes as a tablet, syrup an extended-release tablet; it can also be inhaled by mouth using a nebulizer.

An unlicensed assistive staff member asks the nurse manager to explain the spiritual beliefs of Christian Scientist's clients. The best response of the nurse would be which of these statements? "The primary belief is that dietary practices result in health or illness." "Meditation is intensive in the initial 48 hours and daily thereafter." "Spiritual healing is emphasized and the mind contributes to the cure." "Fasting and prayer are initial actions to take in physical injury."

"Spiritual healing is emphasized and the mind contributes to the cure." For clients who follow Christian Scientist beliefs, a mind cure uses spiritual healing methods. For the believer, medical treatments may interfere with the drawing closer to God.

A client exhibits delusional behaviors and refuses to eat because of a belief that the food is poisoned. What should be the initial response by the nurse? "You're safe here. I won't let anyone poison you." "You think that someone wants to poison you?" "Why do you think the food is poisoned?" "These feelings are a symptom of your illness."

"You think that someone wants to poison you?" This response acknowledges perception of the client's comment through a reflective question. This reflective question presents an opportunity for discussion, clarification of meaning and expressing doubt. It also provides for verification of the nurse's perceptions and the client's communication.

The parents of a 15 month-old child ask the nurse to explain their child's lab results and how the results show the child has iron-deficiency anemia. The nurse's response should include which statement? "There are not enough total blood cells in your child's circulation from not eating enough foods with iron." "Although the results are here, your health care provider needs to talk with you about the details." "The blood cells that carry nutrients to the cells are too large and indicate a lack of iron-rich food." "Your child has fewer red blood cells that carry oxygen and this is called anemia."

"Your child has fewer red blood cells that carry oxygen and this is called anemia." To tell the parents that their child has fewer red blood cells that carry oxygen is a simple and clear explanation of anemia. The results of a complete red blood cell count in clients with iron-deficiency anemia will show decreased red blood cell numbers, a low hemoglobin and microcytic, hypochromic red blood cells. There is no reason to defer answering the question to the health care provider.

The provider ordered 500 mg Erythromycin oral suspension every six hours for a client diagnosed with pneumonia. The client has a gastrostomy tube. The pharmacy sends up the medication in a liquid suspension of 250 mg/5 mL. How much medication will the nurse administer every six hours? mL.

10 250 mg/5 mL = 500 mg/X mL 250x = 2500 x = 2500/250 = 10 mL

The nurse is given an order that reads: infuse IV of 1000 mL D5W with 100 mEq KCl at a rate of 50 mL/hour. Which component of this order should the nurse question? .

100 This dose of potassium is too high for a routine infusion. If not sufficiently agitated (mixed) in solution it will burn the vein and can cause cardiac arrhythmias.

The order reads: infuse IV aminophylline at 30 mg/hr. The pharmacy sends a 1000 mL bag of D5W containing 500 mg of aminophylline. In order to administer 30 mg per hour, how many milliliters per hour will the nurse set on the infusion pump? Report the answer to the nearest whole number. mL/hour.

60 Ratio: 30 mg/hour = 500 mg/1000 mL = 30 X 1000/500 = 60 mL/hour Dimensional Analysis: mL/hour = 1000 mL/500 mg X 30 mg/hour = 60 mL/hour

A client is being discharged with a prescription for chlorpromazine (Thorazine). Before the client leaves for home, which finding should the nurse teach the client to report right away? Sore throat and fever Lethargy and drooling Change in libido and breast enlargement Abdominal pain and nausea

A sudden sore throat and fever may be findings of agranulocytosis, a serious side effect of chlorpromazine. If white blood cell and differential counts are low, the treatment should be stopped and antibiotic therapy started. Other common side effects of chlorpromazine include dry mouth and nasal congestion, extrapyramidal reactions, motor restlessness and hypotension.

A nurse is assessing a 4 year-old child for possible developmental dysplasia of the right hip. Which finding should the nurse expect with this condition? Abnormal gait Positive Ortolani test Pelvic tip downward Negative Barlow maneuver

Abnormal gait Developmental hip dysplasia produces a characteristic limp in children who are walking. In infants, the Barlow maneuver and Ortolani test are used to detect developmental dysplasia of the hip. Dislocation of the hip with adduction is a positive Barlow test. This should be confirmed by the Ortolani test, which is a click or clunking sensation or sound when the hip is abducted, as the ball moves back into the socket. Both are used to test for congenital hip dislocation in infants. However, the expected clunk of the Ortolani test may not be present when testing older children.

The client is in her first trimester of pregnancy. What is the major developmental task that a mother must accomplish during this stage of pregnancy? Satisfactory resolution of fears related to giving birth Acceptance of the fetus as a separate and unique being Acceptance of the pregnancy Acceptance of body image changes

Acceptance of the pregnancy During the first trimester the maternal focus is directed toward acceptance of the pregnancy and adjustment to the minor discomforts. To have some ambivalence in the first trimester is expected.

A client in the emergency room is given 100 mg meperidine hydrochloride (Demerol) and 50 mg hydroxyzine hydrochloride (Vistaril) IM for pain related to a fractured lower right leg. One hour later, the client reports the "pain is getting worse." The nurse should recognize that the client may be developing which complication? Acute compartment syndrome Thromboembolitic complications Osteomyelitis Fatty embolism

Acute compartment syndrome Increasing pain that is not relieved by narcotic analgesics is a possible sign of compartment syndrome after a bone fracture. It requires immediate action by the nurse to prevent permanent muscle damage. Thromboembolic complications, such as deep vein thrombosis and pulmonary embolism, are not characterized by increasing pain at the site of injury. Both pulmonary embolism and fat embolism are associated with sudden changes in respiratory status. Osteomyelitis is a bone infection that could occur some time after the initial injury, typically around 48 to 72 hours later.

A 62 year-old client arrives at the emergency department and reports having chest pain. What is the first intervention the nurse should take? Obtain a set of vital signs and a focused history Order a 12-lead ECG according to standing orders Administer morphine according to standing orders Administer oxygen according to standing orders

Administer oxygen according to standing orders Ischemic damage to the heart is caused by a lack of oxygen (usually secondary to decreased blood flow). Oxygen should be administered immediately while other parameters are assessed.

The nurse is caring for a client admitted to the acute care setting with a diagnosis of Guillain-Barré. While reviewing the client's chart, which of the following orders would the nurse question? Administer pyridostigmine (Mestinon) Obtain vital signs prior to plasmapheresis Schedule surgery for a tracheostomy Physical therapy and occupational therapy consults

Administer pyridostigmine (Mestinon) Pyridostigmine (Mestinon) is an anticholinesterase/cholinesterase inhibitor medication used to treat myasthenia gravis. All the other options are treatments for Guillain-Barré. Plasmapheresis is a blood purification procedure used to treat autoimmune diseases; it reduces the severity and duration of the Guillain-Barré episode. During the acute phase of the disease, the client may be totally paralyzed and may need to be placed on a respirator. Once recovery begins and the client recovers limb control, physical therapy is ordered.

