Saunders NCLEX Questions
The nurse is assessing a client diagnosed with posttraumatic stress disorder (PTSD). The nurse knows that according to current references, PTSD signs/symptoms can be grouped into which three main categories? Select all that apply.
Acute stress can lead to posttraumatic stress disorder (PTSD) if symptoms extend beyond 1 month. The three main categories are avoidance, hyperarousal, and reexperiencing. Avoidance occurs when the client changes routines to escape similar situations to the trauma. Hyperarousal occurs when the client has difficulty concentrating or falling asleep, being easily startled, feeling tense, and exhibits angry outbursts. These can combine to make it difficult for victims to complete normal daily tasks. Reexperiencing is repeated reliving of the event that interferes with daily activity. This category includes flashbacks, frightening thoughts, recurrent memories or dreams, and physical reactions to situations that remind you of the event. Anxiety, flashbacks, and difficulty concentrating are behaviors included within the three main categories.
A client is receiving heparin sodium by continuous intravenous (IV) infusion. The licensed practical nurse (LPN) is concerned that the client received a bolus of medication when the tubing was removed from the IV pump during a gown change. The LPN immediately notifies the registered nurse or health care provider and then checks to see whether which medication is available in the medication supply area in case it is prescribed?
If the tubing is removed from an IV pump and the tubing is not clamped, the client will receive a bolus of the solution and the medication contained in the solution. The client who receives a bolus dose of heparin is at risk for bleeding. A partial thromboplastin time (PTT) will be drawn and evaluated. If the results of the PTT are too high, a dose of protamine sulfate, the antidote for heparin, may be prescribed. Aminocaproic acid is an antifibrinolytic (inhibits clot breakdown). Enoxaparin is an anticoagulant. Vitamin K is the antidote for warfarin sodium.
The client presents to the pediatrician's office with a temperature of 103° F for the past 3 days. The nurse also observes conjunctivitis without discharge, cracked lips, enlarged reddened papilla on the tongue, inflamed oropharyngeal membranes, and enlarged nontender lymph nodes. Using situation, background, assessment, and recommendation (SBAR communication), which statements and/or questions should the nurse use in communication with the primary health care provider regarding this client's condition? Select all that apply.
Kawasaki's disease is a disease that affects the cardiovascular system leading to fever, oropharyngeal inflammation, enlarged lymph nodes, fissured lips, conjunctivitis, rash, peeling of palms and soles, irritability, and aneurysms. The nurse should communicate to the provider the situation, background, assessment, and recommendation (SBAR communication). The nurse should say, "This client is a 4-year-old male who presented to the clinic with a temperature of 103° F for the past 3 days. I observed this client to have conjunctivitis without discharge, cracked lips, enlarged reddened papilla on the tongue, inflamed oropharyngeal membranes, and enlarged nontender lymph nodes. I am concerned this client has Kawasaki's disease. Can you please come assess this client? I think this client is at risk for aneurysm and thrombi development and should be taken to the hospital immediately." The nurse should not say, "It is most likely Kawasaki disease because it is the leading cause of acquired cardiovascular disease in the U.S." Although this statement is true, it is not necessary and should not be included in SBAR communication.
A primary health care provider prescribes an intramuscular (IM) dose of 250,000 units of penicillin G benzathine. The label on the 10-mL ampule sent from the pharmacy reads penicillin G benzathine 300,000 units/mL. How much medication will the nurse prepare to administer the correct dose? Fill in the blank. Record your answer to one decimal place.
0.8 mL 250,000 units ------------- × 1 mL = mL per dose 300,000 units 250,000 ------- = 0.83 = 0.8 mL 300,000
The nurse is collecting data regarding the motor development of a 24-month-old child. Based on the age of the child, the nurse expects to note which highest level of developmental milestone?
A 24-month-old would be able to use a doorknob to open a door. At age 15 months, the child could build a tower of two blocks. At age 30 months, the child would be able to snap large snaps and put on simple clothes independently.
The nurse is teaching a hospitalized client who has had aortoiliac bypass grafting about measures to improve circulation. The nurse should tell the client to do which?
A graft can become clotted from any form of pressure that results in impaired blood flow through the graft. Positions and movements to be avoided include bending at the hip or knee, crossing the knees or ankles, or the use of a knee gatch or pillows under the knees.
