Reduce Risk Potential

Butorphanol tartrate

(Trade Name: Tobutrol, Torbugesic) synthetic, partial opioid agonist. It is a class IV controlled substance. Butorphanol has 4-7X the analgesic properties of morpine and significant antitussive effects.

A 1-month-old infant is admitted to the pediatric unit with a tentative diagnosis of Hirschsprung disease (congenital aganglionic megacolon). What procedure does the nurse expect to be used to confirm the diagnosis? 1 Colonoscopy 2 Rectal biopsy 3 Multiple saline enemas

2 Rectal biopsy A full-thickness rectal biopsy involves the removal of some rectal tissue, which is examined microscopically for the absence of ganglion cells. A colonoscopy is not necessary to obtain a rectal biopsy specimen. A saline enema may relieve the obstruction, but it is not a definitive diagnostic tool; a barium enema may be used for diagnosis after the age of 2 months. A fiberoptic nasoenteric tube is not used to identify the cause of intestinal obstruction in infants.

A client presents to the emergency department with severe epistaxis. Which client position is most beneficial? 1 Trendelenburg position 2 Semi-Fowler position on a stretcher 3 Sitting in a chair with head tilted back 4 Sitting with head tilted slightly forward

4 Sitting with head tilted slightly forward

A client with achalasia is to undergo bougienage to dilate the lower esophagus and cardiac sphincter. Which clinical manifestations should the nurse assess in the client after the procedure? Select all that apply. 1 Facial flushing 2 Abdominal pain 3 Increased heart rate 4 Feelings of fullness 5 Increased blood pressure

-Abdominal pain -increased heart rate -increased BP A client with achalasia is to undergo bougienage to dilate the lower esophagus and cardiac sphincter. Which clinical manifestations should the nurse assess in the client after the procedure? .

A spontaneous pneumothorax is suspected in a client with a history of emphysema. In addition to calling the healthcare provider, which action should the nurse take? 1 Place the client on the unaffected side 2 Administer 60% oxygen via a Venturi mask 3 Give oxygen at 2 L per minute via nasal cannula 4 Prepare for intravenous (IV) administration of electrolytes

Give oxygen at 2 L per minute via nasal cannula

Hirschsprung disease (congenital aganglionic megacolon)

Hirschsprung's disease (also called congenital aganglionic megacolon) occurs when some of your baby's intestinal nerve cells (ganglion cells) don't develop properly, delaying the progression of stool through the intestines.

Aspirin (ASA)

Increased risk for GI bleeding (coffee ground emesis, black tarry stool) Increase Prothrombin time (PT/INR) ...stop a week before surgery due to platelet life of 7 days Enteric coated = prevent GI bleed/upset Toxicity = tinnitus, humming, dizzy, bad balance, nausea Caution = with heparin, lovenox, coumadin, Nsaids

A client who has an above-the-knee amputation is fitted for a prosthesis. Two days after beginning to use the prosthesis, a small blister develops on the residual limb near the healed incision. Which action will the nurse anticipate when planning care for this client? 1 Stopping use of the prosthesis until the blister heals 2 Increasing the frequency of limb-toughening exercises 3 Changing the type of covering used to avoid irritation 4 Placing a bandage on the blister before putting the prosthesis back on

1 Stopping use of the prosthesis until the blister heals Pressure on the blister will not allow it to heal; use of the prosthesis should be discontinued until healing occurs. Increasing the frequency of limb-toughening exercises will neither heal the blister nor alleviate pressure on the blister by the prosthesis. Changing the type of covering will not help heal the blister. The client should not put the prosthesis back on because it causes pressure, which will prevent healing.