A client with a history of asthma is admitted for a minor surgical procedure. Preoperatively, the peak flow is measured at 480 liters/minute. Postoperatively the client reports chest tightness and the peak flow is now 200 liters/minute. What action should the nurse now take? Repeat the peak flow reading in 30 minutes Notify both the surgeon and primary care provider Apply oxygen at two liters per nasal cannula Administer the PRN dose of albuterol

Administer the PRN dose of albuterol Peak flow monitoring during exacerbations of asthma is recommended for clients with moderate-to-severe persistent asthma to determine the severity of the exacerbation and to guide the treatment. A peak flow reading of less than 50% of the client's baseline reading is a medical alert condition and a short-acting beta agonist must be taken immediately. Notifying the health care provider is important, but that is not what would be done first. First, the client needs assistance. Oxygen administration will not be effective if the airway constriction is not relieved with the albuterol. Leaving the client and returning in 30 minutes will do nothing to help a client in acute distress.

A nurse is to administer a liquid medication to a 9 month-old infant. Which method is appropriate? Hold the child upright and administer the medicine by spoon Administer the medication with a syringe next to the tongue Mix the medication with the infant's formula in the bottle Allow the infant to drink the liquid from a medicine cup

Administer the medication with a syringe next to the tongue Using a needleless syringe to slowly give liquid medicine to an infant is often the safest method. If the nurse directs the medicine toward the side or the back of the mouth, gagging will be reduced.

The nurse is assessing a client with myasthenia gravis who has a dose of pyridostigmine (Mestinon) ordered for 7 am. Prior to giving the medication the nurse observes and notes diplopia, dysphagia and a weak cough. The client has ordered breakfast for 8 am. Which of the following actions should the nurse take first? Assess for lower extremity weakness Hold the medication and notify the health care provider Administer the pryidostigmine as soon as possible Give the client edrophonium chloride (Tensilon)

Administer the pryidostigmine as soon as possible The findings indicate the need for the medication to be administered promptly to decrease the symptoms of muscle weakness and facilitate the client's ability to eat breakfast. Lower extremity weakness is expected in this diagnosis and is not relevant to the situation. Holding the medication would only be an option if a cholinergic crisis is suspected. Edrophonium chloride (Tensilon) is typically administered for diagnostic purposes, not for treatment.

The client, who lives in a long term care facility, was placed on contact precautions when drainage from a wound tested positive for MRSA (methicillin-resistant Staphylococcus aureus). When can contact precautions be discontinued? After treatment is completed and three consecutive cultures are negative If wound drainage can be contained by a dressing When the wound is no longer draining If the client is asymptomatic after treatment is completed

After treatment is completed and three consecutive cultures are negative Contact precautions are recommended for MRSA when there's a risk for transmission or wounds that cannot be contained by dressings. Contact precautions are usually discontinued when there is documentation of 3 consecutive negative screens from previously positive sites. Screens should be obtained no sooner than 72 hours after completion of decolonization and/or treatment of infection; the screens should be at least 5 days apart. If screening cultures are positive, continued treatment is needed.

The nurse is planning the care for an 18 year-old female diagnosed with anorexia nervosa who is a long-distance runner. Which of these concerns, related to promoting the client's exercise patterns both now and in the future, should the nurse determine to be the priority? Blood disorders Amenorrhea Electrolyte imbalance Digestive problems

Amenorrhea Anorexia affects the whole body. But young women athletes with anorexia nervosa experience a decrease in hormones, which causes irregular periods or even amenorrhea. Low estrogen levels and poor nutrition, especially low calcium intake, can lead to premenopausal osteoporosis. Young women athletes are also at a much higher risk of stress fractures and other bone pathology. The three conditions (eating disorder, amenorrhea and osteoporosis) are sometimes referred to as the female athlete triad.

Several clients all have the findings of a board-like abdomen. Which client would the nurse suggest the health care provider examine first? A middle-aged client admitted with diverticulitis who has taken only clear liquids for the past week A teenager with a history of falling off a bicycle without hitting the handle bars An older adult client who stated, "The awful pain in my right side suddenly stopped about three hours ago." A pregnant woman of eight weeks newly diagnosed with an ectopic pregnancy

An older adult client who stated, "The awful pain in my right side suddenly stopped about three hours ago." This client has the highest risk for hypovolemic and septic shock because the appendix has most likely ruptured, based on the history that over three hours ago the pain suddenly stopped. Older adult clients have less functional reserve for the body to cope with shock and infection. The others are at risk for shock also. However, given that these clients fall into younger age groups, they would more likely be able to tolerate an imbalance in circulation. A common complication of falling off a bicycle is hitting the handle bars in the upper left abdomen, which often results in a ruptured spleen.

The perioperative nurse must place the anesthetized client into the lithotomy position for a cystoscopic procedure. What is the safest technique for moving the client into this position? First raise one leg, flex the knee and place leg in a padded stirrup; repeat with other leg Ask for assistance to raise both legs simultaneously, then to flex both knees and place legs in padded stirrups Abduct the legs and then flex the knee of one leg before placing in padded stirrup; repeat with other leg Gently externally rotate the hips and flex the knees one at a time before placing in padded stirrup

Ask for assistance to raise both legs simultaneously, then to flex both knees and place legs in padded stirrups Raising both legs simultaneously and flexing the knee prevents excessive stretching and potential nerve damage.

The nurse is caring for a client with cancer who is two days postop following the surgical creation of an ileostomy. Which of these interventions would be the most important for the nurse to implement? Teaching the care and management of the pouch Addressing concerns about body image Assessing the stoma Providing emotional support

Assessing the stoma While all of these interventions would be appropriate, assessing the health and functioning of the stoma is the most important intervention at present to ensure stoma health and to monitor for possible complications. As the stoma starts to function, the nurse would empty the pouch, explaining the procedure to the client. Teaching is necessary to facilitate acceptance of the ostomy and to help promote self-care; self-care is vital to independence and self-esteem. Body image is often a concern following this type of surgery. Information about support groups, such as those found online, can be helpful.

The client has received fentanyl, atropine and benzocaine for an endoscopic procedure. The nurse is monitoring the client and notes the pulse has increased from the preprocedure baseline. Which medication could cause an increased pulse rate? (Write the name of the medication.)

Atropine, ATROPINE, atropin Atropine is anticholinergic drug that dries secretions. However, it can also increase heart rate and dilate the pupils. Fentanyl is a short-term CNS depressant and should provide some relief from anxiety and discomfort during the procedure; it slows breathing and often lowers heart rate and blood pressure. Benzocaine is a topical anesthetic and should not affect heart rate.

