PTB 61-75

An oncology client has developed an infection, and there is now an order for a 50 mL bag of IV antibiotics to infuse over 15 minutes. After 5 minutes, 40 mL remains in the bag. The package insert indicates the IV tubing delivers 15 gtt/mL. Calculate the flow rate in drops/minute (gtt/min) to deliver the volume on time. (Round to the nearest whole number and write only the number.) gtt/min.

60 To solve, recognize what is really asked. There are 40 mL remaining and 10 more minutes to get it infused. If you use dimensional analysis to solve the problem, and the final answer is in gtt/min, begin the equation with gtts on top, then multiply to cancel out unwanted units (mL) until the answer (gtt/min) remains. 15 gtt/1 mL X 40 mL/10 min = 600/10 = 60

The parents of a child who has recently been diagnosed with asthma ask the nurse to explain the condition to them. The best response should include the point that asthma causes what change? The nerves that control respiration become hyperactive There's a decrease in the stress hormones that prevents the airways from opening Air is trapped in the lungs because the air sacs are enlarged The airway becomes narrowed, obstructing airflow in response to triggers

The airway becomes narrowed, obstructing airflow in response to triggers Asthma is defined as airway obstruction or a narrowing that is characterized by bronchial irritability after exposure to various stimuli.

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A 187-pound client with a subdural hematoma and findings of increased intracranial pressure has been prescribed 25% solution mannitol (Osmitrol) 0.25 g/kg to be administered by intravenous push right away. The pharmacy has sent up four 50 milliliter bottles (12.5 g/50 mL is written on the label). How many milliliters should the nurse prepare to give the client? (Write the answer using whole numbers.) mL.

85 Convert pounds to kilograms, calculate the dose this client requires based on his weight. Convert from pounds to kilograms: 187 lbs/2.2 = 85 kg 0.25 g x 85 kg = 21.25 g (12.5 g/50 mL) = (21.25 g/x mL) x = 1062.50/12.5 = 85 mL An alternate method for solving the problem is to use dimensional analysis. Because the answer will be milliliters, begin the equation with milliliters on top, then multiply to cancel unwanted units until only the milliliters remain. (50 mL/12.5 g) X (0.25 g/kg) X (1 kg/2.2 lbs) X (187 lb/1) = 85

A 65-year-old Hispanic-Latino client, who is a practicing Catholic, has been diagnosed with prostate cancer. He adamantly refuses pain medication, believing that suffering is part of life. The client states, "Everyone's life is in God's hands." What should be the next action by a nurse? Discuss the situation with the client's family Ask the client if talking with a Catholic priest would be desired Document the situation on the notes Report the situation to the health care provider

Ask the client if talking with a Catholic priest would be desired Belief regarding pain are the oldest culturally-related research areas in health care. Astute observations and careful assessments must be completed to determine the level of pain a person can tolerate. Health care practitioners must investigate the meaning of pain to each person within a cultural explanatory framework. The other actions may be done later.

The nurse is caring for a postoperative client who had a laparotomy. Which of these actions is the most effective nursing intervention to prevent atelectasis from developing? Maintain adequate hydration Ambulate client within 12 hours postop Splint the incision Assist the client to slowly deep breathe and cough

Assist the client to slowly deep breathe and cough Deep air excursion by slow deep breathing and coughing will expand the lungs and stimulate surfactant production. This is the priority to prevent pulmonary complications after surgery. The nurse should instruct the client on how to splint the abdomen when coughing. Humidification, hydration and nutrition all play a part in the prevention of atelectasis.

A postpartum mother is unwilling to allow the father to participate in the newborn's care, although he is interested in doing so. She states, "I am afraid the baby will be confused about who the mother is. Baby raising is for mothers, not fathers." The nurse's initial intervention should be what focus? Arrange for the parents to attend infant care classes Talk with the father and help him accept the wife's decision Set time aside to get the mother to express her feelings and concerns Discuss with the mother sharing parenting responsibilities

Set time aside to get the mother to express her feelings and concerns Set time aside to get the mother to express her feelings and concerns Nonjudgmental support for expressed feelings may lead to resolution of competitive feelings in a new family. Cultural influences may also be clarified.

A nurse admits a 50 year-old client with a three-day history of swelling of the face, hands and feet; foamy brown urine; fever and malaise. Which information obtained in the admission interview alerts the nurse that these findings may reflect a diagnosis of acute glomerulonephritis? History of mild hypertension Type 1 diabetes since age 15 Sore throat two weeks ago Travel to a foreign country

Sore throat two weeks ago Glomerulonephritis commonly presents with proteinuria (foamy urine) that is rusty or brownish in appearance and swelling due to the systemic protein loss. In the majority of cases of acute glomerulonephritis, there is a history of an untreated streptococcal throat infection preceding the onset of symptoms by two to three weeks. The other options are not directly related to the development of acute glomerulonephritis.

Which of these statements best describes the characteristic of an effective reward-feedback system? Positive statements should precede a negative statement Performance goals should be higher than what is attainable Specific feedback is given as close to the event as possible Staff are given feedback in equal amounts over time

Specific feedback is given as close to the event as possible Feedback is most useful when given immediately. Positive behavior is strengthened through immediate feedback, and it is easier to modify problem behaviors if what constitutes appropriate behavior is clearly understood.

A partner is concerned because the client frequently daydreams about moving to Arizona to get away from the pollution and crowding in southern California. What approach should the nurse use in an explanation? Isolating the feelings in this way reduces conflict within the client and with others Such fantasies can gratify unconscious wishes or prepare for anticipated future events Detaching or dissociating in this way postpones painful feelings Converting or transferring a mental conflict to a physical symptom can lead to conflict within the partnership

Such fantasies can gratify unconscious wishes or prepare for anticipated future events Fantasy is imagined events (daydreaming) to express unconscious conflicts or gratify unconscious wishes. The other options cannot be applied to this situation.

The client is being treated for complications of a chronic disease on a medical-surgical unit. Who can have access to the client's medical record? (Select all that apply.) The certified nursing assistant documenting vital signs The client's spouse or other close family member The nursing instructor planning clinical assignments The person who has health care power of attorney The emergency department nurse who originally admitted the client and now wants to know the client's current status The facility researcher collecting data for a study to which the client consented

The certified nursing assistant documenting vital signs The nursing instructor planning clinical assignments The person who has health care power of attorney The facility researcher collecting data for a study to which the client consented Safeguarding client privacy requires strict adherence to the ethical standards of confidentiality and need-to-know access. Only those individuals who are directly involved in the client's care should have access to his or her information. The ED nurse is no longer directly involved in the client's care and should not have access to information about the client. Without valid authorization, such as health care power of attorney, a spouse or other family members cannot access the client's medical records.

A 76 year-old client who smokes one pack of cigarettes per day is diagnosed with chronic obstructive pulmonary disease (COPD). The nurse is teaching the client and family members about the use of oxygen by nasal cannula in the home. Which information is most important for the nurse to include in the discharge instructions? Adjust the liter flow to 5 L as needed for shortness of breath The client should not smoke, now that he has been diagnosed with COPD The client should not smoke while wearing oxygen Turn off oxygen during meals

The client should not smoke while wearing oxygen Because oxygen supports combustion, there is a risk of fire if anyone smokes near the oxygen equipment. The client should take off the oxygen, turn off the flow meter and go to another part of the home or outside to smoke. While continuing to smoke will cause the client's COPD to get worse, it can be very challenging for people who have smoked for many years to quit. Smoking cessation should be encouraged and supported in ways that are appropriate to the client's readiness to cut down or quit, but the most important teaching point at discharge is to stress not smoking while wearing or near the oxygen supply.

The nurse manager is conducting rounds on the floor. Which of these findings would require immediate corrective action and further instruction to the assigned nurse about proper care? The legs of a client who underwent hip replacement surgery yesterday are adducted A client in skeletal traction states, "The other nurse said that clear, yellow and crusty drainage around the pin site is a good sign." The weights of a client in skin traction are hanging several inches above the floor The assigned staff nurse picks up the frame of an external fixation device to move a client's extremity

The legs of a client who underwent hip replacement surgery yesterday are adducted *After having a total hip replacement, the client is positioned with an abduction wedge or pillow(s) between the legs. The abduction pillow helps prevent adduction and internal rotation of the affected leg, which could cause dislocation of the hip prosthesis. Some surgeons recommend clients use an abduction wedge for as long as 6 to 12 weeks postoperatively.

The client, who is diagnosed with a mild traumatic brain injury (MTBI), is experiencing migraine-type post-traumatic headaches. The health care provider has ordered almotriptan (Axert). What should the nurse understand about this medication? The medication will help reduce the number of migraine attacks This medication must be given as soon as the client begins to experience migraine symptoms This medication is used prophylactically to prevent headaches The client should be reminded to restrict fluids while taking this medication

This medication must be given as soon as the client begins to experience migraine symptoms *Almotriptan (Axert) is used to treat acute migraine headaches. It works by narrowing blood vessels around the brain and reducing substances in the body that can trigger headache pain, nausea, and sensitivity to light and sound. It will not prevent headaches or reduce the number of attacks. One of the most common side effects of this medication is dry mouth; clients do not need to restrict fluids. Almotriptan and other triptans are serotonin receptor agonists.

A couple experience the loss of a 7 month-old fetus. In planning for discharge, what should the nurse emphasize? To seek causes for the fetal death and come to some safe conclusion To plan for another pregnancy within two years and maintain physical health To focus on the other healthy children and move through the loss To discuss feelings with each other and use grief resources

To discuss feelings with each other and use grief resources To communicate in a therapeutic manner, the nurse's goal is to help the couple begin the grief process by suggesting they talk to each other, seek family, friends and support groups to listen to their feelings. To look for causes or set a time to plan another pregnancy is inappropriate.

A nurse provides instructions to a new mother on the proper techniques for breast-feeding her infant. Which statement by the mother is incorrect and indicates a need for additional instruction? "I should position my baby completely facing me with my baby's mouth in front of my nipple." "There may be times that I will need to manually express milk." "The baby should latch onto the nipple and areola areas." "I can switch to a bottle if I need to take a break from breast-feeding."

"I can switch to a bottle if I need to take a break from breast-feeding." Babies adapt more quickly to the breast when they are not confused about what is put into their mouths and its purpose. Artificial nipples do not lengthen and compress the way the human nipples (areola) do. The use of an artificial nipple weakens the baby's suck as the baby decreases the sucking pressure to slow fluid flow. Babies should not be given a bottle during the learning stage of breast-feeding.

The mother of a 2 year-old hospitalized child asks the nurse's advice about the child's screaming every time the mother gets ready to leave the hospital room. What is the best response by the nurse? "Keep in mind that for the age this is a normal response to being in the hospital." "I think you or your partner needs to stay with the child while in the hospital." "Oh, that behavior will stop in a few days with patience from you." "You might want to "sneak out" of the room once the child falls asleep."

"Keep in mind that for the age this is a normal response to being in the hospital." The protest phase of separation anxiety is a normal response for a child this age. In toddlers, ages one to three, separation anxiety is at its peak. After three years of age it begins to diminish until the adolescent years, when the behavior is minimal.

When walking past a client's room, the nurse hears one unlicensed assistive personnel (UAP) talking to another UAP. Which statement requires follow-up intervention? "This client seems confused, we need to watch the client more closely." "If we work together we can get all of the client care completed." "Since I am late for lunch, would you do this one client's glucose test?" "I'll come back and make the bed after I go to the lab to pick up some blood for the nurse."

"Since I am late for lunch, would you do this one client's glucose test?" Only the RN and LPN can delegate to UAPs. One UAP cannot delegate a task to another UAP or to any other team member. The RN or LPN is legally accountable for the nursing care. If UAPs cannot complete assignments, they should notify the LPN or the RN on the team.