A child is diagnosed with chicken pox. The nurse collects data regarding the child. Which finding is characteristic of chicken pox?
A macular rash that first appears on the trunk and scalp and then moves to the face and the extremities is a characteristic of chicken pox. Pseudomembrane formation in the throat is characteristic of diphtheria. A maculopapular or petechial rash primarily on the extremities is characteristic of Rocky Mountain spotted fever. Small red spots with a bluish-white center and red base are known as Koplik spots and are characteristic of measles.
A topical corticosteroid is prescribed by the primary health care provider for a child with atopic dermatitis (eczema). Which instruction should the nurse give the parent about applying the cream?
Atopic dermatitis is a superficial inflammatory process involving primarily the epidermis. A topical corticosteroid may be prescribed and should be applied sparingly (thin layer) and rubbed into the area thoroughly. The affected area should be cleaned gently before application. A topical corticosteroid should not be applied over extensive areas. Systemic absorption is more likely to occur with extensive application.
The nurse is caring for a client with emphysema receiving oxygen. The nurse should consult with the registered nurse if the oxygen flow rate exceeded how many L/min of oxygen?
Between 1 L/min and 3 L/min of oxygen by nasal cannula may be required to raise the PaO2 level to 60 mm Hg to 80 mm Hg. However, oxygen is used cautiously in the client with emphysema and should not exceed 2 L/min unless specifically prescribed. Because of the long-standing hypercapnia that occurs in this disorder, the respiratory drive is triggered by low oxygen levels rather than by increased carbon dioxide levels, which is the case in a normal respiratory system.
The nurse is initiating cardiopulmonary resuscitation on an adult client. The nurse should place the hands in which position to begin chest compressions?
Chest compressions are done by placing the hands on the lower half of the sternum. The locations in options 2, 3, and 4 would not provide effective chest compressions.
The nurse is reviewing instructions to a parent of a 6-year-old on how to prevent influenza. Which statement by the parent indicates a need for further teaching?
Children who have influenza should be kept home and away from other children until they are fever-free without the use of antipyretics. Influenza may be prevented with the annual vaccine, by avoiding other children who are sick, and with frequent hand washing.
The nurse is monitoring the behavior of the client and understands that the client with anorexia nervosa manages anxiety by which action?
Clients with anorexia nervosa have the desire to please others. Their need to be correct or perfect interferes with rational decision-making processes. These clients are moralistic. Rules and rituals help the clients manage their anxiety.
A client with multiple sclerosis is receiving diazepam, and the home care nurse reinforces instructions to the client regarding the side effects of the medication. The nurse tells the client that which is a side effect of this medication?
Incoordination and drowsiness are common side effects resulting from this medication. Insomnia, inability to urinate and increased salivation are unrelated to the use of this medication.
A hospitalized client with heart disease who is taking digoxin has a digoxin level prescribed. The level is elevated above normal. Based on this finding the nurse plans to notify the registered nurse and primary health care provider (PHCP) and anticipates which additional interventions will be prescribed? Select all that apply.
Digoxin is a cardiac glycoside that is used as a second-line medication to treat heart failure. It affects the electrical and mechanical actions of the heart and can reach toxic levels easily. An elevated digoxin level is digoxin toxicity. Digoxin toxicity with cardiac dysrhythmias is enhanced by hypokalemia so the electrolytes, especially potassium, should be monitored. Digoxin is excreted through the kidneys so renal function should be determined by the BUN and creatinine levels. The client should be placed on a cardiac monitor so the client can be assessed for dysrhythmias. A repeat digoxin level is not needed because digoxin has a long half-life and the result would not be noticeably different so soon. An additional dose should not be given due to the elevated digoxin level.
Which should be the anticipated therapeutic outcome of an escharotomy procedure performed for a circumferential arm burn?
Escharotomies are performed to alleviate the compartment syndrome that can occur when edema forms under nondistensible eschar in a circumferential burn. Escharotomies are performed through avascular eschar to subcutaneous fat. Although bleeding may occur from the site, it is considered a complication rather than an anticipated therapeutic outcome. The formation of granulation tissue is not the intent of an escharotomy, and escharotomy will not affect the formation of edema.