A client who is diagnosed with multiple sclerosis plans to begin an exercise program. What should the nurse be sure to emphasize when discussing this topic with the client? Focus on strength training Avoid aerobic exercise Dress warmly Avoid dehydration

Avoid dehydration Clients with MS who participate in regular aerobic exercise have better cardiovascular fitness, greater strength, better bowel and bladder function, less fatigue and less depression. But the client must take in adequate fluids before and during exercise periods to prevent dehydration. It is recommended that clients with MS exercise when it is cooler and perform exercise earlier in the day to avoid fatigue.

The nurse is caring for a client who is experiencing urinary incontinence. Which of the following teaching points should the nurse reinforce when discussing this health issue with the client? Avoid eating foods high in sodium Hold the urine to increase bladder capacity Avoid taking antihistamines Restrict fluids to prevent elimination accidents

Avoid taking antihistamines Due to their anticholinergic action on the urinary sphincter and bladder, antihistamines can cause urinary retention, followed by sudden overflow incontinence. Still other antihistamines relax the bladder, which also contributes to incontinence. Avoiding sodium has not been shown to reduce or minimize urinary incontinence. Clients with incontinence should control fluid intake and not drink large amounts of fluids at one time, but they should not restrict fluids. If the bladder becomes over-stretched, the muscle may be permanently damaged and lose its ability to contract.

The parents of a school-age child are providing information to the nurse about their child. Which of these concerns would the nurse recognize as a finding that could suggest type 1 diabetes? Bed-wetting Dehydration Weight gain Being a picky eater

Bed-wetting In school-aged children, warning signs of type 1 diabetes include: fatigue, frequent urination (also bed-wetting), unusual thirst, extreme hunger, and weight loss. Also, diabetics usually have dry skin. The parents may not initially think anything of the polyphagia or polydipsia, but bed-wetting in a school-age child (who previously did not wet the bed at night) would prompt the parents to seek medical intervention.

A client is receiving nitroglycerin intravenously for unstable angina. What assessment would be a priority for the nurse to monitor for the effects of this medication? Respiratory rate Cardiac enzymes Blood pressure Cardiac rhythm strip analysis

Blood pressure Because an effect of this drug is vasodilation, the client must be monitored for hypotension.

The nurse is caring for a client with Parkinson's disease who has developed hallucinations. Which medication may have been a contributing factor? Ropinirole (Requip) Amantadine (Symmetrel) Carbidopa/Levodopa (Parcopa, Sinemet) Selegiline (Eldepryl, Zelapar)

Carbidopa/Levodopa (Parcopa, Sinemet) Levodopa is the treatment of choice in the older adult with Parkinson's disease. Common side effects include dyskinesia, confusion and dizziness; serious side effects include hallucinations, paranoia, and agitation. Hallucinations may be relieved by decreasing the dose of levodopa, but this may decrease the effect of the drug on the motor symptoms of Parkinson's disease. The other anti-Parkinson medications listed are not know to cause hallucinations.

A nurse is teaching parents about the treatment plan for a 2 week-old infant with tetralogy of Fallot. While awaiting future surgery, the nurse instructs the parents to immediately report which finding? Changes in level of consciousness Fatigue with crying Feeding problems Poor weight gain

Changes in level of consciousness While parents should report any of these findings, they need to call 911 immediately if the level of consciousness decreases, or the infant becomes unresponsive. This indicates anoxia, which may lead to death, and is a medical emergency. The structural defects associated with tetralogy of Fallot include pulmonic stenosis, ventricular septal defect, right ventricular hypertrophy and overriding of the aorta. Surgery is often delayed, or may be performed in stages. The other findings can indicate the development of heart failure in an infant.

A client visits a community clinic for the treatment of recurrent pelvic inflammatory disease (PID). The nurse should plan to teach this client with the knowledge that this condition most frequently follows which type of infection? Syphillis Chlamydia Herpes simplex 2 Trichomoniasis

Chlamydia Chlamydia and gonorrhea infections are the most frequent cause of pelvic inflammatory disease. A complication of recurrent infection is the obstruction and scarring of the fallopian tubes, resulting in infertility. These sexually transmitted infections often have subtle findings; therefore they are often not diagnosed early in their course, before more widespread infection and complications occur. This also prevents appropriate detection and treatment before transmission to others during sexual activity.

The medical record review nurse is reading recorded entries. Which entry on a client's progress notes is the most complete? Dark green drainage 100 mL from nasogastric tube at 0600 Demerol 75 mg administered for severe abdominal pain Client's urinary output adequate for the past shift Client expresses anxiety about a low-salt diet

Dark green drainage 100 mL from nasogastric tube at 0600 Entries in client records need to be complete, accurate and factual. Reimbursement from third-party payers is facilitated when records are accurate, reliable and valid. The medication order lacks the route and client's response to the medication. "Anxiety" could be defined more specifically, along with the inclusion of information about the nurse's response. The criteria for "adequate" output needs to be defined.

A nurse is performing a neurological assessment on a client following right cerebrovascular accident (CVA). Which finding, if observed by the nurse, would warrant immediate attention? Emotional lability Altered sensation of stimuli Loss of bladder control Decrease in level of consciousness

Decrease in level of consciousness Stroke or CVA can cause paralysis, sensory disturbances, problems understanding or using language, and emotional disturbances. But a further decrease in the level of consciousness would be indicative of progression of the CVA and would require immediate intervention.

The nurse is caring for a post myocardial infarction client in the intensive care unit. It is noted that urinary output has dropped from 60-70 mL per hour to 20 mL per hour. This change is most likely due to which of the following issues? Renal failure Dehydration Diminished blood volume Decreased cardiac output

Decreased cardiac output Cardiac output and urinary output are directly correlated. Poor cardiac output causes decreased renal perfusion, and therefore a decrease in urine output. The nurse should suspect that a drop in cardiac output has occurred if the urinary output drops. As a consequence, renal function will be compromised and a rise in creatinine will be seen within the next 24 hours. Electrolytes that are excreted renaly, such as potassium, should also be monitored with decreasing renal function.

The nurse is caring for a 7 year-old with acute glomerulonephritis (AGN). Present findings include moderate edema and oliguria. Serum blood urea nitrogen and creatinine are elevated. What dietary modifications are appropriate? Decreased carbohydrates and fat Decreased sodium and potassium Increased potassium and protein Increased sodium and fluids

Decreased sodium and potassium Children with AGN who have edema, hypertension oliguria, and azotemia have dietary restrictions which are to limit sodium, potassium, fluids and protein.

The nurse is assisting with the delivery of a newborn infant. What is the priority nursing intervention for a normal newborn immediately after delivery? Obtain vital signs Dry off infant with a warm blanket or towel Apply identification bracelets Assign the one-minute APGAR score

Dry off infant with a warm blanket or towel The priority interventions are in recovering a normal newborn. Maintaining the infant's temperature by drying, warming, and removing any wet blankets or towels are the priority interventions. All interventions are correct, but warming and drying would be the priority.