A nurse is caring for a mother who has just delivered a stillborn baby. What would be the most therapeutic comment by the nurse to this grieving mother? "Tell me about your pregnancy experience." "You have an angel in heaven watching over you now." "Nature has a way of getting rid of the imperfect." "You are young and will have other children."

"Tell me about your pregnancy experience." The nurse must help the mother actualize the loss by encouraging her to talk about it. Advice and clichés are inappropriate and not comforting

The nurse is performing triage in a hospital's emergency department. Which of these clients would the nurse identify as most critical and being first in need of intervention? A 5 month-old infant who has audible wheezing and grunting A middle-aged man with second-degree burns over the right hand A toddler with singed ends of long hair that extends down to the waist An adolescent who has soot over the face and shirt

A 5 month-old infant who has audible wheezing and grunting The age and the findings suggest this client is at immediate risk for respiratory complications. The other clients are at lesser risk for respiratory problems.

The parents of a 4 year-old child recovering from chickenpox (varicella) would like the child to return to day care as soon as possible. In order to ensure that the illness is no longer communicable, what should the nurse assess for in this child? All lesions crusted Rhinorrhea and coryza Presence of vesicles Elevated temperature

All lesions crusted The chickenpox rash begins as a macule, with fever, and progresses to a vesicle that breaks open and then crusts over. When all lesions are crusted, the child is no longer in a communicable stage.

A parent asks the school nurse how to eliminate lice from a child's head. What is the appropriate response by the nurse? Cut the child's hair short to remove the nits Apply a pediculicide as directed Wash the child's linen and clothing in a bleach solution Apply warm soaks to the head twice daily

Apply a pediculicide as directed Treatment of head lice usually consists of an application of a pediculicide. Parents should be sure to follow the product directions. It is important that parents understand that no product is 100% ovicidal and, consequently, some nits will survive. Parents will need to use a nit comb to remove any surviving nits that cling to the hair shaft. In order to avoid reinfestation, bed linens must be washed in hot water and dried in the dryer; toys and objects that cannot be washed should be bagged.

A 3 year-old child is treated in the emergency department after ingestion of one ounce of a liquid narcotic. What action should the nurse perform first? Assess airway, breathing, circulation and level of consciousness Prepare for gastric lavage Start the ordered intravenous fluids Obtain blood and urine samples

Assess airway, breathing, circulation and level of consciousness The first step in treatment of a toxic exposure or ingestion is to assess the airway, breathing and circulation (ABCs), particularly when the substance is known to cause CNS depression, such as a narcotic. The level of consciousness will also be an important indicator of the CNS-depressant effects of the medication. The other actions are correct and also important, but they are not the first priority.

An 85 year-old client reports experiencing generalized muscle aches and pains. What should be the first action by a nurse? Encourage the client to gradually increase daily activity Assess the severity and location of the pain Request an order for a nonsteroidal anti-inflammatory drug Reassure the client that this is not unusual for age

Assess the severity and location of the pain Most older adults have one or more chronic painful illnesses, and in fact, they often must be asked about discomfort (rather than "pain") to reveal the presence of pain. There is no evidence that pain of older adults is less intense than in younger adults. It is important for the nurse to assess the pain thoroughly before the implementation of pain relief measures or recommendations. The nurse should also be sure to ask clients about any drugs they are taking (OTC, prescribed and herbal); certain medications, such as the statins, can cause muscle aches in the legs.

A nurse is assigned to care for a client who had a myocardial infarction (MI) two days ago. The client has many questions about this condition. What area is a priority for the nurse to discuss with the client at this time? Medication and diet guideline Activity and rest guidelines The overview cardiac rehabilitation Daily physical and mental needs and concerns

Daily physical and mental needs and concerns At two days after MI, the client's education should be focused on the immediate needs and concerns for the day. The physical needs are an initial focus. Then the mental or psychosocial needs are secondary.

A client had a thoracotomy with a right upper lobectomy. The nurse should focus on pain management for which of the following reasons postoperatively? Internal incisional healing Relaxation and sleep Deep breathing and coughing Maintain full range of motion

Deep breathing and coughing A lobectomy is often performed to treat tuberculosis, bronchiectasis and cancer. Postoperatively, the focus of care is to prevent respiratory complications, such as atelectasis and pneumonia. Without proper pain management, clients will be reluctant to cough and deep breathe, which will predispose them to these and other complications.

The nurse is planning care for an 8 year-old child. Which approach should be included in the plan of care? Talk with the child to stimulate the child to express opinions Encourage the child to engage in activities while in the playroom Provide frequent reassurance and cuddling as nonverbals indicate Promote dependence for activities of daily living

Encourage the child to engage in activities while in the playroom According to Erikson, school-age children are in the stage of industry versus inferiority. To help them achieve industry, the nurse should encourage this group of children to carry out tasks and activities in their rooms or while in the playroom.

As a nurse is speaking with a group of teens about cancer chemotherapy. The nurse anticipates that this group will be most interested in discussing which of the following side effects of the treatment? Hair loss Diarrhea Fatigue Mouth sores

Hair loss The major concern in adolescence is body image. Thus, hair loss would be the most disturbing side effect for this group of clients.

A client had a full leg plaster cast applied during surgery. What is the priority reason for the nurse to elevate the casted leg postoperatively? Decrease irritation to the skin Improve venous return Reduce the drying time Promote the client's comfort

Improve venous return Elevating the leg on one or two pillows will improve venous return, which will reduce the amount of swelling in the extremity. Ice may be ordered to also help prevent or reduce swelling. Elevating the leg will have little effect on drying time. Skin irritation can be decreased by handling the wet cast with the palms of the hands.

The nurse is teaching a client with tuberculosis, who is being treated with isoniazid (INH), about follow-up home care. In addition, the nurse should emphasize that appointments are mandatory for which of these serum lab tests? Kidney function Liver enzymes Cardiac enzymes Pancreatic enzymes

Liver enzymes INH, as well as other long-term by-mouth medications, often causes hepatocellular injury with resultant liver malfunction. The monitoring of liver enzymes is a solid approach because these enzymes (ALT, AST and alkaline phosphatase) are released into the blood from the damaged liver cells.

The nurse is caring for a victim of domestic abuse. Which of these behavioral characteristics is commonly associated with a domestic abuser? Overconfident Low self-esteem High tolerance for frustrations Alcohol addiction

Low self-esteem Batterers are usually physically or psychologically abused as children or have had experiences of parental violence. Batterers, who have manipulative behaviors, have a great need to exercise control or power over their partners.

According to Piaget, which finding indicates that a child has attained the stage of concrete operations? Reasons that homework is time-consuming yet necessary Makes the moral judgment that "stealing is wrong" Thinks in mental images or word pictures Explores the environment with the use of sight and movement

Makes the moral judgment that "stealing is wrong" The stage of concrete operations is depicted by logical thinking and moral judgments. This stage is associated with school-aged children from ages 7 to about 11. It is a time when children develop transitive thinking and reversibility concepts. They do well with inductive logic, which involves going from a specific experience to a general principle. They do not do well with deductive logic, or the use of a general principle to determine an outcome of a specific event.

The unlicensed assistive personnel (UAP) reports to the nurse that the oral temperature of a post-surgical client has increased from 99 F (37.2 C) at 5:00 pm to now 101 F (38.3 C) at 6:00 pm. The nurse walks into the room to check the client and observes a cup of steaming, hot coffee at the bedside. What instructions are appropriate to give to the UAP? Encourage the client to drink more oral fluids to prevent dehydration Chart this temperature elevation on the flow sheet and retake the temperature in 2 hours Recheck the oral temperature 15 minutes after removing the hot coffee from the bedside Provide the client with only cold water and juices to drink every hour

Recheck the oral temperature 15 minutes after removing the hot coffee from the bedside A recheck of the oral temperature is needed to eliminate the possibility of an artificial elevation of temperature from the hot coffee. Hot or cold liquids, smoking, eating, chewing gum, and talking can all elevate or lower the temperature if done within 10 minutes of the temperature being taken. Waiting to take the temperature for 15 minutes will help the temperature return to its normal reading and facilitate an accurate reading. The nurse should avoid premature assumptions about explanations for findings and the initial action is to do an assessment of the client.

A client with a history of heart disease takes prophylactic aspirin daily. What should the nurse monitor to help prevent aspirin toxicity? Serum albumin Conductive hearing loss Protein intake Serum potassium

Serum albumin Aspirin and salicylic acid are bound to serum albumin. A low serum albumin level may result in altered salicylate binding, thereby increasing the availability of unbound (active) drug for toxic effects. The effect is more evident in the elderly, especially someone with heart disease taking other medications that may be albumin-bound. Although aspirin can cause tinnitus and hearing loss, conductive hearing loss is typically the result of ear infections, allergies or tumors, not aspirin toxicity.

A nurse is caring for an acutely ill 10 year-old child. Which assessment finding would require the nurse's immediate attention? Rapid bounding pulse Temperature of 101.3 F (38.5° C) Slow, irregular respirations Profuse diaphoresis

Slow, irregular respirations A slow and irregular respiratory rate is a sign of respiratory fatigue and failure in an acutely ill child. Respiratory failure can rapidly lead to respiratory arrest. Emergency intervention for respiratory support is indicated.

The school nurse is preparing information to present to parents about mandated health assessments for all students. Based on the image below, which of the following statements should be included in the presentation? (Select all that apply.) *PIC OF GIRLS BACK AND HER SHOULDERS ARE UNEVEN...* Treatment for this condition always involves surgery This is an image of lordosis This is an image of scoliosis More cases occur in girls than boys Screening for this condition is typically mandated for students in 6th grade

This is an image of scoliosis More cases occur in girls than boys Screening for this condition is typically mandated for students in 6th grade This is an image of scoliosis, which typically becomes more apparent during growth spurts, especially at the onset of adolescence. During the assessment, the nurse stands behind the child and observes for differences in height of the shoulders or iliac crests. Treatment is determined by many factors and may involve the use of a brace or surgery.

A postoperative client is admitted to the post anesthesia care unit (PACU). An anesthetist reports that malignant hyperthermia occurred during surgery. A nurse should approach the care of this client with what knowledge about this complication? A genetic predisposition acts as the stimulus to such a reaction It is an allergic response to general anesthesia A pre-existing bacterial infection precipitated the situation Selected surgical procedures place clients at a higher risk for this complication

A genetic predisposition acts as the stimulus to such a reaction Malignant hyperthermia is a rare, potentially fatal adverse reaction to inhaled anesthetics. There is a genetic predisposition to this disorder. Findings include: a rapid rise in temperature to 105 F (40.5 C) or higher, muscle rigidity and stiffness, dark brown urine and muscle aches without a history of obvious exercise to explain sore muscles.

A client is to begin taking alendronate (Fosamax). Which of these instructions should the nurse emphasize when teaching about this medication? "Be sure to take this medication on an empty stomach." "Take the medication with a full glass of milk two hours after meals." "It is recommended that you take this medication with calcium and a glass of juice." "You may take this medication after any meal, at the same time every day."

"Be sure to take this medication on an empty stomach." Alendronate is used to treat and prevent osteoporosis. It should be taken first thing in the morning with 6 to 8 ounces of plain water at least 30 minutes before other medication or food. Food and fluids (other than water) greatly decrease the absorption of this medication. The client must also be instructed to remain in the upright position for 30 minutes following the dose to facilitate passage into the stomach and minimize irritation of the esophagus.