A client is to undergo a tuberculin test as part of her prenatal workup. Before administering the test, what information about the client should the nurse obtain? 1 Whether she has had a previous tuberculin test 2 Whether the client is prone to respiratory diseases 3 Whether an earlier tuberculin test's result was positive 4 Whether the client's family has a history of tuberculosis

A tuberculin test should not be administered to a client with a previous positive result on a tuberculin test, because a severe reaction may occur at the test site in a previously sensitized individual. It is more important to know whether the test result was positive than whether a test was performed. Being prone to respiratory diseases is not a contraindication to having a tuberculin test unless the client is infected with tuberculosis. Although a family history may have involved exposure of the client to tuberculosis, the client may not have had a positive tuberculin test result; also many years may have elapsed since the exposure.

What is a non-stress test (NST)?

Fetal heart rate monitoring used to check the baby's health. The NST is performed before labor begins. Accelerations with movement and a baseline variability of 5 to 15 beats/min indicate fetal well-being. This reactive NST is considered positive.

A client's arterial blood gas report indicates the pH is 7.52, PCO 2 is 32 mm Hg, and HCO 3 is 24 mEq/L. What does the nurse identify as a possible cause of these results? 1 Airway obstruction 2 Inadequate nutrition 3 Prolonged gastric suction 4 Excessive mechanical ventilation

The high pH and low carbon dioxide level are consistent with respiratory alkalosis, which can be caused by mechanical ventilation that is too aggressive. Airway obstruction causes carbon dioxide buildup, which leads to respiratory acidosis. Inadequate nutrition causes excess ketones, which can lead to metabolic acidosis. Prolonged gastric suction causes loss of hydrochloric acid, which can lead to metabolic alkalosis.

Of what does the nurse expect the primary health care provider to advise the parents after their child is diagnosed with a mitochondrial disorder? 1 "There is no risk of recurrence of this disease in the next child." 2 "You may need to use a donor egg or sperm for future children." 3 "There are more chances of miscarriage in the next pregnancy." 4 "You can find additional information on this disease on the Internet."

The nurse informs the parents about alternative options, such as the use of a donor egg or sperm for the next pregnancy. This is because there is an increased risk for the mitochondrial disorder in future children. The diagnosis of the mitochondrial disorder in this child does not carry an increased chance of miscarriage for the mother in future pregnancies. It is not a good idea to encourage the parents to look for additional information on the Internet, because some information may be inaccurate.

A nursing instructor asks a nursing student about the sleep pattern of teenagers. Which statements made by the student indicate adequate learning? Select all that apply. 1 Teenagers often have reduced hours of sleep. 2 Teenagers often suffer from restless leg syndrome. 3 Teenagers get roughly 7.5 hours of sleep each night. 4 Twenty percent of a teen's sleep cycle is rapid eye movement (REM) sleep. 5 Teenagers resist sleeping because they are unaware of fatigue

1 Teenagers often have reduced hours of sleep. 3 Teenagers get roughly 7.5 hours of sleep each night. The typical adolescent is subject to a number of changes, such as school demands, after-school social activities, and part-time jobs, that reduce the time spent sleeping. On average, teenagers get about 7.5 hours of sleep per night; preschoolers sleep an average 12 hours a night. Restless leg syndrome is common in young adults, not teenagers. Young adults, not adolescents, have 20% of their sleep time in REM sleep. Preschoolers often resist sleeping because they are unaware of fatigue or have a need to be independenT

A client who survived a lightning strike is admitted to the emergency unit. Which interventions could be beneficial for this client's condition? Select all that apply. 1 Administration of diphenhydramine 2 Applying spinal immobilization technique 3 Stabilization of airway, breathing, and circulation 4 Applying ice packs in the axillae and groin and on the neck and head 5 Rapid rewarming in a water bath at a temperature range of 104° F to 108° F (40° C to 42° C)

2 Applying spinal immobilization technique 3 Stabilization of airway, breathing, and circulation Applying spinal immobilization would reduce spinal cord injury pain. Stabilization of airway, breathing, and circulation may be beneficial to prevent respiratory and cardiac arrest. Administration of diphenhydramine would be beneficial in case of bee or wasp stings, not after a lightning strike. Applying ice packs in the axillae and groin and on the neck and head is beneficial for heat stroke victims, not lightning strike victims. Rapid rewarming in a water bath at a temperature range of 104° to 108° degrees Fahrenheit (40° to 42° degrees Celsius) would help clients with cold-related injuries such as hypothermia and frostbite.