The nurse is in the process of admitting a client to an acute inpatient psychiatric unit. Which approach by the nurse will result in the most useful information? Adhere to preplanned interview goals and structure Observe the client's nonverbal behaviors carefully Elicit the client's description of experiences, thoughts and behaviors Allow clients to talk about whatever they want

Elicit the client's description of experiences, thoughts and behaviors Psychiatric nurses must gather assessment data on admission that is accurate and comprehensive. Active listening to focused discussions about behaviors, feelings and insights will assist the nurse to develop and implement a personalized plan of care.

The clinic nurse is caring for a 15 month-old child with a first episode of otitis media. Which intervention should the nurse include in the instructions to the child's parents? Provide them with handout describing care of myringotomy tubes Explain that the child should complete the full five days of antibiotics Emphasize the importance of a return visit after completion of antibiotics Describe the tympanocentesis to detect persistent infections

Emphasize the importance of a return visit after completion of antibiotics The usual treatment for otitis media is oral antibiotics for 10 to 14 days. The child should be examined again after completion of the full course of antibiotics to assess for persistent infection or middle ear effusion.

A 6 year-old child with moderate edema and severe hypertension associated with acute glomerulonephritis (AGN) is admitted to the hospital. Which intervention would be the priority for the nurse? Establish seizure precautions Relieve boredom through physical activity Encourage the child to eat protein-rich foods Administer prescribed antibiotics

Establish seizure precautions The severity of the acute phase of AGN is variable and unpredictable. A child with edema, severe hypertension and gross hematuria may be subject to complications such as the development of hypertensive encephalopathy. Assessment for findings such as headache, confusion and vomiting is indicated as well as institution of seizure precautions. The child would typically be on bed rest during the acute phase. Dietary restrictions should include fluids, protein, sodium and potassium. Although antibiotics may be indicated if a bacterial infection is still present, this is not the priority action.

A nurse walks into a client's room and finds the client lying still and silent on the floor. What should the nurse do next? Assess the client's airway Call for help Determine if anyone saw the client fall Establish that the client is unresponsive

Establish that the client is unresponsive The first step in CPR is to establish responsiveness. The nurse would then call for help and check the victim's pulse (for at least five seconds, but not more than 10 seconds). If there is no pulse, the nurse would perform chest compressions. Remember, after determining unresponsiveness and pulselessness, the steps are: C-A-B: C = compressions, A = airway, and B = breathing.

An 82 year-old client is prescribed eye drops for treatment of glaucoma. What assessment is needed before the nurse begins teaching proper administration of the medication? Determine third-party payment plan Identify the client's proximity to health care services Evaluate the client's manual dexterity Assess the client's ability to use visual assistive devices

Evaluate the client's manual dexterity An inability to self-administer eye drops is a common problem among the older adult due to decreased finger dexterity along with decreased vision to see things clearly within 2 or 3 feet in front of the face.

The nurse is caring for an unconscious client. To prevent keratitis, the nurse should apply moisturizing ointment to which area of the body? External ear canals Eyes Perianal area Finger and toenail quicks

Eyes Keratitis is eye inflammation from a corneal ulcer or abrasion. Keratitis is caused by exposure to the air without the normal blink. It requires regular applications of moisturizing ointment to the exposed cornea and a plastic bubble shield or eye patch.

At 40-weeks gestation, a client in active labor is admitted to the labor and delivery unit. Based on the trend in cervical examination findings listed in the table below, what does the nurse anticipate for this birth? Timeline Dilation Effacement 8 am 4 centimeters 30% 9 am 7 centimeters 60% 10 am 9 centimeters 90% Neonatal APGAR score of 9 at one minute Maternal happiness and anticipation Maternal episiotomy Fetal hypoxia

Fetal hypoxia This labor is precipitous, which is defined as active labor lasting less than three hours. Because the contractions are coming rapidly, with little time in between contractions, there is a risk of fetal hypoxia. Maternal episiotomy is incorrect because there is little time for this (lacerations would be anticipated). Due to the potential for fetal hypoxia, the APGAR score would be lower than 9. Extremely rapid delivery can be anxiety-provoking for the client (and partner). When the actual birth event is not what is expected, other reactions may include hostility, fear and disappointment.

At a community health fair, the blood pressure (BP) of a 62 year-old client is 160/96 mm Hg. The client states, "My blood pressure is usually much lower." A nurse should tell the client to take what action? Go get a blood pressure check within the next 48 to 72 hours See the health care provider immediately Check blood pressure again in two months Visit the health care provider within one week for a BP check

Go get a blood pressure check within the next 48 to 72 hours The blood pressure reading is moderately high and should be rechecked within a few days. Since the client states it is "usually much lower" the elevated BP could be a concern but it is not clear what the client considers to be a "much lower" BP. The nurse should measure the blood pressure in the other arm and compare the two readings. Waiting two or three weeks for follow-up is too long.

A woman comes to the antepartum clinic for a routine prenatal examination. She is 12 weeks pregnant with her second child. Which of the following shows proper documentation of the client's obstetric history by the nurse? Primigravida 1, Para 1 Nulligravida 2, Para 1 Para 2, Gravida 1 Gravida 2, Para 1

Gravida 2, Para 1 Gravida describes a woman who is or has been pregnant, regardless of pregnancy outcome. Para describes the number of babies born past a point of viability. Therefore, a woman pregnant with her second child would be described as Gravida 2, Para 1. Primipara refers to a woman who has completed one pregnancy to the period of viability. Multipara refers to a woman who has completed two or more pregnancies to the stage of viability.

A polydrug user has been in recovery for eight months. The client has been skipping breakfast, not eating regular dinners, and frequenting bars to "see old buddies." The nurse should understand that the client's behaviors are warning signs to indicate what situation? Approaching recovery Feeling hopelessness Heading for relapse Needing increased socialization

Heading for relapse Recovery from addictions takes 9 to 15 months to adjust to a lifestyle free of chemical use. Clients need to acknowledge that relapse is a possibility and to identify early signs of relapse. The behaviors given in the stem strongly suggest relapse.

The nurse in the physician's office is assessing a geriatric client who began taking omeprazole (Prilosec) a month ago. Which finding indicates the drug has had the desired effect? Feelings of depression are not as severe Heartburn discomfort is lessened Chronic pain level is markedly decreased Blood pressure readings are lower

Heartburn discomfort is lessened Omeprazole (Prilosec) is a proton pump inhibitor used to decrease stomach acid and relieve symptoms of gastroesophageal reflux disorder (GERD), such as heartburn. The generic spelling of most of the proton pump inhibitors end with "prazole." Be careful not to confuse omeprazole (Prilosec) with other drugs with similar names but different effects: Prozac (fluxetine is the generic name) is an antidepressant, Prinivil (lisinopril is the generic name) is an antihypertensive, and Percocet (oxycodone and acetaminophen) is a pain medication.

The nurse is caring for a client who is involved in an abusive relationship. The nurse understands that during the "tension building" phase, the battered client may experience which of these feelings? Helplessness Explosiveness Anger Calmness

Helplessness Individuals who are battered internalize appropriate anger of the batterer's unfairness. These individuals feel depressed and have a sense of helplessness when their partner explodes, in spite of best efforts to please the batterer.