A client is diagnosed with a spontaneous pneumothorax that requires the insertion of a chest tube with a flutter valve. What is the best explanation that the nurse should provide to the client? "The hole in your lung will be sealed with this tube insertion." "The amount of air that enters your chest will be controlled by the flutter valve." "The excess air from your chest will be removed by the tube." "The tube will drain fluid from your chest."

"The excess air from your chest will be removed by the tube." The purpose of the chest tube is to create negative pressure to allow the passive removal of the air that has accumulated in the pleural space. The flutter valve is a one way valve that allows the air to leave the pleural space. It blocks any air reentry. The use of a flutter valve with a spontaneous pneumothorax allows for increased mobility without the use of a chest seal drainage system.

A client who had a vasectomy is in the post anesthesia care unit (PACU) at an outpatient clinic. Which of these points is most important to be reinforced by the nurse? "The health care provider at this clinic recommends rest, ice, an athletic supporter or over-the-counter pain medication to relieve any discomfort." "This procedure doesn't impede the production of male hormones or the production of sperm in the testicles. The sperm can no longer enter your semen and no sperm are in your ejaculate." "Until the health care provider has determined that your ejaculate doesn't contain sperm, continue to use another form of contraception." "After your vasectomy, strenuous activity needs to be avoided for at least 48 hours. If your work doesn't involve hard physical labor, you can return to your job as soon as you feel up to it. The stitches generally dissolve in 7 to 10 days."

"Until the health care provider has determined that your ejaculate doesn't contain sperm, continue to use another form of contraception." All of these options are correct information. The most important point to reinforce is the continued need to take additional action for birth control until it is determined that no risk is present for a possible pregnancy outcome.

The RN is caring for a client immediately after a cholecystectomy. Which of these tasks can the RN safely ask an unlicensed assistive personnel (UAP) to document? The check for the return of bowel sounds or passing flatus Amount of drainage on the surgical dressing Amount of output into the drainage collection device Changes in abdominal distention

Amount of output into the drainage collection device The emptying, measuring and recording of drainage from a postoperative drain may be delegated to unlicensed assistive personnel who have demonstrated competence in performing this task. While the RN is responsible for all care-related decisions, delegation of tasks not requiring independent judgment is appropriate.

The emergency department is sending a client with a diagnosis of delirium tremens to the floor. The admitting nurse would expect which of the following findings? A generalized shaking of the body accompanied by repetitive thoughts expressed verbally Single or multiple jerks caused by rapid contracting muscles with alternating relaxation An excited state accompanied by disorientation, hallucinations and tachycardia Disorganized thinking, feelings of terror and non-purposeful behavior

An excited state accompanied by disorientation, hallucinations and tachycardia Delirium tremens is a severe form of alcohol withdrawal that involves sudden and severe changes of the nervous system. The client initially presents with impaired cognition or agitation. The other findings typically progress in the following order: confusion, disorientation, agitation, hallucinations, diaphoresis, fever, tachycardia, hypertension and extreme tremors.

A nurse is caring for a client with active tuberculosis who has a history of noncompliance. Which of these actions by the nurse would represent appropriate care for this client? Ask the health care provider to change the regimen to fewer medications Instruct the client to wear a high efficiency particulate air mask in public places Ask a family member to supervise daily compliance Schedule weekly clinic visits for the client

Ask a family member to supervise daily compliance Direct-observed therapy (DOT) is a recognized method for ensuring clients' compliance to drug regimens. A program can be set up to directly observe the client taking the medication in the clinic, home, workplace or other convenient location.

The client had a plaster cast applied after fracturing the left radius. Two days later, the client reports a constant deep throbbing pain that's unrelieved by narcotics. What should be the first action by the nurse? Elevate the left arm a little higher than the level of the heart Apply an ice pack to the area of the fracture Assess color, temperature and movement of the exposed fingers Consider calling the health care provider to ask for a different pain reliever

Assess color, temperature and movement of the exposed fingers Pain that is unrelieved by narcotics, out of proportion to the injury, and described as deep and throbbing, suggests compartment syndrome. The arm must be elevated no higher than the heart to maintain arterial perfusion. Applying ice will do nothing to decreased the tissue pressure in the affected arm. The nurse should first assess the client - remember the 5 Ps: pain, pallor, pulselessness, paresthesia and paralysis. The nurse will then contact the health care provider with the assessment findings. The cast must be bivalved (a longitudinal cut to divide the cast in half) to relieve the pressure and prevent permanent damage to the arm.

client with cirrhosis of the liver underwent a paracentesis yesterday. Today, the unlicensed assistive personnel (UAP) reports the client is lethargic and has musty-smelling breath. Which assessment should the nurse perform next? Assess for flap-like tremors of the hands Monitor the client's clotting status Measure the abdominal girth changes Auscultate the upper abdomen for bruits

Assess for flap-like tremors of the hands Subtle changes in mental status and a musty odor to the breath are findings associated with hepatic encephalopathy. Hepatic encephalopathy is often seen in people with chronic liver disease (cirrhosis or hepatitis). A classic sign of this disorder is flapping tremors of the hands (asterixis).

The unlicensed assistive person (UAP) reports to the registered nurse (RN) that the client has a blood pressure of 78/46 mm Hg and a pulse of 116 BPM using electronic equipment. Which action should the nurse implement first? Notify the health care provider immediately Instruct the UAP to recheck the vital signs manually and report back with the information Assess the client's cardiovascular status Place the client in Trendelenburg position

Assess the client's cardiovascular status The RN is responsible for client care and must complete an assessment in order to plan for and provide appropriate interventions. It's not necessary to notify the health care provider until the report of the vital signs has been verified (by using a different machine or manually taking the pulse), an assessment by the RN has been completed, and the data compared with previously recorded vital signs. Even though the Trendelenburg position is still taught in schools, recent evidence does not support the use of this technique; even so, the nurse must still assess the client before taking further action.

The client is now in an outpatient detoxification program. The nurse should understand that a priority during withdrawal from any substance is which of these actions by the client? Avoid alcohol use during this time Discontinue the drug by weaning Rise slowly from a lying to standing position Expect mild physical symptoms

Avoid alcohol use during this time Central nervous system depressants interact with alcohol. The client will gradually reduce the dosage under the health care provider's direction. During this time, alcohol must be avoided. The other options are correct. However, the question asks for a priority, which is the correct answer.

The charge nurse in a long-term care (LTC) facility is making assignments for staff. Which assignment is appropriate for the certified nursing assistant (CNA)? Teach family members how to perform passive range-of-motion exercises Calculate and record intake and output Apply a dry dressing to a skin tear Provide oral suctioning for an unresponsive client as needed

Calculate and record intake and output CNAs are trained to perform a number of tasks or basic nursing skills, including calculating and recording intake and output. Although CNAs can wash and apply emollients on skin, they would not apply dressings. CNAs in LTC would not suction a client's mouth. Although CNAs can perform passive range-of-motion exercises, they cannot teach others how to do this.

A child is to have chest physiotherapy (CPT) by the nurse. Which nursing action is appropriate? Schedule the therapy 30 minutes after meals Place the child in a prone position for the therapy Confine the percussion to the rib cage area Teach the child not to cough during the treatment

Confine the percussion to the rib cage area *Percussion (clapping) should be done in the area of the rib cage anterior and posteriorly. The position depends on the desired outcome for secretion removal. This therapy should be done one hour prior or two hours after meals.

A nurse is evaluating the growth and development of a toddler with AIDS. The nurse would anticipate which finding in this child? Delay in musculoskeletal development Delay in achievement of most developmental milestones Achieve developmental milestones at an erratic rate Difficulty with speech development

Delay in achievement of most developmental milestones Developmental delays are common in children with AIDS, and after achievement of normal development, there may be loss of milestones. The majority of children with AIDS have neurological involvement. There is decreased brain growth as evidenced by microcephaly and abnormal neurologic findings. The other options are accurate but are too limited to be the best response.

The nurse is caring for a client newly diagnosed with atrial fibrillation. The atrial heart rate is 250 and the ventricular rate is controlled at 75. Which finding is a cause for the most concern? Loss of appetite Tachypnea with movement Diminished bowel sounds Difficulty speaking

Difficulty speaking Anticoagulant therapy is usually given to patients with atrial fibrillation to prevent blood clots and stroke. A new finding of difficulty speaking may indicate that the client has suffered a stroke. The nurse should assess for any other cognitive changes, assess lung function, and immediately contact the provider and possibly the stroke team. The atrial rate of 250 is normal for atrial fibrillation and is of no concern; the ventricular rate of 75 indicates that the cardiac rate is well-controlled (a ventricular rate above 100 would not be adequately controlled, necessitating additional rate control medications such as a beta blocker, calcium channel blocker or digoxin).

The nurse is preparing to administer medications for a client with a gastrostomy tube. The nurse should contact the health care provider before giving which drug through the gastrostomy tube? Digoxin (Lanoxin) liquid Diltazem SR (Cardizem SR) tablet Acetaminophen (Tylenol) liquid Calcium carbonate (Os-cal) tablet

Diltazem SR (Cardizem SR) tablet Cardizem SR is a "sustained-release" drug form. Sustained release, controlled release or long-acting drug formulations are designed to release the drug over an extended period of time. If crushed, as would be required for gastrostomy tube administration, sustained-release properties and blood levels of the drug will be altered. The health care provider must substitute another medication.

A 72-year old client reports having discomfort one day after a below-the-knee amputation. Which action by the nurse is an appropriate initial action? Wrap the stump snugly in an elastic bandage Ensure that the stump is elevated Conduct guided imagery or distraction Administer opioid narcotics as ordered

Ensure that the stump is elevated Elevating the stump is the priority intervention because it prevents pressure caused by expected postoperative swelling, which will minimize the pain or discomfort. Without this action, a firm elastic bandage, opioid narcotics, or guided imagery will have little effect. Analgesics appropriate to the level of pain should be administered as needed in the postoperative period to promote client comfort. The other nonpharmacologic interventions for pain relief may also be helpful

The nurse compares the third postoperative assessment findings to the first two postoperative assessments. What action should the nurse take to provide optimal care for this client? (Select all that apply.) Blood Pressure Pulse Respiratory Rate Oxygen Saturation 1st Postop Assessment 110/80 mm Hg 80 10 98% 2nd Postop Assessment 100/72 mm Hg 88 16 97% 3rd Postop Assessment 92/64 mm Hg 106 24 95% Move the bed into Trendelenburg position Assist the client to use the incentive spirometer Inspect the surgical incision site Administer pain medication Elevate the client's lower extremities Administer an intravenous fluid bolus

Inspect the surgical incision site Elevate the client's lower extremities Administer an intravenous fluid bolus Hypovolemia due to blood loss should be considered in the postoperative client who develops tachycardia and hypotension (a systolic BP reading below 90 in an adult indicates possible shock.) The nurse should check the incision site and any area dependent of the site for any blood loss. Evidence supports elevating the lower extremities in hypotensive episodes, to bring fluid from the lower body to the core; there is no evidence to support using the Trendelenburg position. An IV fluid bolus can also be used to increase volume. Although hypotension and tachycardia may also indicate pain, the nurse should ensure that the client's ABCs are stable before medicating for pain. Assisting the client to use the incentive spirometer can be done later.

A newly admitted client has a diagnosis of depression. The client reports having "twitching muscles" and a "racing heart" and states, "I stopped taking sertraline (Zoloft) a few days ago because it was not helping my depression. Instead, I began to take my partner's tranylcypromine (Parnate)." A nurse should immediately assess for which of these adverse reactions? Pulmonary edema Atrial fibrillation Mental status changes Muscle weakness

Mental status changes Use of serotonergic agents may result in serotonin syndrome with confusion, nausea, palpitations, increased muscle tone with twitching muscles and agitation. Serotonin syndrome is most often reported in clients taking two or more medications that increase CNS serotonin levels by different mechanisms. The most common drug combinations associated with serotonin syndrome involve the MAOIs, SSRIs, and the tricyclic antidepressants.