The nurse reinforces dietary instructions to a client at risk for hypokalemia about the foods high in potassium that should be included in the daily diet. The nurse determines the client has understood if the client plans to include which foods in the diet? Select all that apply.
Foods that are high in potassium include bananas, cantaloupe, kiwifruit, oranges, and dried fruits such as raisins. Fruits low in potassium include apples, cherries, grapefruit, canned peaches, pineapple, and cranberries.
The nurse has reinforced instructions to a client regarding the method for instilling eye drops into the left eye. The nurse determines that the client needs further teaching if the client does which during a return demonstration?
It is correct procedure for the client to either lie down or sit with the head tilted back. The thumb or finger is used to pull down on the lower lid. The client holds the bottle like a pencil (tip facing downward) and squeezes the bottle so that the drop falls into the sac. The client then gently closes the eye. An alternative method for clients who blink very easily is to place the client in the supine position with the head turned to one side. The eye to be used is uppermost. The client squeezes the drop onto the inner canthus. The client turns from this side to the other while blinking. Surface tension and gravity then cause the drop to move into the conjunctival sac.
The nurse has a prescription to give a client a scheduled dose of digoxin. Before administering the medication, the nurse routinely screens for which signs/symptoms that could indicate early signs of digoxin toxicity?
Loss of appetite and nausea are early signs of digoxin toxicity. Other signs of digoxin toxicity include bradycardia, visual alterations (e.g., green and yellow vision or seeing spots or halos), confusion, vomiting, or diarrhea. The other options are incorrect.
The nurse inspects the skin of a client receiving external radiation therapy and documents a finding as moist desquamation. The nurse understands that moist desquamation is best described as which?
Moist desquamation occurs when the basal cells of the skin are destroyed. The dermal level is exposed, which results in the leakage of serum. Reddened skin, a rash, and dermatitis may occur with external radiation but are not described as moist desquamation.
Which safety measures should be implemented at delivery and when working in the newborn nursery? Select all that apply.
Newborn safety and abduction prevention are a major responsibility for nurses working in the newborn nursery. Standard precaution guidelines are always followed to prevent transmission of bacteria and other illnesses to infants. Safety precautions to prevent infant abduction include footprinting the infant along with fingerprinting the mother on the identification card, as well as placing bracelet identification on the mother and infant immediately following delivery. Educating parents to only release their infant to those wearing proper identification is key in preventing infant abductions in the inpatient situation. Bassinets are to be 3 feet apart, not 1 foot apart.
A client newly diagnosed with chronic kidney disease will be receiving peritoneal dialysis. During the infusion of the dialysate, the client complains of abdominal pain. Which action by the nurse is appropriate?
Pain during the inflow of dialysate is common during the first few exchanges because of peritoneal irritation; however, it disappears after a week or two. The infusion amount should not be decreased, and the infusion should not be slowed or stopped.
The nurse prepares to administer a pancreatic enzyme powder to the child with cystic fibrosis (CF). Which food item should the nurse mix with the medication?
Pancreatic enzyme powders are not to be mixed with hot foods or foods containing tapioca or other starches. Enzyme powder should be mixed with nonfat, nonprotein foods such as applesauce. Pancreatic enzymes are inactivated by heat and are partially degraded by gastric acids.
The nurse is caring for a new postoperative client and is monitoring the client for signs of shock. The nurse monitors for which signs of this postoperative complication?
Postoperative hypotension or shock can have numerous causes such as inadequate ventilation, side effects of anesthetic agents or preoperative medications, and fluid or blood loss. The symptoms of shock include hypotension; tachycardia; cold, moist, pale, or cyanotic skin; and increased restlessness and apprehension.
A pregnant client asks the nurse in the clinic when she will be able to start feeling the fetus move. The nurse responds by telling the mother that fetal movements will be noted between which weeks of gestation?
Quickening is fetal movement that usually first occurs between 16 and 20 weeks' gestation. The expectant mother first notices subtle fetal movements during this time, and these gradually increase in intensity. Options 1, 2, and 3 are incorrect; these gestational time frames are too early for quickening.
