Reduction of Risk Potential

A client has sustained a right tibial fracture and has just had a cast applied. Which instruction should the nurse provide concerning cast care?

"Keep your right leg elevated above heart level."

A nurse uses Nitrazine paper to determine whether a pregnant client's membranes have ruptured. If the membranes have ruptured, the paper will turn which color?

Blue

A client with type 1 diabetes has a highly elevated glycosylated hemoglobin (Hb) test result. In discussing the result with the client, the nurse is most accurate in stating

It tells us about your sugar control over the past 3 months

Which client is at greatest risk for Buerger's disease?

a 29-year-old male with a 14-year history of cigarette smoking.

A client has a positive reaction to the Mantoux test. How should the nurse interpret this reaction? The client has:

been exposed to Mycobacterium tuberculosis. A positive Mantoux skin test indicates that the client has been exposed to tubercle bacilli. Exposure does not necessarily mean that active disease exists. A positive Mantoux test does not mean that the client has developed resistance. Unless involved in treatment, the client may still develop active disease at any time. Immunity to tuberculosis is not possible.

When preparing a multigravid client who has undergone evacuation of a hydatidiform mole for discharge, the nurse explains the need for follow-up care. The nurse determines that the client understands the instruction when she says that she is at risk for developing which problem?

choriocarcinoma

A client undergoes a laryngectomy to treat laryngeal cancer. When teaching the client how to care for the neck stoma, the nurse should include which instruction?

hands

An infant, age 3 months, undergoes surgical repair of a cleft lip. After surgery, the nurse should use which equipment to feed the infant?

rubber dropper

Which activities should the nurse teach the client to do to strengthen the hand muscles in preparation for using crutches?

squeezing a rubber ball

A nurse is reviewing self-care measures for a client with peripheral vascular disease. Which statement indicates proper self-care measures?

"I have my spouse look at the soles of my feet each day."

A client in active labor is planning on epidural anesthesia for labor and birth. After the anesthesiologist has explained the procedure and potential complications, the nurse determines that the client needs further instructions when she makes which statement?

"I may need to lie flat for 6 hours and drink plenty of fluids after I give birth."

A nurse provides preoperative education to a client scheduled to undergo elective surgery. The nurse includes instructions about proper skin care. Which client statement indicates the need for further education?

"On the morning of the surgery, I can shave my surgical area at home to save time."

The nurse is caring for a primagravida in active labor. The provider performs an amniotomy to augment labor. What is the nurse's priority action after the procedure is completed?

Check the fetal heart rate for bradycardia. After a client has an amniotomy, the nurse should ensure that the cord is not prolapsed and that the fetus tolerated the procedure well. The most effective way to do this is to check the fetal heart rate. Fetal well-being is assessed via a nonstress test. Fetal position is determined by vaginal examination. Artificial rupture of membranes does not indicate an imminent birth.

The mother calls the nurse to report that her toddler has just been burned on the arm. What should the nurse should advise the mother to first?

Run cool water over the burned area, and then wrap it in a clean cloth.

A client at 7 weeks' gestation is being treated for a ruptured ectopic pregnancy in the emergency department. The client's vital signs are blood pressure 84/45 mmHg, heart rate 122 beats/min, respiratory rate 26 breaths/min, temperature 98.6°F (36.8°C). What is the nurse's priority?

administering fluid resuscitation and preparing the client for surgery

A client with renal insufficiency is admitted to the hospital with pneumonia. The client is being treated with gentamicin. Which laboratory value should be closely monitored?

blood urea nitrogen (BUN)

A 4-year-old child with suspected leukemia is admitted to the hospital for diagnosis and treatment. What tests will the nurse teach the parents are used in diagnosing leukemia? Select all that apply.

bone marrow aspiration and analysis complete blood count lumbar puncture

A nurse is performing discharge teaching with a client who had a total gastrectomy. Which statement indicates the need for further teaching?

"I will have to take vitamin B12 shots up to 1 year after surgery."

During physical assessment, the nurse should further assess the client for signs of atrial fibrillation when the nurse palpates the radial pulse and notices which signs?

irregular rhythm with pulse rate greater than 100 bpm

An athletic teenager who is diagnosed with infectious mononucleosis is told to avoid contact sports for 3 to 4 weeks. The teenager protests to the nurse and demands to know why sports must be avoided for so long. What is the best response by the nurse?

"Your spleen is enlarged from your illness and could easily rupture with an injury."

When teaching a primigravid client about the diagnostic tests used in pregnancy, the nurse should include which information?