A nurse detects fluid leaking from the nose and ears of a client admitted for head trauma. Which is the appropriate nursing action? Pack the nose and ears with sterile gauze Place loose dressings below the nostril and ear Position an ice pack on the back of the neck Raise the head of the bed so the client is sitting upright

Place loose dressings below the nostril and ear Drainage from the nose and ear in a client with head trauma may be caused by leakage of cerebrospinal fluid (CSF). Applying a loose dressing to the nose and ears permits the fluid to drain and provides a visual reference to assess the type and amount of drainage. The nose and ear should not be packed if CSF leakage is suspected. If the drainage contains blood, look for the halo sign: a ring formed when protein in the CSF migrates to the edge of the wet spot as the gauze dries. If the drainage is clear, the nurse should check it for glucose. The head of the bed should be elevated 15 to 30 degrees to facilitate the drainage and decrease intracranial pressure.

A nursing student is discussing delegation to an unlicensed assistive personnel (UAP) with a preceptor. Which of these tasks, assigned to a UAP by the student, indicates that further instruction about delegation is needed? Assist a 2 year-old in skeletal traction with meals and snacks Provide information about a low-sodium diet prior to discharge Collect a sputum specimen prior to eating breakfast Ambulate the client in the hallway twice a shift

Provide information about a low-sodium diet prior to discharge The focus of this question is to select the incorrectly delegated task. UAP are typically assigned tasks with predictable outcomes. They assist with activities of daily living, such as eating, collect specimens, and can assist with ambulation. It is the registered nurse (RN), and not the UAP, who can teach, initiate referrals or conduct evaluations, as in the case of the client who is being prepared for discharge

The nurse is teaching the parents of a client diagnosed with sickle cell anemia. What should the nurse discuss with the parents about their child's condition? There's a depression of the platelets and also the red and white blood cells There is a reduced number of red blood cells due to inadequate iron in the diet Sickle-shaped red blood cells carry carbon dioxide to the tissues instead of oxygen. Red blood cells are abnormally shaped, preventing adequate oxygen delivery to the tissue

Red blood cells are abnormally shaped, preventing adequate oxygen delivery to the tissue Sickle cell anemia is caused by an abnormal type of hemoglobin, which changes the shape of red blood cells from a round to a sickle shape. These fragile abnormal blood cells carry less hemoglobin and can get stuck in the smaller blood vessels, depriving the tissue of oxygen and causing severe pain and tissue damage. Inadequate dietary iron causes iron-deficiency anemia. Platelets, red blood cells and white blood cells are all depressed in pancytopenia.

A newly admitted client reports taking phenytoin (Dilantin, Phenytek) for several months. Which of the following assessments should the nurse be sure to include in the admission report? (Select all that apply.) Report of anorexia, numbness and tingling of the extremities Report of unsteady gait, rash and diplopia Serum phenytoin levels Report of any seizure activity

Report of unsteady gait, rash and diplopia Serum phenytoin levels Report of any seizure activity Serious adverse outcomes of antiseizure medications are unsteady gait, slurred speech, extreme fatigue, blurred vision or feelings of suicide. Increased hunger (not anorexia), increased thirst or increased urination are additional serious side effects.

A client is newly diagnosed with bipolar disorder and has a prescription for lithium (Eskalith, Lithobid). Which of these points should the nurse be sure to emphasize? Take other medication as usual Maintain a salt-restricted diet Substitute generic form if desired Report vomiting or diarrhea

Report vomiting or diarrhea If dehydration results from vomiting, diarrhea or excessive perspiration, the client may experience findings of toxicity due to a build up of the drug. Lithium has a relatively narrow therapeutic index. Clients with serum lithium levels higher than 2 mEq/L should be admitted to the hospital.

A health care provider has ordered daily high doses of aspirin for a client with rheumatoid arthritis. The nurse instructs the client to discontinue the medication and contact the provider if which of these symptoms occur? Ringing in the ears Diarrhea for more than one day Infection of the gums Numbness in the lower extremities

Ringing in the ears Aspirin stimulates the central nervous system which may result in ringing in the ears, which is called tinnitus.

A 5 year-old child is rushed to the emergency department approximately six hours after ingesting an undetermined amount of acetaminophen. Which lab test should receive priority attention by the nurse? Prothrombin time (PT) and INR Electrolytes and blood urea nitrogen (BUN) Alanine transaminase test (ALT) and aspartate transaminase test (AST) Serum acetaminophen concentration (APAP)

Serum acetaminophen concentration (APAP) Emergency treatment of acetaminophen overdose involves checking the client's 4-, 6-, and 8-hour acetaminophen concentration (APAP) levels. These levels will determine N-acetylcysteine (NAC) therapy (the antidote). Clients who ingest an acute overdose and have NAC therapy initiated within 8 hours usually do well and do not develop liver failure. However, because acetaminophen poisoning can lead to liver failure, it is important to evaluate hepatotoxicity; ALT and AST will help determine the degree of liver cell damage. PT (or INR) may also be used to detect impaired liver function. BUN and electrolytes may show renal impairment or acidosis.

A client diagnosed with an aplastic sickle cell crisis is within the initial 10 minutes of receiving a blood transfusion. The client reports "feeling hot." Almost immediately, the client begins to have audible wheezes. What should be the nurse's first action? Send blood samples to the lab Take and record vital signs Stop and disconnect the blood infusion Notify the health care provider

Stop and disconnect the blood infusion If a reaction of any type is suspected during administration of blood products, stop the infusion immediately, disconnect the blood product line and connect a line with 0.9% normal saline at a keep open rate, notify the health care provider, monitor the vital signs and any other changes, and then send a urine and blood sample to the lab.

A nurse is teaching a smoking cessation class and notices there are two pregnant women in the group. Which information is a priority for these women? The placenta serves as a barrier to nicotine There is a relationship between smoking and low birth weight Moderate smoking is effective in weight control Low tar cigarettes are less harmful during pregnancy

There is a relationship between smoking and low birth weight *Nicotine reduces placental blood flow and may contribute to fetal hypoxia or placenta previa, which results in a decreased growth potential of the fetus.

A pregnant woman who is 28-weeks pregnant is admitted with painless vaginal bleeding. The nurse should immediately prepare the client for which of these tests? Nonstress test Serum hCG level Transvaginal ultrasound Pelvic exam

Transvaginal ultrasound Any vaginal bleeding during the second and third trimesters of pregnancy is abnormal. The most common cause of late-pregnancy bleeding involves a problem with the placenta, such as placenta previa, but it may also be due to an abnormal cervix or vagina. An ultrasound is the least invasive and most appropriate diagnostic test; placenta previa can be detected about 95% of the time using an ultrasound. A pelvic exam would not be performed until previa was ruled out. Other tests would include urinalysis, blood type and Rh, and CBC. After six to seven weeks, the best indication of a healthy pregnancy is a good fetal heartbeat (detected using a sonogram); blood hCG levels are not useful for testing the viability of the pregnancy after six to seven weeks.

During the two-month well-baby visit, the mother explains that formula seems to stick to her baby's mouth and tongue. Which assessment would provide the most valuable data for a nurse? Obtain cultures of the mucous membranes Use a soft cloth to attempt to remove the patches Flush both sides of the mouth with normal saline Inspect the baby's mouth and throat

Use a soft cloth to attempt to remove the patches Candidiasis can be distinguished from coagulated milk when attempts to remove the patches with a soft cloth are unsuccessful or trigger bleeding of the tongue under the white substance.

A nurse is performing a physical assessment on a toddler. Which approach should be the first one to use with this age client? Use minimal physical contact initially in the exam Proceed from head to toe in a sequential manner Explain the exam in detail as areas are examined Perform traumatic procedures first

Use minimal physical contact initially in the exam The nurse should approach a toddler slowly and use minimal physical contact initially so as to gain the toddler's cooperation. Other approaches with this age group are to be flexible in the sequence of the exam and give only brief simple explanations just prior to any action.

A nurse is giving instructions to the parents of a child with cystic fibrosis. What information should the nurse emphasize about administration of pancreatic enzymes? With each meal or snack Once each day in the morning Each time a high-carbohydrate or high-fat meal is eaten Crush the tablet and sprinkle on food three times a day

With each meal or snack Pancreatic enzymes are necessary for digesting fat, starch and protein. They should be taken with each meal and most snacks to allow for the proper digestion of the food. If taken on an empty stomach, they may cause gastric irritation and possibly ulcers. Enzyme capsules should be swallowed whole, not crushed or chewed, and the microspheres should not be sprinkled on or mixed with the whole meal.

A client is being maintained on heparin therapy for deep vein thrombosis (DVT). A nurse must closely monitor which of these following laboratory values? Bleeding time Activated partial thromboplastin time D-dimer Platelet count

Activated partial thromboplastin time Heparin is used to prevent further clots from being formed and to prevent the present clot from enlarging. The activated partial thromboplastin time (APTT) test measures the time it takes blood to clot and is used to monitor the effectiveness of heparin therapy. The therapeutic range is about 1 1/2 to 2 or 2 1/2 times the normal values. D-dimer is used to evaluate blood clot formation. Platelet counts are used to evaluate abnormal bleeding times. Bleeding time refers to the time it takes for a pinprick to stop bleeding (normally, about 2 1/2 minutes.)

The nurse is caring for a client admitted to the hospital with severe left-sided flank pain and hematuria. Diagnostic tests indicate a kidney stone partially obstructing the left ureter. Which of the following outcomes is the most important for this client? Verbalizes understanding of the disease process Pain controlled with medication Tolerates diet without nausea and vomiting Adequate urinary elimination is maintained

Adequate urinary elimination is maintained While all options are appropriate to the care of this client, urinary elimination is the nursing priority. A stone that completely obstructs the ureter can cause hydronephrosis and potential kidney damage. Remember Maslow - physiologic needs are more important than nutritional needs. Pain control and teaching are lower priorities.

There is an order to administer atropine (generic) to a client preoperatively. The nurse understands that which effect is the intended purpose for giving this medication preoperatively? Reduce heart rate Enhance sedation Elevate blood pressure Decrease secretions

Decrease secretions Atropine is a common anesthesia adjunct. It decreases the amount of secretions which, in turn, decreases the risk of aspiration during the operative procedure.

The nurse is caring for a client who is unconscious and receiving gastric tube feedings. Which assessment finding requires an immediate action from the nurse? Decreased bowel sounds in all quadrants Formula residual volume 100 mL Decreased breath sounds in the right lower lobe Urine output of 250 mL in the past eight hours

Decreased breath sounds in the right lower lobe The most common problem associated with enteral feedings is aspiration with resulting atelectasis and pneumonia. A nursing action should be to maintain clients at a minimum of 30 degrees of head elevation during feedings and up to two hours afterwards. The nurse should verify tube placement prior to each feeding or every four to eight hours if the client receives a continuous feeding.

The nurse is suctioning a client's tracheostomy. During this procedure, the nurse should instill saline for what purpose? Reduce the viscosity of secretions Decrease the client's discomfort Facilitate the removal of mucus plugs Prevent client aspiration from secretions

Facilitate the removal of mucus plugs According to evidence-based practice, the use of saline is no longer recommended during routine suctioning. However, if a client is suspected to have a mucous plug in the larger bronchial or in an artificial airway (such as a tracheostomy tube), the nurse can instill sterile normal saline to thin and loosen the plug or viscous secretions.