An intoxicated client is brought to the emergency department by local police. The client is told that the primary health care provider (PHCP) will be in to see the client in about 30 minutes. The client becomes very loud and offensive and wants to be seen by the PHCP immediately. The nurse assisting to care for the client should take which appropriate nursing intervention?
Safety of the client, other clients, and staff is of prime concern. Option 3 is in effect an isolation technique that allows for separation from others and provides for a less stimulating environment where the client can maintain dignity. When dealing with an impaired individual, trying to talk may be out of the question. Waiting to intervene could cause the client to become even more agitated and a threat to others. Option 4 would only further aggravate an already agitated individual.
The nurse is reinforcing instructions to the mother of a preschool child who was recently diagnosed with pediculosis capitis (head lice). Which item should be included in discussions to prevent a reinfestation?
The adult louse can survive up to 48 hours away from a host, although nits can hatch in 7 to 10 days if they are shed into the environment. Thus, 2 weeks represents a safe interval of time that prevents reinfestation from occurring. Hot water and hot air should be used in the washer and dryer. Shaving the hair is unnecessary with proper treatment and would have an adverse psychological effect on the child. Insecticides can endanger children and animals and should not be sprayed on furniture and beds.
The nurse has given the client diagnosed with hepatitis instructions about post discharge management during convalescence. The nurse determines a need for further teaching if the client makes which statement? 1."I should avoid alcohol and aspirin." 2."I should eat a high-carbohydrate, low-fat diet." 3."I should resume a full activity level within 1 week." 4."I should take the prescribed amounts of vitamin K."
The client with hepatitis is easily fatigued and may require several weeks to resume a full activity level. It is important for the client to get adequate rest so that the liver may heal. The client should take in a high-carbohydrate and low-fat diet. The client should avoid hepatotoxic substances, such as aspirin and alcohol. If prescribed for prolonged clotting times the client should take vitamin K
The nurse is preparing for the admission of an infant with a diagnosis of bronchiolitis caused by the respiratory syncytial virus (RSV). Which interventions should be included in the plan of care? Select all that apply.
The infant with RSV should be isolated in a private room or in a room with another child with RSV. The infant should be placed in a room near the nurses' station for close observation. The infant should be positioned with the head and chest at a 30- to 40-degree angle and the neck slightly extended to maintain an open airway and to decrease pressure on the diaphragm. Cool, humidified oxygen is delivered to relieve dyspnea, hypoxemia, and insensible water loss from tachypnea. Contact precautions (wearing gloves and a gown) reduce the nosocomial transmission of RSV.
The nurse prepares to administer digoxin to a 3-year-old with a diagnosis of heart failure and notes that the apical heart rate is 120 beats per minute. Which nursing action is appropriate?
The normal apical heart rate for a 3-year-old is 80 to 125 beats per minute. Because the apical heart rate is within normal range, options 1, 3, and 4 are inappropriate.
An older client has been prescribed digoxin. The nurse determines that which age-related change would place the client at risk for digoxin toxicity?
The older client is at risk for medication toxicity because of decreased lean body mass and an age-associated decreased glomerular filtration rate. Although the other changes identify age-related changes that occur in the older client, they are not specifically associated with this risk.
The nurse is checking a client's record for probable signs of pregnancy. Which are the probable signs of pregnancy that the nurse should note? Select all that apply.
The probable signs of pregnancy include uterine enlargement; Hegar's sign (the compressibility and softening of the lower uterine segment that occurs at about week 6); Goodell's sign (the softening of the cervix that occurs at the beginning of the second month of pregnancy); Chadwick's sign (the violet coloration of the mucous membranes of the cervix, vagina, and vulva that occurs at about week 4); ballottement (the rebounding of the fetus against the examiner's fingers on palpation); Braxton Hicks contractions; and a positive pregnancy test that measures for human chorionic gonadotropin. Positive signs of pregnancy include a fetal heart rate that is detected by an electronic device (Doppler transducer) at 10 to 12 weeks' gestation and by a nonelectronic device (fetoscope) at 20 weeks' gestation; active fetal movements that are palpable by the examiner; and an outline of the fetus via radiography or ultrasound.
The nurse reinforces instructions to the client prescribed to take cyclosporine oral solution. Which instruction should the nurse primarily include?