A fetal biophysical profile involves assessments of breathing movements, body movements, tone, amniotic fluid volume, and fetal heart rate reactivity.

The nurse is assessing the lower extremities of the client with peripheral artery disease (PVD). Which findings are expected? Select all that apply.

mottled skin coolness

The nurse teaches the parents of an infant who has had surgery to correct imperforate anus how to position the infant to prevent tension on the perineum. The nurse determines more teaching is need when the parents put the infant in which position?

abdomen, with legs pulled up under the body

Which behavior should cause the nurse to suspect that a client's labor is moving quickly and that the physician should be notified?

an increased sense of rectal pressure

A client is experiencing symptoms of early alcohol withdrawal. The client's blood pressure is 150/85 mm Hg, and the pulse is 98 bpm. What should the nurse do?

Administer lorazepam.

The nurse reviews the daily weights of a breastfeeding term newborn. What conclusion does the nurse make about the weight loss?

Breastfeeding is going as expected.

A multigravid client at 38 weeks' gestation is scheduled to undergo a contraction stress test. What should the nurse include in the explanation as the purpose of this test?

assessment of fetal ability to tolerate labor

A multigravid client at 34 weeks' gestation visits the hospital because she suspects that her water has broken. After testing the leaking fluid with nitrazine paper, the nurse confirms that the client's membranes have ruptured when the paper turns which color?

blue

An elderly client who is receiving steroids has secondary diabetes and chronic kidney disease (CKD) and takes insulin. The client has had episodes of hypoglycemia. The nurse should:

continue to monitor the client's blood glucose values.

When taking a diet history from the mother of a 7-year-old child with phenylketonuria, a report of an intake of which food should cause the nurse to gather additional information?

diet cola

A full-term neonate is suspected of having hydrocephalus. The nurse collects what assessment finding to best assist in confirming the diagnosis?

increasing occipital frontal circumference

Which food should the nurse eliminate from the diet of a client in alcohol withdrawal?

regular coffee

The nurse is monitoring a client during moderate sedation. The client is laying on the gurney with eyes closed and opens the eyes and moans when the nurse touches the shoulder, but not when the nurse says the client's name. The nurse charts the client responds to what type of stimuli?

tactile

A client who was prescribed clozapine 2 months ago arrives in the clinic and informs the nurse that the they have been feeling extremely fatigued and feverish and has a sore throat. The nurse observes that the client has two small ulcerations of the oropharynx. Which does the nurse suspect may be occurring with this client?

agranulocytosis

A client with no known history of peripheral vascular disease comes to the emergency department complaining of sudden onset of lower leg pain. Inspection and palpation reveal absent pulses; paresthesia; and a mottled, cyanotic, cold, and cadaverous left calf. While the physician determines the appropriate therapy, the nurse should

keep the affected leg level or slightly dependent.

A nurse has been asked to insert peripheral I.V. lines in several clients on the nursing unit. Which site would the nurse need to avoid in order to maintain client safety?

the arm of a client where an arteriovenous shunt has been inserted The nurse should avoid the arm with an arteriovenous shunt so the shunt is not jeopardized if the I.V. infiltrates, if the area becomes infected or inflamed, or if a thrombosis develops. The other options are incorrect because they could be used without risk to the client. It would be unsafe to use the affected side of a client who has had a mastectomy, but the unaffected side would be appropriate. The nurse should avoid broken or inflamed skin, but a sunburn without blisters could be considered.

A parent asks, "How should I bathe my baby now that he has had surgery for his inguinal hernia?" Which instruction should the nurse give the mother?

"Give him a sponge bath daily for 1 week."

The nurse is instructing a client on how to care for skin that has become dry after radiation therapy. Which statement by the client indicates that the client understands the teaching?

"It's safe to apply a nonperfumed lotion to my skin."

Having had only one prenatal visit, a 16-year-old primigravida at 37 weeks' gestation is admitted to the hospital in active labor. Her cervix is 7 cm dilated with the presenting part at +1 station. Soon after admission, the nurse observes that the client is hyperventilating. Which action would be most appropriate?

Give the client a paper bag and have her breathe into it.

After the physician explains the prognosis and medical management for atrial septal defect to a primiparous client whose 2-day-old female neonate was diagnosed with this condition, the nurse determines that the mother needs further instructions when she says which of the following?

"About half of the children born with this defect heal spontaneously."

A client has been prescribed a new antihypertensive medication and is reporting dizziness. Which is the best way for the nurse to assess blood pressure?