A nurse is teaching the parents of a 3 month-old infant about nutrition. What is the main source of fluids for an infant until about 12 months of age? Diluted nonfat dry milk Formula or breast milk Room temperature fruit juice Fluoridated tap water

Formula or breast milk Formula or breast milk are the perfect food and source of nutrients and liquids up to 1 year-old. Juice should not be used as the main fluid.

The nurse is developing a home care plan for a client with severe arthritis. What is the most important aspect for the nurse to include in the plan for care? Ensure compliance with medications Maintain and preserve functional status Support coping with limitations Anticipate side effects of therapy

Maintain and preserve functional status To maintain quality of life and to ensure safety, the plan for care must emphasize maintaining functional status. Proper body positioning and posture as well as active and passive range of motion exercises are important interventions for maintaining function of the affected joints. The nurse should also assess the client's ability to perform activities of daily living and instrumental activities of daily living.

A nurse is taking a health history from a Native American client. It is critical that the nurse remember that eye contact with such clients is considered as which behavior? Professional Enjoyable Rude Expected

Rude!!!!!!! *Native Americans consider direct eye contact to be impolite or aggressive among strangers.

A nurse is assessing a 6 year-old child for the first time in the clinic and finds that the child has deformities of the joints, limbs and fingers; a thinned upper lip; and small teeth with faulty enamel. The mother states: "My child seems to have problems in learning to count and recognizing basic colors." Based on this data, the nurse suspects that the child is most likely showing the effects of which problem? a. Fetal alcohol syndrome (FAS) b. Kernicterus c. Down Syndrome d. ADHD

a. Fetal alcohol syndrome (FAS) Major features of fetal alcohol syndrome (FAS) are facial and other malformed physical features, such as small head circumference and brain size (microcephaly), small eyelid openings, a sunken nasal bridge, an exceptionally thin upper lip, a short, upturned nose and a smooth skin surface between the nose and upper lip. Vision difficulties include nearsightedness (myopia). Other findings are mental retardation, delayed development, abnormal behavior such as short attention span, hyperactivity, poor impulse control, extreme nervousness and anxiety. Behavioral problems, cognitive impairment and psychosocial deficits are also associated with this syndrome.

The nurse is coordinating care for a postpartum client and her newborn with the unlicensed assistive personnel (UAP). The mother is human immunodeficiency virus (HIV) positive. The nurse would recognize the need to educate the UAP, who is observed doing which of the following actions? A) Assist the mother who is attempting to breastfeed her baby B) Assist the mother to walk to the bathroom C) Wear gloves while changing the newborn's soiled diaper D) Place the infant on his or her back in the bassinet

Assist the mother who is attempting to breastfeed her baby. *In the United States, it is current practice to counsel a mother who is HIV positive, or has AIDS, against breast feeding; breast feeding can transmit the virus through the breast milk to the infant. It is correct to place an infant on his or her back to prevent sudden infant death syndrome. Standard precautions should be followed when caring for any client; health care providers should wear gloves when they anticipate contact with body secretions (changing a soiled diaper).

A 70 year-old woman is evaluated in the emergency department for a wrist fracture of unknown cause. During the admission process, which of the following findings should the nurse identify as being the client's greatest risk factor for developing osteoporosis? A. Two glasses of red wine each day for the past 30 years B. Inactive lifestyle for the past 10 years C. History of oral corticosteroid use for 20 years to treat chronic lung problems D. History of menopause at age 50

C. History of oral corticosteroid use for 20 years to treat chronic lung problems The use of oral corticosteroids for a long period of time increases the risk for developing osteoporosis. Being postmenopausal and physically inactivity may also contribute, but are less significant. Other factors that increase the risk for osteoporosis and fracture include low bone mass and poor calcium absorption. However, long-term steroid treatment is the most significant risk factor.

The nurse is caring for a client with Legionnaire's disease. Which finding would require the nurse's immediate attention? A decrease in respiratory rate from 34 to 24 Decreased chest wall expansion Dry mucus membranes in the mouth Pleuritic pain on inspiration

Decreased chest wall expansion The respiratory status of a client with this acute bacterial pneumonia known as Legionnaires' disease is critical. Note that all of these findings would be of concern, but a decrease in chest wall expansion is the priority because it reflects a possible decrease in the depth and effort of respirations. Further findings of restlessness, including low oxygen saturation, would indicate hypoxemia. The client may need to have oxygen titrated to maintain adequate O2 saturation. Mechanical ventilation may be needed for signs of respiratory failure.

A nurse is beginning nutritional counseling/teaching with a pregnant woman. What is the initial step in this interaction? Conduct a diet history to determine her normal eating routines Teach her how to meet the needs of self and her family Question her understanding and use of the food pyramid Explain the changes in diet necessary for pregnant women

Conduct a diet history to determine her normal eating routines Assessment is always the first step in planning teaching for any client. A thorough and accurate history is essential for gathering the needed information. The results of this information provides the basis of the planned educational needs.

A client who is terminally ill has been receiving high doses of an opioid analgesic for the past month. As death approaches and the client becomes unresponsive to verbal stimuli. What orders should the nurse expect from the health care provider? Discontinue the analgesic Prescribe a less potent drug Decrease the analgesic dosage by half Continue the same analgesic dosage

Continue the same analgesic dosage *Clients who are actively dying and have been experiencing chronic pain, will probably continue to experience pain even though they cannot communicate this. Pain medication should be continued at the same dose as long as it is effective at that dose; some adjustment may be needed based on the client's physical manifestations of pain, such as grimacing or moaning.

The nurse is teaching a client who has a new prescription for sublingual nitroglycerin. Which point should the nurse emphasize? Take the medication at the same time each day Rest in bed for an hour after taking medication Keep the medication bottle in the refrigerator Carry the nitroglycerine with you at all times

Carry the nitroglycerine with you at all times The medication should be kept in its original dark-colored glass container. Nitroglycerin should be carried by the client at all times so it can be used when anginal pain occurs. When needed, the client should sit and place tablet under his or her tongue. Sitting is safe because the drug can cause lightheadedness or dizziness, but it's not necessary to rest in bed. The client should never pack this and any other medications in a checked a bag when traveling.

he nurse is caring for an 87 year-old client who reports having urinary retention. Which finding should be reported immediately to the health care provider? Fecal impaction Burning with urination Infrequent voiding Stress incontinence

Fecal impaction The nurse should report fecal impaction or frequent constipation, which results in the obstruction of the bladder outlet. Bladder outlet obstruction is a common cause of urine retention in older adults in both males and females. In addition, in men it also may indicate an enlarged prostate. Infrequent voiding may be associated with the amount of fluid intake in this age group. Stress incontinence is an expected finding that may or may not be treated. Burning on urination in this age group may indicate bladder infections or perineal irritations.

A client is being prepared to have a right above-the-knee amputation. Which of the following nursing measures will increase surgical safety? (Select all that apply.) Have the client confirm identify, the surgical site and procedure before administration of anesthesia Verify any allergies Explain the procedure, including any risks, and have the client sign the consent form Verify the surgical leg is marked with indelible marker over, or as close as possible to, the surgical incision site Verify the informed consent form is signed

Have the client confirm identify, the surgical site and procedure before administration of anesthesia This is a part of the correct response Verify any allergies Correct response Explain the procedure, including any risks, and have the client sign the consent form Verify the surgical leg is marked with indelible marker over, or as close as possible to, the surgical incision site This is a part of the correct response Verify the informed consent form is signed Correct response Prior to surgery, the nurse can witness the client's signature on the consent form, but explanation of the procedure, including risks and benefits, needs to come from the health care provider. Any allergies must be noted and verified prior to surgery. The surgeon must use an indelible marker on the surgical leg to indicate the incision site; sometimes the nonsurgical leg will be marked with a "NO." In the operating room, a surgical checklist is completed with a nurse and anesthesiologist. Prior to administration of anesthesia, there is another check with the client to verify identify, the correct surgical site and procedure.

A nurse is planning to administer otic drops to a 6 year-old child. Which action is part of the correct procedure? Assist the child to lie on the affected side afterward Place several drops in the outer ear Insert cotton in the outer ear after giving medication Hold the pinna up and back to instill the drops

Hold the pinna up and back to instill the drops The external auditory canal should be straightened by gently pulling the pinna up and back for otic drop administration. In children who are under three years of age, the pinna should be pulled down and back.

A nurse often works with many clients from different cultures. Which approach is a priority for the nurse? Recognize personal attitudes about cultural differences along with any real or expected biases Have a list of persons for referral when interaction with clients from different cultures occur Learn about the cultures of clients who are most often encountered Speak at least two other languages of clients in the neighborhood

Recognize personal attitudes about cultural differences along with any real or expected biases A nurse must discover personal attitudes, prejudices and biases specific to different cultures. Awareness of these will prevent negative consequences for interactions with clients and families across various cultures.

A 72 year-old client is admitted for possible dehydration. The nurse knows that older adults are particularly at risk for dehydration due to which physiologic change? A decreased sensation of thirst Higher metabolic demands An increased need for extravascular fluid An increase in diaphoresis

A decreased sensation of thirst Older adults have a reduction in thirst sensation and this causes them to consume less fluids. Other risk factors may include fear of incontinence, inability to drink fluids independently, increased frequency to void with increased fluid intake, and lack of motivation.

The hospital staff requests that parents who have a Greek heritage remove the amulet from around their infant's neck. The parents refuse. The nurse should understand that the parents may be concerned about which factor? Evil eye or envy of others Fright from spiritual beings Mental development delays Balance in body systems

Evil eye or envy of others In the Greek heritage the matiasma, "bad eye" or "evil eye, " results from the envy or admiration of others. The belief is that the eye is able to harm a wide variety of things, including inanimate objects and that children are particularly susceptible to attacks. Persons of Greek heritage employ a variety of preventive mechanisms to thwart the effects of envy. One of these is the protective charm in the form of an amulet that consists of blessed wood or incense.

A nurse is caring for a client with acute renal failure who has a subclavian vascular access port for hemodialysis. Which of these findings necessitates immediate action by the nurse? Elevated temperature Chronic fatigue Dry, hacking cough Pruritic rash

Elevated temperature *An elevated temperature in this client would indicate a possible central line infection. This finding should be reported to the provider who should order wound and blood cultures. If a line infection is suspected, the line will need to be removed, necessitating alternate line placement for hemodialysis. Interventions to prevention line infection through maintenance of line sterility and stabilization of the site are a priority in any client with a central line. The other findings should be reported to the health care provider but a febrile reaction is the priority.

he nurse is teaching a client diagnosed with type 2 diabetes mellitus about the prescribed diet. What information would the nurse want to include? Reduce carbohydrate intake to 25% of total calories Keep something sweet available at all times for hypoglycemic episodes Maintain previous calorie intake but add more protein Keep a regular schedule of meals and snacks

Keep a regular schedule of meals and snacks Currently, calorie-controlled diets with strict meal plans are rarely suggested for clients diagnosed with diabetes mellitus. The proper approach to eating is an incorporation of a schedule with food changes into clients' existing dietary patterns. Clients should learn to read labels and identify specific canned foods, frozen entrees, or other foods that are acceptable or to be avoided.

A client receiving chemotherapy has developed sores in the mouth and asks the nurse why this has happened. How should the nurse respond? "You need to have better oral hygiene." "The cells in the mouth are sensitive to the chemotherapy." "It is a sign that the medication is working." "This always happens with chemotherapy." .

"The cells in the mouth are sensitive to the chemotherapy." The epithelial cells in the mouth are very sensitive to chemotherapy due to their high rate of cell turnover.

The nurse is using the SBAR technique to communicate with the health care provider. Which of the following phrases would be associated with "B-Background"? "I would like you to..." "I'm not sure what the problem is, but the client's condition is deteriorating." "Vital signs are..." "The client's treatments are..."