To improve palatability, the client should be taught to mix the concentrated medication solution with chocolate milk or orange juice just before administration. Grapefruit juice can raise cyclosporine levels. The client is instructed to dispense the oral liquid into a glass container using a specially calibrated pipette; mix it well and drink it immediately; fill the container with a diluent such as water and drink it to ensure ingestion of the complete dose; dry the outside of the pipette and return to its cover for storage.
A 3-year-old child is hospitalized because of persistent vomiting. Which conditions should the nurse expect this child to be high risk for? Select all that apply.
Vomiting will cause the loss of hydrochloric acid and subsequent metabolic alkalosis. Metabolic acidosis would occur in a child experiencing diarrhea because of the loss of bicarbonate. The child who is vomiting is also at risk for fluid volume deficit or dehydration. Diarrhea may not accompany vomiting. Hyperactive bowel sounds are not specifically associated with vomiting.
The nurse has been asked to serve on the health care facility ethics committee and knows that this committee serves which purposes? Select all that apply.
The purposes of an ethics committee include processing ethical dilemmas, providing education, and providing policy recommendations and case consultations. An ethics committee would not provide care for aging clients or approve emergency mental health commitment.
The nurse is caring for a client who verbalizes a need to increase her self-esteem. Which action should the nurse plan to assist the client in achieving the goal of gaining self-esteem? Verbalize feelings of being unloved. 2. Maintain a well-groomed appearance. 3. Institute measures to prevent tooth decay. 4. Maintain a daily diary of negative feelings.
The client may demonstrate an increased feeling of self-esteem through maintaining a well-groomed outward appearance. Options 1 and 4 focus on negative issues and would be avoided. Option 3 is indirectly related to self-esteem.
The nurse who works on the night shift enters the medication room and finds a coworker with a tourniquet wrapped around the upper arm. The coworker is about to insert a needle attached to a syringe containing a clear liquid into the antecubital area. Which action would be the appropriate initial action by the nurse?
Nurse practice acts require reporting impaired nurses. The board of nursing has jurisdiction over the practice of nursing and may develop plans for treatment and supervision. This incident needs to be reported to the nursing supervisor, who will then report to the board of nursing and other authorities as required. Option 2 is not the appropriate action. Option 3 is not an initial action. Security may be called if a disturbance occurs, but no data in the question support this. Therefore, this is not the appropriate initial action.
The nurse working in the day care center is told that a child with autism will be attending the center. The nurse collaborates with the staff of the day care center and assists in planning activities that will meet the child's needs. The nurse understands that the priority consideration in planning activities for the child is to ensure which need is met?
Safety with all activities is a priority in planning activities with the child. The child with autism is unable to anticipate danger, has a tendency for self-mutilation, and has sensory-perceptual deficits. Although providing social interactions, verbal communications, and familiarity and orientation are also appropriate interventions, the priority is safety.
A client arrives in the emergency department with an eye injury resulting from metal fragments that hit the eye while the client was drilling into metal. The nurse checks the eye and notes small pieces of metal floating on the eyeball. Which action should the nurse take first?
Surface foreign bodies often are removed simply by irrigating the eye with sterile normal saline. The nurse would not use clamps because this risks causing further injury to the eye. Placing an eye patch would not provide relief for the problem. Visual acuity tests are not the priority at this time and might not be feasible because the client most likely has excessive blinking and tearing as well.
A client receiving total parenteral nutrition (TPN) asks the nurse if he has developed diabetes when the capillary blood glucose level is monitored and he is given insulin. The nurse explains that which is the reason for monitoring glucose levels and administering insulin?
TPN contains a high concentration of glucose and also amino acids, which are proteins. With a continuous infusion, the body does not produce enough insulin to use the glucose effectively. The glucose is monitored usually around the clock if the client is not eating. Fast, or rapid-acting, insulin is administered according to the client's capillary blood glucose level. TPN does not impair pancreatic function or raise cortisol levels. TPN does increase the risk for infection, which often raises glucose levels, but there is no actual infection.
A manic client is placed in a seclusion room after an outburst of violent behavior, including physical assault on another client. As the client is secluded, which action should the nurse perform?
The client needs to be removed to a nonstimulating environment because of the client's behavior. Options 2, 3, and 4 are nontherapeutic. Additionally, option 2 implies punishment. It is best to directly inform the client of the purpose of the seclusion.