Assess the blood pressure in the supine, sitting, then standing positions.

An infant is to have moderate sedation for an outpatient procedure. The nurse knows that

the infant should respond to gentle tactile or verbal stimulation.

What assessment data of a laboring woman would require further intervention by the nurse?

maternal heart rate 125 beats/minute

The nurse is caring for a client recovering from moderate sedation for a routine endoscopy without complications. The nurse applies which statement by the client as evidence of understanding the discharge planning?

"I will need a ride home within a few hours of the procedure."

A multigravid client is receiving oxytocin augmentation. When the client's cervix is dilated to 6 cm, her membranes rupture spontaneously with meconium-stained amniotic fluid. Which action should the nurse perform first?

Assess the fetal heart rate.

A 67-year-old client will be discharged to home with imipramine. Which information would be most important for the nurse to include when instructing the client and spouse about the medication?

Avoid alcohol.

The nurse starts an infusion of tissue plasminogen activase (tPA) for a client with a cerebrovascular accident (CVA). What are the priority nursing interventions during treatment with this medication?

Conduct frequent neurologic assessments to determine whether the stroke is evolving or acute complications are developing.

During the nurse's assessment, the newborn wakes and is in a quiet-alert state. The nurse counts the apical pulse to be 157 beats per minute. Which is the most appropriate nursing action?

Document this finding as on the high end of the normal range and plan to reassess.

The nurse observes that the right eye of an unconscious client does not close completely. Which nursing intervention is most appropriate?

Lightly tape the eyelid shut.

A neonate was born to a mother diagnosed with hydramnios in utero. When the first feeding was given, the newborn began coughing, became cyanotic, and was having difficulty breathing.The nurse suspects esophageal atresia. Which is the priority nursing action for this neonate?

Placing the infant in an upright, 60° angle The infant should be placed in an upright, 60° angle so that acid stomach secretions stay in the stomach through the use of gravity. Thios is the priority intervention. Placing the infant in the prone position can cause pressure on the abdomen and increases the chances of aspiration and difficulty breathing.. Procedures to correct the defect may be minimally invasive using a thoracotomy or be performed in stages in more serious cases. The infant should ingest nothing by mouth and a gastrostomy tube may be inserted. IV fluids should be administered to prevent dehydration.

A pregnant client calls the nurse at 22 weeks gestation to report that she is experiencing some edema of her face and hands, with puffiness in her eyelids in the morning. What is the priorityaction by the nurse?

Refer the client to her physician.

The home health nurse is completing a screening for elder abuse during a client visit. Which findings would require action by the nurse? Select all that apply.

The client who is frequently scheduling appointments with their primary care provider.\ A client who reports having excessive sleepiness after their evening medications. A client who is less talkative recently and avoiding eye contact with the nurse.

When giving a client a tube feeding, what should the nurse do first?

Verify position of the tube before beginning feeding.

The nurse is caring for a 70-year-old male client after a colectomy. The client has received chemotherapy prior to surgery and has hypertension and diabetes mellitus. Which factors put this client at risk for sepsis? Select all that apply.

age abdominal surgery diabetes mellitus

A client whose cervix is 10 cm dilated begins to push. The nurse notes early decelerations of the fetal heart rate. The nurse should interpret this finding as being caused by which factor?

fetal head compression

After a gastric cancer resection, a client is scheduled to undergo radiation therapy. What is the most important information the nurse should include in the discharge teaching plan?

how to maintain adequate nutrition

The surgeon prescribes cefazolin 1 g to be given IV at 0730 when the client's surgery is scheduled at 0800. What is the primary reason to start the antibiotic exactly at 0730?

The antibiotic is most effective in preventing infection if it is given 30 to 60 minutes before the operative incision is made.

A client undergoes a total hip replacement. Which statement made by the client indicates to the nurse that the client requires further teaching?

"I don't know if I'll be able to get off that low toilet seat at home by myself."

When assessing a client with chest trauma, the nurse notes that the client is taking small breaths at first, then bigger breaths, and then a couple of small breaths, then 10 to 20 seconds of no breaths. How should the nurse should record the breathing pattern?

Cheyne-Stokes respiration

What site should the nurse use to obtain a blood sample to screen a neonate for phenylketonuria (PKU)?

heel

A client is seen in the clinic for newly diagnosed hypothyroidism. Which topics should the nurse include in a client teaching plan? Select all that apply.

high-fiber, low-calorie diet use of stool softeners thyroid hormone replacements