A nurse prepares to administer eye drops to a 6 year-old child. Which of these descriptions describes the correct method for the instillation of eye drops? Directly on the anterior surface of the eyeball In the corner where the lids meet In the conjunctival sac as the lower lid is pulled down Under the upper lid as it is pulled upward

In the conjunctival sac as the lower lid is pulled down Eye drops should be placed in the sac between the eye and the lower lid. This sac is formed by pulling the lower lid down.

An 82 year-old client reports having chronic constipation. To improve bowel function, the nurse should first suggest which approach? Use of laxatives when necessary Monitor for a balance between activity and rest Avoid binding foods such as cheese and chocolate Increase fiber intake to 20-30 grams daily

Increase fiber intake to 20-30 grams daily The incorporation of high fiber into the diet is an effective way to promote bowel elimination in the older adult. Furthermore, health care providers will typically want to begin with a non-pharmacologic intervention for managing chronic constipation, particularly in older adults. However, clients should be instructed not to add too much fiber too quickly because this can promote intestinal gas, abdominal bloating and cramping. They should instead gradually increase fiber in their diets and be sure to have sufficient fluid intake. The other options may be recommended later based on additional findings.

The nurse is planning care for a client with pneumococcal pneumonia. Which intervention would be most effective in promoting the clearance of respiratory secretions? Increase in oral fluid intake to 3000 mL per day Maintain bed rest with bathroom privileges Administer pain medications Administration of cough suppressants

Increase in oral fluid intake to 3000 mL per day Secretion removal is enhanced with adequate hydration, which thins and liquefies secretions.

An obese client tells the nurse: "I just started a diet and I am eating no more than 800 calories a day." What information is most important for the nurse to know in order to therapeutically respond to this statement? Individuals following a very low-calorie diet need professional monitoring This diet is classified as low calorie and adequate if balanced with 1 meat, 1 fruit, and 2 fat exchanges A very low-calorie diet is never a successful weight loss program and should be discouraged Very low-calorie diets often have severe and irreversible side effects

Individuals following a very low-calorie diet need professional monitoring A very low-calorie diet (VLCD) is a short-term weight loss method for obese people (BMI greater than 30) and can result in a loss of about 3 to 5 pounds per week. Anyone considering this type of diet should be under the care of health professionals. VLCDs are generally considered safe and common side effects (such as fatigue, constipation or diarrhea) are usually minor and improve within a few weeks. Of course, the best way to maintain weight loss is through a combination of behavioral therapy, exercise and more modest dietary restrictions. The exchange diet, which groups food together by nutritional content, is typically reserved for individuals with diabetes.

A nurse is counseling a 6 year-old child who has been diagnosed with nocturnal enuresis. What must a nurse understand about the pathophysiological basis of this disorder? Enuresis may be associated with sleep phobia Enuresis is a sign of willful misbehavior It often has no clear etiology It has a definite genetic link

It often has no clear etiology Although predictive factors associated with enuresis have been identified, no clear etiology has been determined.

An 80 year-old resident in an assisted living facility has a temperature of 100.6 F (38.1 C). This is a sudden change from the resident's usual temperature. Which should a nurse assess first? Appetite Urine output Level of alertness Lung sounds

Level of alertness Assessing the level of consciousness (alert vs. lethargic vs. unresponsive) will help the provider determine the severity of the acute temperature elevation and the possibility that this represents an infection. Confusion and decreased level of consciousness are commonly seen in older adults with an infection and are often the first sign of infection (even in the absence of a fever). If the client is alert and responds to questions appropriately, then the temperature should be rechecked. The urine and lungs should be assessed for findings of infection because urinary tract infections and pneumonia are common causes of fever in the older adult.

A 30 year-old primigravida arrives at the labor and delivery unit to be admitted for severe preeclampsia. She states she has a headache, and lab results indicate elevated liver enzymes. Place the cursor over the area of the client's body that would provide you with more information about her laboratory results.

Liver enzymes can become elevated when hepatic blood flow is obstructed by fibrin deposits due to hemolysis in severe preeclampsia. Subsequent liver distention follows and epigastric pain. The liver is located in the right upper quadrant of the abdomen.

A school nurse is advising a class of unwed pregnant high school students. What is the most important action the teenagers can perform to deliver a healthy child? Keep in contact with the child's father Stay in school throughout the pregnancy Get adequate sleep every night Maintain good nutrition

Maintain good nutrition Nurses can serve a pivotal role in the provision of nutritional education and case management interventions. Weight gain during pregnancy is one of the strongest predictors of infant birth weight. Specifically, teens need to increase their intake of protein, vitamins and minerals including iron. Pregnant teens who gain between 26 and 35 pounds have the lowest incidence of low-birth-weight babies.

A client has returned to the unit after having a renal biopsy. Which of these nursing interventions is appropriate? Ambulate the client four hours after procedure Maintain client on NPO status for 24 hours Monitor vital signs more frequently Change the dressing every eight hours

Monitor vital signs more frequently The potential complication after this procedure is active bleeding from the site of the biopsy. Monitoring vital signs is critical to detect early indications of active bleeding. The other options are incorrect. There is no reason to ambulate every four hours or withhold food and fluids for a day.

A nurse is going over medication instructions with a client who is taking digoxin (Lanoxin). The nurse should reinforce to the client to report which of these side effects? Polyuria, thirst, dry skin Hunger, dizziness, diaphoresis Nausea, vomiting, fatigue Rash, dyspnea, edema

Nausea, vomiting, fatigue Side effects of digoxin toxicity include fatigue, nausea, vomiting, anorexia, and bradycardia. Digoxin inhibits the sodium potassium ATPase, which makes more calcium available for contractile proteins and this results in an increased cardiac output.

The nurse is teaching a client about precautions while taking warfarin (Coumadin). The client should be instructed to avoid which type of over-the-counter medication? Histamine blockers Cough medicines with guaifenesin Non-steroidal anti-inflammatory drugs (NSAIDs) Laxatives containing magnesium salts

Non-steroidal anti-inflammatory drugs (NSAIDs) Clients should be warned not to take aspirin and other NSAIDs while taking warfarin. The combination may increase the response to warfarin and increase the risk of bleeding. If the health care provider prescribes the two medications together, the client will need to have bleeding times checked more frequently.

A 7 year-old child is hospitalized for acute glomerulonephritis. Which nursing action is a priority on the plan of care? Assess for generalized edema Note patterns of increased blood pressure Encourage rest during hyperactive periods Monitor for increased urinary output

Note patterns of increased blood pressure All of the actions should be included in this child's plan of care. The priority is the evaluation for hypertension because in the the course of the disease, high blood pressure has the most potential for complications.