A client who has been experiencing chest pain and vomiting for several hours is admitted to the hospital with a diagnosis of myocardial infarction. The client is transferred immediately to the cardiac intensive care unit. The client's potassium level is below the expected range. Considering this laboratory result, what should the nurse monitor the client's electrocardiogram (ECG) for? 1 Tall, peaked P waves 2 Increased P-R intervals 3 Elevated U and flattened T waves 4 Multiple trigeminy and bigeminy runs

3 Elevated U and flattened T waves

Naproxen (Aleve)

*class*: nonsteroidal anti-inflammatory agents (NSAID), nonopioid analgesics, antipyretics *Indication*: pain, dismenorrhea, fever, inflammation *Action*: inhibits prostaglandin synthesis *Nursing Considerations*: - use caution with GI bleeding - may increase risk for stroke and MI - can cause GI bleeding, anaphylaxis, Steven's Johnson syndrome - aspirin can decrease blood levels and effectiveness - assess pain - patients should remain up-right for 30 minutes after administration

A person is brought to the emergency department after prolonged exposure to cold weather. What clinical manifestations of hypothermia does the nurse expect?Select all that apply. 1 Stupor 2 Erythema 3 Increased anxiety 4 Rapid respirations 5 Paresthesia in affected body parts

1 Stupor 5 Paresthesia in affected body parts Stupor may occur with hypothermia because of slowed cerebral metabolic processes. Peripheral vasoconstriction and the effect of cold on the peripheral nervous system result in paresthesias in the affected body parts. Pallor, not erythema, is present as a result of peripheral vasoconstriction. Drowsiness occurs; the client is unable to focus on anxiety-producing aspects of the situation. Respirations are decreased.

A nurse is preparing to take the vital signs of a 4-year-old child who was brought to the well-child clinic. What criterion should the nurse use when selecting the appropriate size of blood pressure cuff? 1 It is labeled "pediatric." 2 It is labeled "preschool." 3 The length covers 50% of the circumference of the upper arm. 4 The width is approximately 40% of the circumference of the upper arm.

4 The width is approximately 40% of the circumference of the upper arm.

The nurse ensures that the client's airway is patent and that resuscitation equipment is immediately available after the client is bitten by a snake. What kind of snakebite has led to this priority intervention by the nurse? 1 Rattlesnake 2 Coral snake 3 Copperhead 4 Cottonmouth

2 Coral snake The client has been bitten by a coral snake, and the physiologic effect of the venom involves blocking of neurotransmission, which produces weakness, cranial nerve deficits, an altered level of consciousness, and ultimately, respiratory paralysis. Rattlesnakes, copperheads, and cottonmouths are in the category of pit vipers.

A client has undergone suction curettage for the removal of a hydatidiform mole. What should the nurse emphasize when planning for the client's discharge? 1 The necessity of at least 6 weeks of follow-up care 2 The reasons for postponing another pregnancy for an entire year 3 The risk factors for the development of another hydatidiform mole 4 The basis for chemotherapy if the chorionic gonadotropin hormone level falls slowly

2 The reasons for postponing another pregnancy for an entire year

An 11-year-old client is admitted with enlarged supraclavicular lymph nodes, fatigue, and low-grade fever. She also has a persistent nonproductive cough. In light of these findings, the nurse knows to gear education toward preparation for which therapies? 1 Intravenous (IV) fluids and nutritional therapy 2 Bloodwork and oxygenation therapy 3 IV fluids and antibiotic therapy 4 Computed tomography (CT) and lymph node biopsy