A postoperative client has a prescription to receive an intravenous (IV) infusion of 1000 mL normal saline solution over a period of 10 hours. The drop (gtt) factor for the IV infusion set is 15 gtts/mL. The nurse sets the flow rate at how many drops per minute? Fill in the blank.
25 gtts/minute Formula: Total volume × gtt factor ------------------------- = gtt/ minute Time in minutes 1000 mL × 105gtt/mL ------------------- = 25 gtt/min600 minutes
The nurse is reading the primary health care provider's (PHCP) documentation regarding a pregnant client and notes that the PHCP has documented that the client has a platypelloid pelvic shape. The nurse recognizes which characteristics to be present in the platypelloid pelvis? Select all that apply. 1. Shallow depth 2.Wide suprapubic arch 3.Deep, curved sacral area 4.Compatible with vaginal delivery 5.Flattened anteroposteriorly and wide transversely
A gynecoid pelvic shape is rounded with a wide pubic arch and is the most favorable pelvic shape for a vaginal birth. The platypelloid pelvic shape has a shallow depth, wide suprapubic arch, may be compatible with vaginal delivery, and has a flattened anteroposterior diameter. The gynecoid pelvis is the only pelvic type to have a deep, curved sacral area.
A mother tells the pediatrician's office nurse that she is concerned because her children must let themselves into the house after school each day while she is at work and they feel isolated and fearful. The nurse should suggest which to the mother?
A mother tells the pediatrician's office nurse that she is concerned because her children must let themselves into the house after school each day while she is at work and they feel isolated and fearful. The nurse should suggest which to the mother?
The nurse is planning to administer amlodipine to a client. The nurse should plan to check which before giving the medication?
Amlodipine is a calcium channel blocker. This medication decreases the rate and force of cardiac contraction. Before administering a calcium channel blocking agent, the nurse should check the blood pressure and heart rate, which could both decrease in response to the action of this medication. This action will help to prevent or identify early problems related to decreased cardiac contractility, heart rate, and conduction.
A 50-year-old client with a history of cardiac disease has been admitted to the intensive care unit (ICU) with a diagnosis of acute alcohol withdrawal. Which initial client data should the nurse expect to find? Select all that apply.
Clients over 40 years of age with a history of cardiac disease who are experiencing acute alcohol withdrawal should be admitted to the cardiac care unit. They will exhibit irritability, agitation, anxiety and tremors, confusion, hallucinations, and delusions. Insomnia, diaphoresis, tachycardia, fever and seizures, and nausea and vomiting will also be present. Because of the history of alcoholism and related cirrhosis, an increased serum total bilirubin level is expected. Hypertension and not hypotension occurs, and because of associated liver damage, the ammonia level is increased and not decreased.
A client with type 1 diabetes mellitus has had a left above-the-knee amputation. The nurse carefully inspects the residual limb for which complication because of the history of diabetes?
Clients with diabetes mellitus are at greater risk of wound infection and separation of wound edges leading to delayed wound healing. Postoperative residual limb edema and hemorrhage are complications in the immediate postoperative periods that apply to any client with an amputation. Pain is also considered normal, although the nurse carefully administers analgesia to minimize it.
A client is brought to the emergency department with suspected diabetic ketoacidosis (DKA). Which finding should the nurse note as being consistent with this diagnosis?
In DKA the blood glucose level is higher than 250 mg/dL, and ketones are present in the blood and urine. The arterial pH is low (less than 7.35.) The plasma bicarbonate is also low. The client would exhibit polyuria and Kussmaul's respirations. The potassium level usually is elevated as a result of dehydration.
A hospitalized client with coronary artery disease complains of substernal chest pain. After checking the client's heart rate and blood pressure, the nurse administers nitroglycerin, 0.4 mg sublingually. After 5 minutes, the client states, "My chest still hurts." If the vital signs have remained stable, which action should the nurse perform?
Nitroglycerin tablets usually are prescribed 1 every 5 minutes as needed (PRN) for chest pain, for a total dose of 3 tablets. Waiting 10 minutes is inappropriate if the client is having chest pain. Oxygen at 10 L is an unsafe dose. There is no need to call the resuscitation team at this time.