"The client's treatments are..." The correct option gives the health care provider background information about the client, including age, primary diagnosis, treatments, etc. Stating that the client's condition is deteriorating is the situation (S). Stating, "I would like you to..." is the request or recommendation (R). Vital signs are part of the assessment (A). Using SBAR is an effective technique used to improve communication with other members of the health care team. This, in turn, helps to foster a culture of safety.

A nurse is planning to give a 3 year-old child oral digoxin. Which action is the best approach by the nurse? "You will feel better if you take your medicine." "Do you want to take this pretty red medicine?" "Would you like to take your medicine from a spoon or a cup?" "This is your medicine, and you must take it all right now."

"Would you like to take your medicine from a spoon or a cup?" At 3 years of age a child often feels a loss of control when hospitalized. Giving a choice about how to take the medicine allows the child to express an opinion and have some control

The public health nurse is reviewing data about trends in tuberculosis (TB) in the U.S. Which factor should the nurse understand about the current trends in TB? All TB clients should be counseled and tested for HIV There is no significant difference between TB rates for foreign-born and U.S.-born people NonHispanic Asians have the lowest TB case rate The number of new cases of TB in the U.S. continues to increase each year

All TB clients should be counseled and tested for HIV There has been a steady decrease in the total number of new cases of TB in the U.S. over the last nine years. According to current statistics, non-Hispanic Asians have the highest TB case rate in the U.S. and more than half of all new TB cases were in foreign-born people. The American Thoracic Society and the Infectious Disease Society of American recommend that everyone who tests positive for TB be counseled and tested for HIV; conversely, people with HIV or AIDS should be tested for TB because the chance of having both diseases is extremely high.

A child with tetralogy of Fallot visits the clinic several weeks before the scheduled surgery. The nurse should give priority attention to which focus? Prevention of infection Observation for developmental delays Maintenance of adequate nutrition Assessment of oxygenation

Assessment of oxygenation *All of the responses would be important for a child diagnosed with tetralogy of Fallot. However, persistent hypoxemia causes acidosis, which further decreases pulmonary blood flow. Additionally, low oxygenation leads to development of polycythemia and may result in neurological complications.

A client is receiving digoxin (Lanoxin) 0.25 mg by mouth daily. A health care provider has written a new order to give metoprolol tartrate (Lopressor) 25 mg twice a day by mouth. In assessing the client prior to administering the medications, which finding should the nurse report to the health care provider? Urine output of 50 mL/hour Heart rate of 76 BPM Blood pressure of 94/60 Respiratory rate of 16

Blood pressure of 94/60 Both medications decrease the heart rate. Metoprolol affects blood pressure. Therefore, the heart rate and blood pressure must be within normal range (HR 60 to 100 BPM and systolic BP greater than 100 mm Hg) in order to safely administer both medications.

The nurse is providing postoperative care for a client who has undergone a laparoscopic cholecystectomy. Which assessment finding should be reported immediately to the health care provider? Client reports severe right upper quadrant tenderness Absence of bowel sounds Client reports shoulder pain Client is drowsy

Client reports severe right upper quadrant tenderness Shoulder pain is a common complaint following laparoscopic surgery due to the effects of carbon dioxide gas. Postoperative drowsiness is expected. Although bowel sounds should be assessed after surgery, absence of bowel sounds immediately after surgery is not a cause for alarm. Right upper quadrant pain could be from a retained gallstone or bile duct injury; severe postoperative pain in the right upper quadrant is a medical emergency after a laparoscopic cholecystectomy.

The parent of a 2 year-old reports the child has experienced mild diarrhea for the past two days. Which statement by the nurse provides the best nutritional information for the child? A) Clear liquids and gelatin for 24 hours B) Offer bananas, apples, rice and toast as tolerated C) NPO for 24 hours, then rehydrate with milk and water D) Continue with the regular diet and include oral rehydration fluids

Continue with the regular diet and include oral rehydration fluids. *Current recommendations for mild to moderate diarrhea are to maintain a normal diet with fluids to rehydrate. If the diarrhea was severe then the BRAT (for bananas, apples, rice and toast) diet may be appropriate.

During assessment of a postpartum client, the nurse palpates a firm fundus and observes a constant trickle of bright red blood from the vagina. What is the most likely cause of these findings? Clotting disorder Genital lacerations Uterine atony Retained placenta

Genital lacerations Continuous trickling of blood in the absence of a boggy fundus indicates undetected genital tract lacerations. The client may need to return to surgery to close up the lacerations.

The client has an order for benztropine. After assessing the client, which condition would contraindicate the use of this medication? Acute extrapyramidal syndrome Neuromalignant syndrome Parkinson's disease Glaucoma

Glaucoma Benztropine is an anticholinergic medication used to treat extrapyramidal disorders caused by antipsychotic medications or Parkinson's disease. Use of benztropine or other anticholinergic is contraindicated for individuals diagnosed with glaucoma, ileus and prostatic hypertrophy. Adverse effects include tachycardia, anticholinergic psychosis and heat stroke.

The nurse is providing diet instruction to the parents of a child with cystic fibrosis. The nurse would emphasize that the diet should follow which of the following guidelines? High-fat, high-calorie foods Skim milk and low-fat dairy products Sodium-restricted Restricted calorie

High-fat, high-calorie foods *The child with cystic fibrosis requires a well-balanced diet that is high in calories (approximately 2,900 to 4,500 calories a day). The diet should include increased amounts of protein, iron, salt, zinc and calcium (especially full-fat dairy products.) Fat does not need to be restricted because these children lose fat in the stool. Recall one of the characteristics of this disease is fatty, foul smelling stool.

The nurse manager uses a block scheduling plan for staffing. However, because staff have asked for many changes and exceptions to the schedule over the past few months, the nurse manager is considering self-scheduling. What type of effect does the nurse manager anticipate with self-scheduling? Reduced overtime payouts Improved quality of care Improved team morale Decreased staff turnover

Improved team morale Nurses in direct care positions are more satisfied when opportunities exist for autonomy and control. The nurse manager becomes the facilitator rather than the decision maker of the schedule for unit needs when self-scheduling exists. Peer pressure and team work are the driving forces during self-schedule approaches.

A client is receiving external beam radiation to the mediastinum for treatment of bronchial cancer. Which of these problems should be addressed as a priority in planning care? Leukopenia Skin irritation Esophagitis Fatigue

Leukopenia Clients being treated by radiation over the sternum, which is a bone marrow producing area, develop leukopenia due to the depressant effect of radiation therapy on the bone marrow function. With the resultant low white counts, infection is a potential outcome. The other options are possible complication outcomes of radiation therapy on this part of the body. However, they are not the priority because leukopenia is a threat to the entire body and the other options are more of a local problem.

The client has decreased adrenal function. What should the nursing care plan for this client include? Prevent constipation Encourage physical activity Place the client in reverse isolation Limit the number of visitors

Limit the number of visitors Any stress, either physical or emotional, places additional stress on the adrenal glands, which could precipitate an Addisonian crisis in this client. The plan of care should protect the client from stress by avoiding the emotional stress of (too many) visitors and by reducing physical activity until the client's condition stabilizes.

The client is withdrawn. Which nursing intervention will be most effective to help the client develop relationship and interpersonal skills? Provide the client with frequent opportunities to interact with other clients Discuss with the client the focus that other clients have similar problems Offer the client frequent opportunities to interact with one person Assist the client to analyze the meaning of the withdrawn behavior

Offer the client frequent opportunities to interact with one person *A withdrawn client is uncomfortable in social interaction. The nurse-client or a one-on-one relationship is a corrective relationship in which the client learns tolerance and skills for relationships.

An important goal in the development of a therapeutic inpatient milieu is which of these items? Offer a businesslike atmosphere where clients can work on individual goals Provide a testing ground for new patterns of behavior while clients take responsibility for their own actions Discourage expressions of anger because such feelings can be disruptive to other clients Form a group forum in which clients decide on unit rules, regulations and policies

Provide a testing ground for new patterns of behavior while clients take responsibility for their own actions *A therapeutic milieu is purposeful and planned to provide safety and a testing ground for new patterns of behavior. The other approaches may be part of other types of therapies.

A nurse is caring for a client who was in a motor vehicle accident. Which of these findings would be the highest priority if newly identified by the nurse? Diminished spinal reflexes Pupils fixed and dilated Flaccid paralysis Reduced sensory responses

Pupils fixed and dilated Pupils that are fixed and dilated indicate overwhelming injury and intrinsic damage to the upper brain stem, and would be the highest priority as it is a poor prognostic sign. The other findings are more consistent with partial dysfunction of the brain or spinal cord.

The nurse is caring for a client with a diagnosis of gastroesophageal reflux disease (GERD). The primary health care provider's orders include omeprazole (Prilosec) twice a day, Maalox prior to meals, elevation of the head of the bed, acid-reflux diet, and no alcohol. Which one of these orders would the nurse question? Prescribed diet Schedule for antacid Schedule for the proton-pump inhibitor Bed position

Schedule for antacid *All of the options listed are potential recommendations but the schedule for antacids should be one to three hours after eating and at bedtime as needed.

The nurse is planning care for a 6 month-old infant. What must the nurse provide to assist in the development of trust? Warmth Food Security Comfort

Security While the infant has many physical needs, it must be touched, loved and stimulated to develop security and trust.

The nurse is preparing a handout on infant feeding to be distributed to families visiting the clinic. Which notation should be included in the teaching materials? Solid foods should be mixed with formula in a bottle A variety of ground meat should be started early to provide iron Solid foods are to be introduced one at a time beginning with cereal Egg white is added early to increase protein intake

Solid foods are to be introduced one at a time beginning with cereal Solid foods should be added, one at a time, between 4 to 6 months. If the infant is able to tolerate the food, another is then added each week. Iron-fortified cereal is the recommended first food; rice cereal is recommended due to the low risk of food allergies. Teach parents to mix the cereal flakes with either breast milk or formula. After the baby is eating cereal, pureed meat, vegetables and fruits can be introduced. Egg whites and wheat products should not be given before the baby is at least a year old because these foods are more commonly associated with allergies.

The nurse is assessing a client during a visit to a community mental health center. The client discloses that "I have been thinking about ending my life." Which statement would be the nurse's BEST response to this information? "We will help you deal with those thoughts." "Do you want to discuss this with your pastor?" "Is your life so terrible that you want to end it?" "Have you thought about how you would do it?"

"Have you thought about how you would do it?" Most experts believe that people who commit suicide don't want to die; they just want to stop hurting. When a client tells you s/he is thinking about death or suicide, you must evaluate the immediate danger the person is in. The correct option provides an opening to discuss the plan, the means (pills, gun, etc.), time set for doing it, and intent to commit suicide. Clients who have formulated a suicide plan are closer to suicidal behavior than those who have vague, nonspecific thoughts.

The nurse is working in an inpatient psychiatric unit. Which statement made by a client indicates that the client may have a thought disorder? "I'm a little confused. What time is it?" "I'm so angry about this. Wait until my partner hears about this." "I'm fine. It's my daughter who has the problem." "I can't find my 'mesmer' shoes. Have you seen them?"

"I can't find my 'mesmer' shoes. Have you seen them?" A neologism is a word that is self-invented by a person and not readily understood by another person. The use of neologisms is often associated with a thought disorder. The other statements reflect appropriate connections between the expressed thoughts. Thought disorders are associated with schizophrenia, delusions and hallucinations of psychosis.

A client states, "People think I'm no good, you know what I mean?" Which of these responses by the nurse would be the most therapeutic? "I think you're good. So you see, there's one person who likes you." "I'm not sure what you mean. Tell me a bit more about that." "Let's discuss this to see the reasons you create this impression on people." "Well people often take their own feelings of inadequacy out on others."