4 Computed tomography (CT) and lymph node biopsy

An older adult has undergone chemotherapy. Which intervention would be beneficial for the client in preventing the risk of a potentially contagious common viral infection? 1 Administering famciclovir 2 Administering gabapentin 3 Administering the zoster vaccine 4 Administering vaccines for herpes simplex virus type 1 (HSV-1) and type 2 (HSV-2)

3 Administering the zoster vaccine Herpes zoster or shingles is the most common viral infection that is potentially contagious to anyone who has not had varicella or who is immunosuppressed, such as clients on chemotherapy. Incidence increases with age mainly for adults 50 years old or older. Administering the zoster vaccine helps in preventing the risk of shingles. Famciclovir is an antiviral drug that helps in reducing the symptoms of the infection. Gabapentin is prescribed to clients suffering from neuralgia caused by shingles. Vaccines for HSV-1 and HSV-2 are not available.

A 1-year-old child has a congenital cardiac malformation that causes right-to-left shunting of blood through the heart. What clinical finding should the nurse expect? 1 Proteinuria 2 Peripheral edema 3 Increased hematocrit 4 Absence of pedal pulses

3 Increased hematocrit Polycythemia, reflected in an increased hematocrit reading, is a direct attempt by the body to compensate for the decrease in oxygen to all body cells caused by the mixture of oxygenated and deoxygenated circulating blood. Proteinuria is not a characteristic of heart malformations that cause right-to-left shunting of blood; nor is edema. An absence of pedal pulses is characteristic of coarctation of the aorta, an obstructive malformation.

Which assessment finding in a client signifies a mild form of hypocalcemia? 1 Seizures 2 Hand spasms 3 Severe muscle cramps 4 Numbness around the mouth

A numbness or tingling sensation around the mouth or in the hands and feet indicates mild-to-moderate hypocalcemia. Seizures, hand spasms, and severe muscle cramps are associated with severe hypocalcemia.

suction curettage (vacuum aspiration)

A relatively quick procedure in which a tube is used to suction tissue from the uterine walls. Typically used in the first 6 to 12 weeks of pregnancy

Methadone (Dolophine)

Abstinence maintenance med. Binds with opiate receptors in CNS to produce analgesic and euphoric effects. Prevents withdrawal symptoms in clients who were addicted to opiate drugs. Precautions/interactions: do not use in clients who have severe asthma, chronic respiratory disease, or history of head injury. Side/adverse effects: sedation, respiratory depression, paradoxical CNS excitation.

A nurse explains preterm labor to a group of nursing students. Which description of preterm labor indicates effective teaching? 1 Preterm labor is defined as contractions during the delivery. 2 Preterm labor is defined as contractions induced by prostaglandins. 3 Preterm labor is defined as contractions between 20 and 36 weeks of gestation. 4 Preterm labor is defined as contractions occurring before 20 weeks of gestation.

3 Preterm labor is defined as contractions between 20 and 36 weeks of gestation.

Which type of biopsy would the nurse identify as required for the removal of entire lesions on the skin? 1 Punch biopsy 2 Shave biopsy 3 Incisional biopsy 4 Excisional biopsy

An excisional biopsy is required to remove entire lesions on the skin. A punch biopsy provides full-thickness skin for diagnostic purposes. A shave biopsy provides a thin specimen for diagnostic purposes. An incisional biopsy is used along with shave and punch biopsies.

Which would the nurse consider to be a potential respiratory system-related complication of surgery? 1 Atelectasis 2 Hyperthermia 3 Wound dehiscence 4 Hypovolemic shock

Atelectasis is a potential complication of the respiratory system that can occur after surgery. Hyperthermia is a potential neuromuscular complication. Wound dehiscence is a potential skin complication. Hypovolemic shock is a cardiovascular complication that can occur after surgery.