The nurse is preparing to administer pentamidine isethionate to an assigned client by the intramuscular route. Which most appropriate parameter should the nurse monitor while administering this medication?
Pentamidine isethionate is an anti-infective medication. Life-threatening and fatal hypotension can occur following the administration of this medication. The client must be in a supine position with frequent BP checks following administration. Options 1, 2, and 4 are not associated with the administration of this medication.
A client scheduled for a pulmonary angiography is fearful about the procedure and asks the nurse if the procedure involves significant pain and radiation exposure. The nurse gives a response to the client that provides reassurance, based on which understanding?
Pulmonary angiography involves minimal exposure to radiation. The procedure is painless, although the client may feel discomfort with insertion of the needle for the catheter that is used for dye injection. No and moderate pain and no exposure to radiation are incorrect.
The nurse is monitoring a client at risk for postpartum endometritis. Which observation noted during the first 24 hours after delivery supports this diagnosis?
Signs/symptoms in the postpartum period heralding endometritis include delayed uterine involution, foul-smelling lochia, tachycardia, abdominal tenderness, and temperature elevations up to 104° F. This intrauterine infection may lead to further maternal complications such as infections of the fallopian tubes, ovaries, and blood (sepsis). Options 2, 3, and 4 represent normal maternal physiological responses in the immediate postpartum period. These changes represent the normal adaptation of reproductive organs (involution) and maternal physiological responses because of the decreased hormonal levels and fluid losses that occur during labor.
Two weeks following delivery, a client experiences subinvolution of the uterus. Which findings indicate subinvolution? Select all that apply.
Subinvolution is a condition in which the uterus does not return to its normal size after childbirth. Manifestations include fever, pelvic pain or heaviness, red lochia (or return of bleeding after it has changed), or foul-smelling vaginal discharge. The uterine fundus is no longer palpable by 12 days postpartum; this is a normal finding and not indicative of subinvolution. Lochia alba is normal vaginal drainage at this time following delivery.
A client who has calcium phosphate kidney stones tells the nurse, "Tell me what I can do, so that I never have this pain again." Which instructions should the nurse plan to include in the reinforcement of dietary instructions? Select all that apply.
The client should decrease sodium intake because sodium decreases the kidney tubular calcium reabsorption, which will result in increased phosphorus. Limiting whole grains can aid in the reduction of urinary phosphate. Limiting proteins can decrease the acidity of urine, which prevents calcium precipitation. Spinach should be limited in clients with calcium oxalate calculi, not calcium phosphate calculi. Organ meat should be limited in clients with uric acid calculi stones because of purine content.
The nurse is preparing a discharge plan for a client who attempted suicide. The nurse understands that the plan of care should focus on which intervention?
The client's plan of care needs to focus on contracts and immediate available crisis resources. Crisis times may occur between appointments. Contracts facilitate clients feeling responsibility for keeping a promise, which gives the client control. Option 4 is unrealistic. Providing phone numbers (option 2) will not ensure available and immediate crisis intervention.
The nursing instructor has taught a lecture on the reproductive cycle of the female and asks a nursing student to identify the functions of the vagina. The student correctly responds by identifying which functions? Select all that apply.
The pelvis is a bony structure that supports and protects the lower abdominal and internal reproductive organs. The vagina is the female organ of coitus, allows discharge of the menstrual flow, and assists in the passage of the fetus from the uterus to outside the mother's body during childbirth. The fallopian tubes are lined with folded epithelium containing cilia that beat rhythmically toward the uterine cavity to propel the ovum through the tube. The functions of the ovaries include sex hormone production and maturation of an ovum during each reproductive cycle.
The nurse is monitoring a client with a diagnosis of gastric ulcer. Which finding would indicate perforation of the ulcer?
Perforation is a surgical emergency. It is characterized by sudden, sharp, intolerable severe pain beginning in the midepigastric area and spreading over the abdomen, which becomes rigid and boardlike. Nausea and vomiting may occur with peptic ulcer disease but does not indicate perforation. Tachycardia may occur as hypovolemic shock develops. Numbness in the legs is not an associated finding.