A 3 year-old child is brought to the pediatric clinic after experiencing the sudden onset of irritability, thick muffled voice, croaking on inspiration and skin that's hot to the touch. The child sits leaning forward, tongue protruding, drooling and has suprasternal retractions What should the nurse do first? Prepare the child for x-ray of upper airways Notify the health care provider of the child's status Collect a sputum specimen Examine the child's throat

Notify the health care provider of the child's status These findings suggest epiglottitis, which is a medical emergency. Any child with an acute onset of an inflammatory response in the mouth and throat should receive immediate medical attention in a facility equipped to perform intubation or a tracheostomy in the event of further or complete obstruction.

The nurse is caring for a child who has just returned from surgery following a tonsillectomy and adenoidectomy. Which action by the nurse is most appropriate? Allow the child to drink through a straw Place the child in a supine position Offer ice cream every two hours Observe swallowing patterns

Observe swallowing patterns The nurse should observe for increased frequency of swallowing, which would signal hemorrhage.

The nurse is assessing a client who has paraplegia. What finding would indicate the probable presence of a fecal impaction? Presence of blood in stools Absence of bowel movements Oozing liquid stool Continuous rumbling flatulence

Oozing liquid stool When the bowel is impacted with hardened feces, there is often a seepage of liquid feces around the obstruction. This is often mistaken for uncontrolled diarrhea. This is a classic finding associated with fecal impaction.

The client is instructed to collect stool specimens at home using the guaiac test. In addition to explaining how to collect the specimens, the nurse instructs the client to avoid certain substances prior to obtaining the stool specimens. Which of the following substances should the client avoid? (Select all that apply.) Oranges Broiled or wood-grilled salmon Barbecued pork chops Marinated cauliflower and broccoli Grilled sirloin steak Acetaminophen

Oranges This is a part of the correct response Marinated cauliflower and broccoli This is a part of the correct response Grilled sirloin steak Correct response Foods like beef, which contain hemoglobin, will result in a false positive test and should be avoided for at least 3 days before the fecal occult blood test; chicken, pork and seafood can be consumed. Fruits and vegetables with high peroxidase activity, such as red radishes, broccoli, and cauliflower should also be avoided several days prior to obtaining specimens. Clients should also limit their intake of vitamin C because too much can lead to a false negative result. Aspirin and other nonsteroidal anti-inflammatory drugs can cause bleeding and should be avoided at least 7 days before the test; acetaminophen does not affect the test.

A client is admitted with a diagnosis of acute bacterial endocarditis. Which finding would alert the nurse to a complication of this condition? Hemorrhage Heart murmur Pain and pallor in one foot Macular rash

Pain and pallor in one foot Large, soft, rapidly developing vegetations grow on the heart valves in bacterial endocarditis. These vegetations may break off and travel through the blood stream, lodging in small vessels and resulting in necrosis of the tissue distal to the embolus. Pain and pallor are findings in acute embolic arterial occlusion of an extremity, necessitating rapid intervention to restore circulation and save the foot. Other findings would include pulselessness, parasthesia, paralysis and poikilothermia (coldness), known as the 6 Ps of ischemia. Heart murmur is a common finding in endocarditis, and clients with murmurs caused by valve damage are at highest risk of developing endocarditis.

A client is admitted to the coronary care unit (CCU) after experiencing a myocardial infarction. Which nursing diagnosis should be the priority? Risk for complication: dysrhythmias Risk for altered elimination: constipation Pain related to cardiac ischemia Anxiety related to pain

Pain related to cardiac ischemia Pain in myocardial infarction is related to tissue ischemia of the cardiac muscle, potentially indicating ongoing heart damage, such as extension of the infarction. Any cardiac pain/discomfort should be treated as a priority. Relief of pain will decrease myocardial oxygen demands, reduce blood pressure and heart rate and relieve anxiety. Pain also stimulates the sympathetic nervous system with an outcome of potential increased preload and afterload, which further increases myocardial demands.

The nurse is caring for a 10 month-old infant diagnosed with iron-deficiency anemia. Based on this diagnosis, which of these findings should the nurse anticipate? Pale mucosa of the eyelids and lips Hemoglobin level of 12 g/dL A heart rate between 80 and 130 Poor appetite

Pale mucosa of the eyelids and lips In iron-deficiency anemia, the physical exam reveals a pale, tired-appearing infant with mild-to-severe tachycardia. The normal heart rate of infants typically ranges from 120 to 180 BPM. The normal hemoglobin range for children is about 11 to 13 gm/dL.

A client with liver failure has just been admitted with portal hypertension. Which nursing diagnosis would be a priority in planning care? Fluid volume excess Altered nutrition, less than body requirements Potential complication hemorrhage Ineffective individual coping

Potential complication hemorrhage Esophageal varices are dilated and tortuous vessels of the esophagus that are at high risk for rupture and acute hemorrhage if portal circulation pressures rise, or if the esophagus is injured.

The nurse is caring for a client with a new prescription for a selective serotonin reuptake inhibitor (SSRI) antidepressant. In reviewing the admission history and physical, which item should prompt questions about the safety of this medication? Diagnosis of vascular disease Reported frequent use of antacids History of obesity Prescribed monoamine oxidase (MAO) inhibitor

Prescribed monoamine oxidase (MAO) inhibitor SSRIs, including fluoxetine (Prozac), sertraline (Zoloft), escitalopram (Lexapro) and others, should not be taken concurrently with monoamine oxidase inhibitors (MAOIs) because serious, life-threatening reactions may occur with this combination of drugs. Common MAOIs include: isocarboxazid (Marplan), phenelzine (Nardil), tranylcypromine (Parnate), and selegiline (Eldepryl, Zelapar).

A woman is hospitalized for treatment of pregnancy induced hypertension (PIH) in the third trimester. She is now receiving magnesium sulfate intravenously. The nurse understands that this medication is used mainly for what purpose? Prevent preeclamptic seizures Increase uterine blood flow Decrease the respiratory rate Maintain normal blood pressure

Prevent preeclamptic seizures Magnesium sulfate is a central nervous system depressant. While it has many systemic effects, it is used in the client with pregnancy induced hypertension (PIH) to prevent seizures.

A client is admitted to the hospital with findings of liver failure with ascites. A health care provider orders spironolactone (Aldactone). What is the pharmacological effect of this medication? Combines safely with antihypertensives Depletes potassium reserves Promotes sodium and chloride excretion Increases aldosterone levels

Promotes sodium and chloride excretion Spironolactone promotes sodium and chloride excretion while sparing potassium and decreasing aldosterone levels. It has no effect on ammonia levels.