Define: enlarged supraclavicular lymph nodes

Enlarged lymph nodes above the collarbone: Enlarged lymph nodes above the collarbone (supraclavicular lymphadenopathy) are always considered abnormal. These generally suggest cancer or an infection in the region close by. Examples include lung infection, lung cancer, lymphoma in the chest cavity, or breast cancer. Pulmonary adenocarcinoma, as well as several other forms of cancer, may metastasize through the thoracic duct and cause enlargement of a left supraclavicular lymph node.

Famciclovir (Famvir)

DNA polymerase inhibitor; used for cold sores, genital sores, shingles, active HSV or HZV, or prophylactically; side effects include headaches and GI effects Antiviral

Which diagnostic test may be used to distinguish vascular from nonvascular structures? 1 Chest X-ray 2 Pulmonary angiogram 3 Computed tomography 4 Magnetic resonance imaging

Magnetic resonance imaging is used for distinguishing vascular from nonvascular structures. An X-ray is useful to screen, diagnose, and evaluate changes in the respiratory system. A pulmonary angiogram is used to visualize pulmonary vasculature and locate obstruction of pathologic conditions. Computed tomography is performed for the diagnosis of lesions difficult to assess by conventional X-ray studies.

A client with a history of endometriosis has abdominal surgery to remove abdominal adhesions. What should this client's postoperative plan of care include? 1 Encouraging the client to ambulate in the hallway 2 Elevating the client's legs by gatching the bed 3 Helping the client dangle her legs over the side of the bed 4 Maintaining the client on bed rest until the dressings have been removed

Muscle contraction during ambulation improves venous return, which prevents venous stasis and thrombus formation. Gatching the bed and dangling the legs each place pressure on the popliteal spaces, limiting venous return and increasing the risk of thrombus formation. Bed rest is associated with venous stasis, which increases the risk of thrombus formation.

A 36-year-old multigravida who is at 14 weeks gestation is scheduled for an alpha-fetoprotein test. She asks the nurse, "What does this test do?" The nurse responds that this test can reveal what? 1 Kidney defects 2 Cardiac anomalies 3 Neural tube defects 4 Urinary tract anomalies

The alpha-fetoprotein test can detect not only neural tube defects, but also Down syndrome and other congenital anomalies. It is a screening test that affords a tentative diagnosis; confirmation requires more definitive testing. Anomalies of the kidneys, heart, and urinary tract are not revealed by the alpha-fetoprotein test.

A client had a gastric bypass procedure to treat morbid obesity. After surgery, the client reports weakness, sweating, palpitations, and dizziness after eating. What should the nurse encourage the client to do? 1 Reduce the intake of protein-rich foods 2 Drink 8 ounces (240 mL) of water with meals 3 Divide the daily caloric intake into six smaller meals 4 Remain in an upright position for one hour after eating

The client's clinical manifestations are related to the dumping syndrome from the gastric bypass procedure. Smaller meals along with other interventions will help minimize this response. After gastric bypass, a bolus of hypertonic fluid enters the intestines before carbohydrates and electrolytes are diluted. Extracellular fluid is drawn into the bowel lumen; this causes a decrease in plasma volume, distention of the bowel lumen, and rapid intestinal transit. Protein intake should be increased, not decreased, to meet energy needs and promote healing. Fluids should be avoided at mealtimes because they increase the volume in the stomach and decrease the transit time of gastric contents moving from the stomach to the intestine, which contributes to dumping syndrome. An upright position decreases the transit time of gastric contents moving from the stomach to the intestines via gravity, which contributes to the dumping syndrome; clients may lie flat after eating for a short time.

Optimal blood pressure for: infants toddlers children 6 to 13 adolescents

The optimal blood pressure of an adolescent is 110/65 mm Hg. The average optimal blood pressure in an infant is 85/54 mm Hg. The average optimal pressure in a toddler is 95/65 mm Hg. The average optimal blood pressure seen in children between the ages of 6 and 13 is 105/65 mm Hg.

Achalasia

absence of peristalsis of the lower esophagus resulting in difficulty swallowing, regurgitation, and sometimes pain