"I'm not sure what you mean. Tell me a bit more about that." This therapeutic communication technique elicits more information, especially when delivered in an open, nonjudgmental fashion. The use of the nursing process when a client has a problem is "further assessment" of the situation.

During administration of medications to a client, the client says to a nurse, "I do not want to take that medicine today." Which of these statements should the nurse use as a response? "Do you understand the consequences of refusing your prescribed treatment?" "Is there any particular reason why you don't want to take your medicine?" "I will have to call your doctor and report this." "That's OK, its all right to skip your medication now and then."

"Is there any particular reason why you don't want to take your medicine?" When a new problem is identified, it is important for the nurse to collect accurate information directly from clients. This is crucial to ensure that clients' needs are adequately identified in order to select the best nursing care approaches. The nurse should pursue a conversation with the client to reveal any reasons for the medication refusal. It may be that the client has developed untoward side effects.

The nurse has completed discharge teaching to a client who had a total hip arthroplasty. Which statement made by the client indicates further teaching is needed? "When I go home, I should not stand for long periods." "Now I'll finally be able to bend forward to tie my shoes without pain." "I'll use an electric razor to shave." "If my hip pain gets worse I should call my doctor."

"Now I'll finally be able to bend forward to tie my shoes without pain." Someone who had a total hip replacement should not sit or stand for prolonged periods of time to help prevent thromboembolism and muscle fatigue. Because anticoagulants are typically used postoperatively, the use of an electric razor is indicated. Any increase in hip pain must be evaluated for complications. Following hip replacement surgery, a person should never bend at the waist more than 90 degrees, which would mean the person should not bend over to tie shoes.

When admitting a client to the ambulatory surgery unit, the nurse notices the client has painted fingernails. The nurse reviews the pre-op orders and notes that pulse oximetry is prescribed. Which statement by the nurse is appropriate? "So that we can measure your oxygen levels, may I please remove the polish from at least two nails?" "If you do not remove all your polish, I will request a needlestick to test oxygen levels." "I am sorry. All your nail polish must be removed." "I will ask your provider if we must ruin those beautiful nails."

"So that we can measure your oxygen levels, may I please remove the polish from at least two nails?" In order to effectively measure pulse oximetry, there can be no nail polish on the finger fitted with the reading device. The client should be approached using therapeutic communication skills. The other options are inappropriate.

A 3 year-old child has tympanostomy tubes in place. The child's parent asks the nurse if the child can swim in the family pool. How best should the nurse respond? "Your child may swim anywhere without restrictions." "Your child may swim in your own pool but should not dive under the water." "Your child should not swim in the pool while the tubes are in place." "Your child may swim and dive if earplugs are worn when in and around the pool."

"Your child may swim in your own pool but should not dive under the water." After this procedure, the child can swim in the family pool, without earplugs, as long as s/he does not dive under the water. Since lakes and oceans are not as clean as pool water, the child should not put his/her head under the surface of the water unless waterproof ear protection is used. Children should also not submerge their heads under the water in a bathtub. Unless the child develops frequent drainage after swimming or bath, routine use of earplugs are usually not recommended.

Following craniotomy surgery the client develops a cardiac arrhythmia, and the provider orders lidocaine (Xylocaine) infusion at 3 mg/minute. The label states the 500 mL IV bag contains 2 grams of lidocaine (Xylocaine). What is the flow rate setting (milliliter/hour)? (Round to the nearest whole number and write only the number.) _________mL/hour.

45 Using dimensional analysis to solve, because the final answer will be in mL/hour, begin the equation with milliliters on top. Multiply by known factors to cancel out unwanted units until only mL/hour remains. (500 mL/2 gram) X (1 gram/1000 mg) X (3 mg/min) X (60 min/hr) = 90,000/2,000 = 45 mL/hour.

The charge nurse needs to delegate some duties. Which of these clients should the charge nurse assign to the practical nurse (PN)? A middle-aged client diagnosed with hemiplegia and with a G-tube and a client with a left leg below-the-knee amputation (BKA) in rehabilitation An adolescent trauma victim newly admitted with a diagnosis of quadriplegia and a client one day postop of radical neck dissection A young adult client client with a diagnostic history of schizophrenia with current alcohol withdrawal syndrome and a client diagnosed with chronic renal failure and anemia An older client with newly diagnosed type 2 diabetes and a client who is HIV-positive with a diagnosis of pneumonia

A middle-aged client diagnosed with hemiplegia and with a G-tube and a client with a left leg below-the-knee amputation (BKA) in rehabilitation *This client requires supportive care and interventions within the scope of practice of a PN. This client is the most stable with a minimal risk of complications or instability. In the other options some of the clients would require RN care. The clues are: "newly admitted," "newly diagnosed" and current alcohol withdrawal. All of these clients would have a high risk of instability.

A mother asks a nurse if she should be concerned about her child's tendency to stutter. What assessment data will be most useful in counseling the parent? Sibling position in family Age of the child Stressful family events Parental discipline strategies

Age of the child During the preschool period children use their rapidly growing vocabulary faster than they can produce their words. This failure to master sensorimotor integrations results in stuttering. This dysfluency in speech pattern is a normal characteristic of language development. Therefore, knowing the child's age is most important in determining if any true dysfunction might be occurring with stuttering.

The nurse is caring for a client who has a history of asthma and is now diagnosed with gastroesophageal reflux disease (GERD). Which of these types of medications, which are all prescribed for the client, may aggravate the GERD? Corticosteroid Anticholinergic bronchodilator Histamine blocker Anti-infective

Anticholinergic bronchodilator An anticholinergic medication will decrease gastric emptying and diminish the pressure on the lower esophageal sphincter. This will enhance gastric reflux.

A 23 year-old single client in the 33rd week of her first pregnancy tells the nurse that she has everything ready for the baby and has made plans for the first weeks together at home. Which normal emotional reaction does the nurse recognize? Focus on fetal development Anticipation of the birth Ambivalence about pregnancy Acceptance of the pregnancy

Anticipation of the birth Directing activities toward preparation for the newborn's needs and personal adjustment are indicators of appropriate emotional response in the third trimester and a part of "nesting" according to Rubin. Ambivalence about pregnancy is an expected emotion during the first trimester. Acceptance of the pregnancy with a focus on fetal development are important in the second trimester.

While performing an initial assessment on a newborn following a breech delivery, the nurse suspects hip dislocation. Which of these findings is most suggestive of this abnormality? Flexion of lower extremities Irregular hip symmetry Lengthened leg of affected side Negative Ortolani response

Irregular hip symmetry Early assessment of irregular hip symmetry alerts the nurse and the provider to a correctable congenital hip dislocation. The leg is shortened on the affected side. One check for hip dislocation is the Ortolani click; if it is found, it is called a positive response.

healthy 18 year-old is entering college in the fall. Which immunization would the health care provider recommend prior to college? (Select all that apply.) Human papillomavirus (HPV) vaccine Shingles vaccine Seasonal influenza vaccine Tetanus, Diphtheria, Pertussis vaccine (Tdap) Pneumococcal polysaccharide vaccine (PPSV23) Meningococcal conjugate vaccine (MCV4)

Human papillomavirus (HPV) vaccine Seasonal influenza vaccine Tetanus, Diphtheria, Pertussis vaccine (Tdap) Meningococcal conjugate vaccine (MCV4) Adults older than age 50 should get the shingles vaccine. The PPSC23 is given to adults older than age 65. (The pneumococcal vaccine PCV13 is routinely given to infants/children.) An 18 year-old who is going to college should receive the TDAP, MCV4 and seasonal influenza vaccine. He or she should also receive the HPV vaccine if s/he has not already received it.

The client who is experiencing an acute asthmatic episode is admitted to the hospital with intermittent nonproductive coughing. The pulse oximeter reading is 88%. The client states to the nurse, "I feel like this is going to be a bad episode. I wish I would not have gone into that smoky bar last night." Which nursing diagnosis would be the priority for this client? A) Impaired gas exchange related to bronchoconstriction and mucosal edema B) Anxiety related to hospitalization C) Altered health maintenance related to preventative behaviors associated with asthma D) Ineffective airway clearance related to potential thick secretions

Impaired gas exchange related to bronchoconstriction and mucosal edema. *The low pulse oximetry reading indicates poor gas exchange, with inadequate oxygenation of arterial blood resulting from the bronchoconstriction and mucosal edema of the acute asthma attack. Treatments will include oxygen administration to correct the hypoxia, titrated to maintain a saturation at or above 92-95%, intravenous or oral corticosteroids to reduce the mucosal edema and inhaled bronchodilators such as albuterol via nebulizer or metered dose inhaler with a spacer to treat airway bronchoconstriction. While the other diagnoses may be appropriate for this client, they are not the priority at this time.

A mother brings her 26 month-old to the well-child clinic and expresses frustration and anger due to the child constantly saying "no" and refusing to follow directions. The nurse should explain that this is normal for the age, as negativism is an attempt to meet which developmental need? Trust Independence Initiative Self-esteem

Independence In Erikson's theory of development, toddlers struggle to assert independence. They often use the word "no" even when they mean yes. This stage is called autonomy versus shame and doubt. At this stage other characteristics are "grazing" instead of eating a meal, a behavior of rituals especially at bedtime and parallel play with other children.

A newly appointed nurse manager is having difficulties with time management. Which advice from an experienced manager should the new manager implement first? Ask for additional assistance when you feel overwhelmed Set daily goals and establish priorities for each hour and each day Keep a time log of your day in hourly blocks for at least one week Complete each task before beginning another activity in selected instances

Keep a time log of your day in hourly blocks for at least one week Apply the nursing process to time management, so the assessment of the current activities is the initial step. A baseline is established for activities and time use so that needed changes can be pinpointed.

A nurse is assigned to care for a comatose client. The client is diagnosed with type 1 diabetes and has an IV infusion of insulin running. Which task would be most appropriate to delegate to an unlicensed assistive personnel (UAP)? Determine if special skin care is needed when reddened areas are identified Answer questions from the client's spouse about the plan of care Obtain a peripheral blood glucose reading Measure and document the hourly output in a urine collection bag

Measure and document the hourly output in a urine collection bag The UAP perform tasks, including measuring and recording urine output. In long term care and other health care settings, UAPs are not allowed to obtain blood glucose readings. You should be aware that a national license exam has to subscribe to the lowest level of practice, which is why obtaining a blood glucose reading is an incorrect response.

A nurse is teaching a school-age child and family members about the use of inhalers prescribed for asthma. What is the best way to evaluate the effectiveness of the treatments? Monitor pulse rate Rely on child's self-report Observe use of peak flow meter Note skin color changes

Observe use of peak flow meter The peak flow meter can help determine if the symptoms of asthma are in control or are worsening. It works by measuring how fast air comes out of the lungs when the client forcefully exhales (the peak expiratory flow or PEF) after inhaling fully. The client should record the highest of three readings in an asthma diary. Children ages 4 and up should be able to use a peak flow meter.

A client is admitted with a pressure ulcer in the sacral area. The partial thickness wound is 1.5 x 2.7 inches (4 cm x 7 cm), the wound base is red and moist with no exudate and the surrounding skin is intact. Which covering should the nurse select for this wound? Dry sterile dressing with antibiotic ointment Transparent dressing Occlusive moist dressing Wet to dry dressing

Occlusive moist dressing This wound has granulation tissue present and must be protected. The granulation tissue is evident by wound base being red and moist with no exudate. The use of a moisture retentive dressing is the best choice because moisture supports wound healing.