The nurse is educating a client about how to use a metered-dose inhaler with spacer. Drag and drop the options below in the order that demonstrates correct use of a metered-dose inhaler with spacer. Remove the mouthpiece from the lips Release the medication into the spacer Hold breath for 10 seconds Breathe out slowly Breathe in deeply

Release the medication into the spacer Breathe in deeply Remove the mouthpiece from the lips Hold breath for 10 seconds Breathe out slowly

A 17 year-old client is newly admitted to the emergency department with a spinal cord injury, suspected to be at the level of the 2nd cervical vertebrae. A nurse's priority assessment should be which of the following? Response to stimuli Muscle weakness Bladder control Respiratory function

Respiratory function A spinal injury at the C-2 level results in quadriplegia with impairment of neural control of respiration. While the client will experience all of the problems identified, the respiratory function is the highest priority (A-B-Cs). This client will need intubation and long-term mechanical ventilatory support.

The home care nurse is teaching the client about managing heart disease at home. What lifestyle change will promote comfort and potentially help prevent a medical crisis and unwanted hospitalization? Participate in a progressive exercise routine Relax and contract leg muscles Record and monitor daily weight Rest in an armchair instead of lying in bed

Rest in an armchair instead of lying in bed Some people with heart failure may need bed rest, but the client's upper body should be elevated. For most clients, resting in an armchair is better than lying in bed because this decreases cardiac workload and facilitates breathing. Exercise may not be appropriate for all people with heart failure, but strength training, for example, can be useful to keep muscles from deteriorating. Monitoring and recording daily weight and relaxing and contracting leg muscles are important lifestyle changes, but they don't directly promote comfort.

A newborn is infected with human immunodeficiency virus (HIV) in utero. What principle should the nurse keep in mind when planning care for the infant? The infant is very susceptible to other infections Careful monitoring of renal function is indicated Growth and development patterns will proceed at a normal rate The disease will incubate longer and progress more slowly in this infant

The infant is very susceptible to other infections HIV-infected children are susceptible to opportunistic infections due to a compromised immune system.

A nurse in the labor and delivery unit is caring for several clients. For which of these mother-baby pairs should the nurse review the results of the Coombs test in preparation for the administration of Rho (D) immune globulin within 72 hours of birth? Rh positive mother with Rh negative baby Rh positive mother with Rh positive baby Rh negative mother with Rh positive baby Rh negative mother with Rh negative baby

Rh negative mother with Rh positive baby A Rh negative mother who delivers a Rh+ baby may develop antibodies to the fetal red cells to which the mother may have been exposed during pregnancy or at placental separation. If the Coombs test is negative, no sensitization has occurred.

A nurse is teaching a class for new parents at a local community center. Which activity would the nurse stress as being the most hazardous for an 8 month-old? Eating whole peanuts Riding in a car Jumping on a bed Playing around electrical outlets

Riding in a car Car accidents are a leading cause of death in babies and children, as well as a major cause of permanent brain damage and spinal cord injury. Although all the other options pose a danger to young children, drowning is actually the second most common cause of accidental death among children.

A nurse is assessing a 2 year-old client with a possible diagnosis of congenital heart disease. Which of these findings is most likely to be seen with this diagnosis? Takes frequent rest periods while playing Several otitis media episodes in the last year Changing food preferences and dislikes Weight and height in the 10th percentile since birth

Takes frequent rest periods while playing Children with heart disease tend to have exercise intolerance. The child self-limits activity, which is consistent with manifestations of congenital heart disease in children.

A client refuses to take the medication prescribed because the client prefers to take self-prescribed herbal preparations. What is the initial action the nurse should take? Talk with the client to find out about the preferred herbal preparation Contact the client's primary care provider Explain the importance of the medication to the client Report the behavior to the charge nurse

Talk with the client to find out about the preferred herbal preparation All the options are correct, but the question asks for an "initial" action. The correct answer is further assessment of the situation; it is the first action to be taken. The other options may be implemented afterward. The challenge for the health care provider is to understand the client's perspective and to support, facilitate or enable cultural values that can help the client recover from illness or to cope with any handicaps and/or death.

The nurse is discharging a client after a laparoscopic cholecystectomy. Which finding should the client be instructed to report to the primary care provider? Decrease in appetite Seeing spots of blood on the Band-Aids Temperature of 101 F (38.3 C) Experiencing shoulder pain

Temperature of 101 F (38.3 C) Laparoscopic surgery allows quick discharge and recovery. However, clients need to know what to expect and which postop discomforts are reportable. A temperature of 101 F (38.3 C) and above may signal infection and should be reported. The other listed symptoms are expected after this surgery. Shoulder pain (ranging from mild to severe) is due to the CO2 gas injected during surgery; it will dissipate within days. Band-Aids or other small dressings will be placed over the small incision sites and may have some spots of blood on them. It may take a day or two before appetite returns to normal.

The nurse is monitoring a client's initial postoperative condition after a thyroidectomy. Which of these findings should the nurse report immediately? Irritability and insomnia Headache and nausea Tetany and paresthesia Mild sore throat and hoarseness

Tetany and paresthesia Because the parathyroid gland may be damaged in this surgery, secondary hypocalcemia may occur with outcomes of these findings. Other assessments for hypoparathyroidism include muscle cramps and seizures. The other findings may be expected outcomes from any surgery in the postop phase.

The nurse is preparing to administer 2 different vaccines to a toddler, using a separate limb for each vaccine. If the nurse uses a limb on the right side of the body for the first vaccine, which injection site would be appropriate for the second vaccine?

The anterolateral thigh muscle is the correct injection site for the toddler. It is easily accessible and provides a position where the parent or caregiver can make eye contact and provide comfort to the toddler. When more than one vaccine is scheduled during the same office visit, it's recommended to use separate limbs. If there's a reaction to one vaccine, the health care provider will know which site was used for each injection.

A newborn weighed 7 pounds 2 ounces at birth. The nurse assesses the newborn at home two days later and finds the weight to be 6 pounds 7 ounces. What should the nurse tell the parents about this weight loss? The mother should breast-feed more frequently The newborn needs additional follow-ups A change to formula is indicated for an increase The loss is within normal limits for this time period

The loss is within normal limits for this time period A newborn is expected to lose 5 to 10% of the birth weight in the first few days postpartum because of changes in elimination and feeding. Within one week the newborn should regain the weight or exceed the birth weight.

A client is receiving nitroprusside (Nitropress) intravenously for the treatment of acute heart failure with pulmonary edema. What diagnostic lab value should the nurse monitor during the administration of this medication? Blood urea nitrogen Potassium level Thiocyanate Arterial blood gasses

Thiocyanate Nitroprusside metabolism involves the production of cyanide (CN), which may be extremely toxic. Cyanide is normally converted to thiocyanate and is eliminated by the kidneys. The risk of thiocyanate toxicity increases in clients with underlying renal insufficiency. Thiocyanate should not be over 1 millimole/liter.

First-time parents bring their 5 day-old infant to the pediatrician's office with concern about the infant's breathing pattern. A nurse assesses the infant and finds the breath sounds are clear with equal chest expansion. Respiratory rate is 38 to 42 breaths per minute with occasional periods of apnea lasting 10 seconds in length. What is the correct analysis of these findings? Emergency equipment should be available This breathing pattern is normal A future referral may be indicated The pediatrician must examine the baby

This breathing pattern is normal Respiratory rates in a newborn, which is the initial four weeks of life, is 30 to 60 breaths/minute. Periods of apnea often occur, lasting up to 15 seconds. The nurse should reassure the parents that this is an expected finding and is known as "periodic breathing" and occurs as the newborn lungs and brain become more coordinated.