The nurse is providing instructions for a client with asthma. Which of these factors is a priority for the client to monitor daily? Pulse oximetry Respiratory rate Respiratory effort Peak air flow volumes

Peak air flow volumes The peak airflow volume decreases about 24 hours before clinical manifestations of exacerbation of asthma. Note that the question asks for a priority so all of the options would be monitored. However, the peak air flow is the priority

An 80 year-old client on digoxin (Lanoxin) reports nausea, vomiting, abdominal cramps and halo vision. Which laboratory result should the nurse analyze first? Magnesium levels Potassium levels Blood urea nitrogen Blood pH

Potassium levels Nausea, vomiting, abdominal cramps and halo vision are classic signs of digitalis toxicity. The most common cause of digitalis toxicity is a low potassium level. Clients are to be taught that it is important to have adequate potassium intake, especially if taking loop or thiazide diuretics that enhance the loss of potassium.

The nurse is caring for a client in labor. Which of the following situations will most likely put the neonate at risk for sepsis? Premature rupture of membranes Maternal gestational diabetes Cesarean delivery Precipitous vaginal birth

Premature rupture of membranes *Premature rupture of the membranes (PROM) is a leading cause of newborn sepsis. After 12 to 24 hours of leaking fluid, actions should be taken to reduce the risk of infection to the mother and the fetus/newborn.

The client has a new order for an oral form of dexamethasone. What should the nurse understand about this medication? It should be given on an empty stomach If ordered once a day, it should be given at bedtime The client should start on the highest dose possible for the shortest length of time The client should avoid being near people who are sick or have infections

The client should avoid being near people who are sick or have infections Dexamethasone is used to treat many different inflammatory conditions including arthritis, allergic reactions, breathing problems, certain bowel disorders and certain cancers. The medication should be taken with food or milk to prevent stomach upset. It is taken in the morning, between 6:00 am and 8:00 am, when cortisol levels are highest. Clients taking corticosteroids are more susceptible to infections and should avoid contact with people who are sick or have infections. To help avoid potentially serious side effects, the lowest effective dose should be used for the shortest possible length of time.

A client is diagnosed with iron-deficiency anemia. What is the cause of the symptoms associated with this condition? A) Tissue hypoxia B) Destruction of red blood cells (RBCs) C) Decreased cardiac output D) Reduced oxygen saturation

Tissue hypoxia *Iron-deficiency anemia is when the RBCs are unusually small and pale (due to their low hemoglobin content.) Tissue hypoxia is the result of not having enough functioning hemoglobin in the blood to oxygenate the tissues; tissue hypoxia is responsible for symptoms such as fatigue, leg cramps and chewing ice. It's possible the client could have a normal SpO2 because the small amount of hemoglobin that's in the blood may be well saturated with oxygen. Anemia does not decrease cardiac output. Destruction of RBCs is associated with hemolytic anemia, not iron-deficiency anemia.

The nurse is auscultating the heart of a client who is diagnosed with dilated cardiomyopathy. What finding would the nurse expect to hear? Split S2 Ventricular gallop of S3 Apical click Diastolic murmur

Ventricular gallop of S3 A ventricular gallop, S3 is caused by blood flowing rapidly into a distended noncompliant ventricle. This is the most common sound with left-sided heart failure. It sounds like "Kentucky." Increased left heart pressures may cause dilation of the mitral valve in the client with heart failure resulting in a systolic murmur.

A nurse is providing instructions for a client with asthma who is allergic to house-dust mites. Which information about prevention of asthma episodes would be the most helpful to include during the teaching? Open the curtains to let the sunlight in each morning Change the pillow covers every month Wash and rinse the bed linens in hot water Wash bed linens in warm water with a cold rinse

Wash and rinse the bed linens in hot water *For asthma clients who are allergic to house-dust mites, the mattresses and pillows should be encased in allergen-impermeable covers. All bed linens such as pillow cases, sheets and blankets should be washed and rinsed weekly in hot water at temperatures above 130 F (54.4 C), the temperature necessary to kill the dust mites.

A nurse is caring for a client who had a mastectomy two months ago. Which of these statements, made by a client, is incorrect and indicates a need for an additional assessment associated with the impact of an alteration in body image? "I plan to volunteer to work with others who have had mastectomies in Reach for Recovery." "It really isn't much of a problem for me, I never had large breasts anyway." "I only look at myself in the mirror after I am fully dressed." "I guess it's time for me to quit wearing a bikini at my age anyway."

"I only look at myself in the mirror after I am fully dressed." An inability to look at the incision or surgical site is associated with possible denial or anger during the process of coping with a loss. This indicates that a problem area for this client is body image. The other statements reflect movement towards acceptance of the loss of a "normal" figure.

An immobile hospitalized client is eating less than 25% of served meals. The client gains 5 pounds (2.27 kg) in two days. The most likely explanation for this is the retention of how many milliliters of fluid? _______mL.

2500, 2270 *454 g = 1 lb (1g ~ 1 mL) or 500 mL = 1 lb. 1 kg ~ 1 liter. "A pint is a pound the world around."

A 72 year-old client diagnosed with osteomyelitis requires a six-week course of intravenous antibiotics. In planning for home care, what is the priority approach by a nurse? Select the appropriate venous access device for the long-term IV medication Determine if there are adequate handwashing facilities in the home Assess the client's ability to participate in self-care and/or the reliability of a caregiver Investigate the client's insurance coverage for home IV antibiotic therapy

Assess the client's ability to participate in self-care and/or the reliability of a caregiver The cognitive ability of the client as well as the availability and reliability of a caregiver must be assessed to determine if home care is a feasible option. The other approaches are correct and would be pursued after this initial approach.

A child is admitted to the pediatric unit with a diagnosis of suspected meningococcal meningitis. Which admission orders should the nurse implement first? Institute seizure precautions Monitor neurologic status every hour Administer cefotaxime (Claforan) IV 50 mg/kg/day divided every six hours Initiate droplet precautions

Initiate droplet precautions Meningococcal meningitis is a bacterial infection that can be communicated to others. The initial therapeutic management of acute bacterial meningitis includes droplet precautions, initiation of antimicrobial therapy, monitoring neurological status along with vital signs, instituting seizure precautions and, lastly, maintaining optimum hydration. The first action is to initiate any necessary precautions to protect themselves and others from the potential infection. Viral meningitis usually does not require protective measures of isolation and these clients often return home to recover.

The nurse is working to establish a therapeutic relationship with a client. Which of these approaches would be most damaging to the client's self-esteem? Indifference Fear Disapproval Anger

Indifference Therapeutic relationships that build or maintain self-esteem are incongruent with indifference. Positive connectedness or caring characterizes a therapeutic relationship, which will enhance self-esteem.

The nurse is caring for a client taking antipsychotic drugs. Why is it important for the nurse to monitor blood pressure in this client? Orthostatic hypotension is a common side effect Blood pressure will determine if dietary restriction of sodium is needed Rising trends in blood pressure will indicate when an antiparkinsonian drug is needed Most antipsychotic drugs cause elevated blood pressure

Orthostatic hypotension is a common side effect Clients should be made aware of the possibility of dizziness and syncope from postural hypotension for about an hour after taking an antipsychotic medication. Clients should be advised to get up slowly from a sitting or lying position.

The nurse is caring for a 10 year-old child who is diagnosed with diabetes insipidus (DI) and is receiving vasopressin (Pitressin). What is the priority for the nurse to teach the child and the family members about this prescribed medication? The child will need intravenous therapy for several weeks Parents should administer the daily intramuscular injections The family must monitor the child for arrhythmias The family must observe the child for dehydration

The family must monitor the child for arrhythmias Diabetes insipidus is characterized by a decreased secretion of antidiuretic hormone (ADH). Decreased ADH results in polyuria and polydipsia; the person is unable to concentrate urine. Vasopressin is the drug of choice to treat central DI. At home, it can be administered 2-3 times a day, either IM, subQ or intranasally. Not drinking enough fluids can cause arrhythmias, fatigue and muscle pain. Other serious side effects include chest pain, skin discoloration and paresthesia.

A nurse admits a 3 week-old infant to the special care nursery with a diagnosis of bronchopulmonary dysplasia. As the nurse reviews the birth history, which data would be most consistent with this diagnosis? Gestational age assessment suggested growth retardation The infant received mechanical ventilation for two weeks Meconium was cleared from the airway at delivery Phototherapy was used to treat Rh incompatibility

The infant received mechanical ventilation for two weeks Bronchopulmonary dysplasia (BPD) is an iatrogenic disease caused by mechanical ventilation. When the prematurely born infant is treated with mechanical ventilation, over time the pressure from the ventilation and excess oxygen can injure the infant's lungs, causing BPD.

The nurse is teaching a client about precautions while taking warfarin (Coumadin). The nurse should instruct the client to avoid foods with excessive amounts of which nutrient? A) Iron B) Calcium C) Vitamin K D) Vitamin E

Vitamin K *Vitamin K is an essential vitamin required for blood clotting. Eating foods with excessive amounts of Vitamin K may alter anticoagulant effects. Foods highest in vitamin K include (dried and fresh) herbs, dark leafy greens, scallions, brussel sprouts, broccoli, chili powder, prunes, asparagus and cabbage.

A nurse is reinforcing teaching to a 24 year-old woman receiving acyclovir (Zovirax) for a herpes simplex virus type 2 infection. Which of these instructions should the nurse give the client? Begin treatment with acyclovir at the onset of symptoms of recurrence Continue to take prophylactic doses for at least five years after the diagnosis Stop treatment if she thinks she may be pregnant to prevent birth defects Complete the entire course of the medication for an effective cure

Begin treatment with acyclovir at the onset of symptoms of recurrence *When the client is aware of early symptoms, such as pain, itching or tingling, treatment is very effective. Medications for herpes simplex do not cure the disease. They simply decrease the intensity of the symptoms. Acyclovir is not known to have an impact on the fetus. Acyclovir should not be taken for preventive purposes, regardless of the date of diagnosis.

The nurse works in an assisted living facility and cares for older adults. The nurse understands that older adults are at a greater risk for drug toxicity than younger adults due to which physiological change associated with aging? Drugs are absorbed more readily from the gastrointestinal tract Older adults have more rapid hepatic metabolism Older adults are often malnourished and anemic Older adults have less body water and more fat

Older adults have less body water and more fat Because older adults have decreased lean body tissue and water in which to distribute medications, more drug remains in the circulatory system, creating a potential for drug toxicity. Increased body fat results in greater amounts of fat-soluble drugs being absorbed, leaving less medication in circulation, thus increasing the duration of action of the drug.

A nurse is caring for a 69 year-old client with a diagnosis of hyperglycemia. Which tasks could the nurse delegate to an unlicensed assistive personnel (UAP)? Check skin condition of lower extremities with special focus on the toes Record dietary intake and deliver between meal snacks on time Monitor for mental status changes prior to and after insulin administration Review with family and client initial signs of hyperglycemia

Record dietary intake and deliver between meal snacks on time *The UAP can do routine, standard, unchanging procedures with expected outcomes. Although UAP are usually responsible for bathing clients and would be able to see changes in skin condition, it is the nurse who would need to assess and document the changes. The UAP should tell the nurse about any changes in the client's condition so the nurse can follow up with an assessment and plan of action for the client.

The nurse is teaching a parent about side effects of routine immunizations. Which of these findings must be reported immediately? Local tenderness Slight edema at site Seizure activity Irritability

Seizure activity *While severe complications are rare, any seizure activity must be immediately reported; seizures can occur up to 7 days after injection. Other reactions that should be reported include crying for more than three hours, temperature over 105 F (40.5 C) following DTaP immunization, and tender, swollen, reddened areas where the shot was given.