The nurse assesses several postpartum women. Which of these women is at the highest risk for a puerperal infection? Twelve hours postpartum following vaginal delivery, temperature is 100 (37.7 C) Seven days postpartum, temperature is 99 F (37.2 C) since vaginal delivery Five days postpartum, temperature is 99.6 F (37.6 C) since undergoing cesarean section Three days postpartum, temperature is 100.8 (38.2 C) for two days after undergoing cesarean section

Three days postpartum, temperature is 100.8 (38.2 C) for two days after undergoing cesarean section A temperature of 100.4 F (38 C) or higher on two successive days, not counting the initial 24 hours after birth, indicates a postpartum infection. Puerperal infections can be due to endometritis, wound and other infections; the risk of endometritis increases after cesarean delivery. The other women are not at risk for infection because their temperatures are within the expected normal findings for the time period.

Upon admission to an intensive care unit, a client diagnosed with an acute myocardial infarction is ordered oxygen per nasal cannula. The nurse should care for the client with the knowledge that the major reason for the oxygen order in this situation is for what purpose? To decrease the risk for cyanosis To increase the oxygen delivered to the myocardium To relieve or prevent dyspnea To saturate the red blood cells with oxygen

To increase the oxygen delivered to the myocardium The border tissues around the injured myocardium are ischemic. Oxygen administration will help to prevent or relieve dyspnea and cyanosis associated with the condition. However, the major purpose is to increase the oxygen concentration in the damaged myocardial tissue.

The nurse assesses a client who has been taking haloperidol (Haldol) for 5 days. Which finding must be immediately reported to the health care provider? Tongue thrusting and facial grimacing Altered mental status Muscle flaccidity Dry, harsh cough

Tongue thrusting and facial grimacing Haloperidol is a neuroleptic antipsychotic drug that may cause a dystonia. The client may experience tongue thrusting, chewing movements and puffing or puckering of the mouth. The health care provider may need to adjust the haloperidol dosage and/or order anticholinergic agents, such as benztropine (Cogentin), to help prevent this side effect. Haloperidol does not affect mental status and does not cause a dry or harsh cough. Haloperidol may cause muscle spasm or stiffness, not muscle flaccidity.

A 40 year-old male, with a history of intravenous drug use, is seen in the emergency department with severe myalgia and a petechial rash. The initial diagnosis is infective endocarditis (IE). Which approach would be the priority test for diagnosing IE? Echocardiogram Two sets of blood cultures Chest x-ray Complete blood count and coagulation panel

Two sets of blood cultures All options are expected components of any workup of suspected IE. The key to making a diagnosis is blood cultures; at least two sets (usually more) of blood cultures must be collected (with separate venipunctures). Echocardiography can help detect IE for clients with a nondiagnostic blood culture result (usually seen with fungal infections). A chest x-ray can detect embolic abscesses. A variety of other baseline blood tests are also ordered, such as a CBC, BUN, electrolytes, creatinine, glucose and coagulation panel.

The nurse is reviewing the assessment data of a client suspected of having diabetes insipidus. Which of these findings should the nurse expect after a water deprivation test? Unchanged urine specific gravity Increased edema and weight gain Rapid protein excretion Decreased serum potassium

Unchanged urine specific gravity Diabetes insipidus (DI) is a condition in which the kidneys are unable to conserve water. Symptoms of DI are excessive thirst and excessive urine volume. Even when fluids are restricted, as with the fluid deprivation test, the client continues to excrete large amounts of dilute urine. This finding supports the diagnosis. Normally, urine is more concentrated in situations of reduced fluid intake.

When should a nurse initiate discharge planning for a client? Upon admission to a hospital unit or the emergency department Immediately after a client's condition is stabilized on the assigned unit When the client or family demonstrate readiness to learn self-care modalities When the client is informed that a date for discharge has been determined

Upon admission to a hospital unit or the emergency department With decreased lengths of stay, discharge plans must be incorporated into the initial plan of care upon admission to an emergency department or hospital unit. Thus, is the thought "discharge planning begins on admission."

A nurse needs to administer cardiopulmonary resuscitation to a 5 year-old child. In order to be effective, the nurse should take which action as a single rescuer? Assess the brachial pulses bilaterally Use a ratio of 2 breaths to 30 compressions Compress the chest at a rate of about 90 times per minute Initiate compression-only CPR and compress the chest at least 1 1/2 inches

Use a ratio of 2 breaths to 30 compressions The American Heart Association recommends 30 compressions and 2 breaths. The compression rate is at least 100 beats per minute. Compression-only CPR is recommended for lay persons. Compressions should be one-third to one-half of the chest depth in children. Health care professionals should assess the carotid pulse on children; the brachial pulse is assessed in infants.

The client is diagnosed with emphysema. What information should the nurse emphasize when teaching this client about nutritional needs? Increase intake of dairy products to soothe the throat Use oxygen during meals to improve gas exchange Perform exercise after respiratory therapy to enhance appetite Eat foods high in sodium to increase sputum liquefaction

Use oxygen during meals to improve gas exchange Clients diagnosed with emphysema breathe easier when using oxygen while eating. This facilitates the digestion of the food as well as keeping the oxygen available for the rest of the body. Dairy and other mucous-producing foods, as well as gas-producing foods, should be avoided. Reducing salt intake is also recommended.

The nurse receives a telephone call from a health care provider who wants to give a telephone order. Which of the following actions should the nurse take? (Select all that apply.) Verify understanding by reading the order back to the provider before hanging up Ask a second nurse to listen on another extension while the order is being given Record the order word-for-word and sign the order Begin the order with the abbreviation "P.O." to indicate that it was a "phone order" Request that the order is signed by the provider before implementation

Verify understanding by reading the order back to the provider before hanging up Correct response Record the order word-for-word and sign the order This is a part of the correct response Reading the order back allows the provider to correct any misunderstanding and is a Joint Commission read-back requirement. The order should be immediately written and signed by the nurse. The order should clearly state "telephone order" as abbreviations can be misunderstood (P.O. could be interpreted as "by mouth"). Having a second person listen in on the conversation is not required unless the nurse cannot understand the health care provider. The order may be implemented right away, but it must be countersigned within the time limits set by the facility.

Privacy and confidentiality of client information is legally protected. In which of these situations would the nurse make an exception to this practice? When the client threatens self-harm or harm to others When the provider decides the family has a right to know the client's diagnosis When a family member offers information about a loved one When a visitor insists that the visitor has been given permission by the client

When the client threatens self-harm or harm to others Privacy and confidentiality of all client information is protected with the exception of the client who threatens self-harm or endangering the public, staff or family. (Tarasoff decision,1974