The nurse is caring for a client who had a total knee replacement and was put on a continuous passive motion (CPM) machine in the postanesthesia care unit (PACU). What are some of the actions the nurse needs to monitor to operate this machine? Select all that apply.
While not as commonly used today, the CPM machine keeps the prosthetic knee in motion and may prevent the formation of scar tissue which could decrease knee mobility and increase postoperative pain. It should be used as much as the client can tolerate. The nurse needs to make sure that the machine is well padded and assess the client's response to the machine. Also, the machine needs to be turned off while the client is having a meal in bed. It is very important that the nurse ensures that the joint being moved is positioned properly on the machine. The cycle and range-of-motion settings must be checked every 8 hours and not once a day. When the machine is not in use, it should not be stored on the floor. If the client is confused, place the controls to the machine out of his or her reach.
An Appalachian family has brought a toddler to the emergency department with a fractured arm. The nurse knows that nonverbal communication is important to evaluate with assessing the family. Which factors are involved in nonverbal communication? Select all that apply.
Communication involves nonverbal messages, which include touch, facial expressions, eye behavior, body posture, and the use of space. Nonverbal communication is powerful and honest, its importance and meaning vary among cultures; therefore, it is essential that the nurse has an awareness of the role that nonverbal cues may have in the communication process. Intonation is specific to verbal communication.
The client is receiving external radiation to the neck for cancer of the larynx. The nurse monitors the client knowing that which are side/adverse effects of the external radiation? Select all that apply.
External radiation is used to treat cancer in a specific area by emission of ionizing radiation beams that destroy cancer cells and have minimal damage to the surrounding normal cells. The client receiving external radiation experiences both general side/adverse effects such as fatigue, nausea, anorexia and localized side/adverse effects in the specific area receiving radiation. A client who is receiving radiation to the larynx is most likely to experience a sore throat and dry, reddened skin in the throat area. Diarrhea or constipation occur with radiation to the gastrointestinal (GI) tract. Dyspnea may occur with lung involvement.
A client receiving therapy with carbidopa/levodopa is upset and tells the nurse that his urine has turned a darker color since he began to take the medication. The client wants to discontinue its use. In formulating a response to the client's concerns, how does the nurse interpret this development?
With carbidopa/levodopa therapy, a darkening of the urine or sweat may occur. The client should be reassured that this is a harmless effect of the medication, and its use should be continued. Options 1, 2, and 4 are incorrect interpretations.
A term client is being seen for a final prenatal appointment. The clinic nurse is making arrangements for the client to be admitted to the labor and delivery unit for an oxytocin induction. The nurse reviews the client's chart and should contact the primary health care provider regarding which documented finding to verify the oxytocin induction?
A previous classical vertical uterine incision is associated with a higher incidence of uterine rupture in subsequent pregnancies and may prohibit the use of an oxytocin induction. An L/S ratio of 2:1 indicates fetal lung maturity and is not a contraindication to an oxytocin induction. Gestational diabetes in a term pregnancy could warrant an induction of labor. A hemoglobin of 11.6 g/dL, is considered normal for a pregnant woman and would not interfere with scheduling an induction.
The nurse is assisting in the care of a client with a left foot that sustained a crush injury. The nurse determines that the client developed third spacing of body fluid based on which observation?
Fluid that shifts into the interstitial spaces and remains there is referred to as third-space fluid. This fluid is physiologically useless because it does not circulate to provide nutrients for the cells. Common sites for third spacing include tissues where an injury or burn occurred, the pleural and peritoneal cavities, and the pericardial sac. Clients at high risk for third spacing include older adults and those with liver or kidney disease, major trauma, burns, sepsis, major surgery, malignancy, gastrointestinal malabsorption, and malnutrition. The left foot that was crushed and is grossly edematous is an example of third spacing of body fluid. The blood pressure represents intravascular fluid status. Normal skin turgor and slight abdominal distention are not examples of third-spacing of fluids.
A child with a diagnosis of a hernia has been scheduled for a surgical repair in 2 weeks. The nurse reinforces instructions to the parents about the signs of possible incarcerated hernia. The nurse tells the parents that which manifestation requires primary health care provider (PHCP) notification by the parents?
The parents of a child with a hernia need to be instructed about the signs of an incarcerated hernia. These signs include irritability, tenderness at the site of the hernia, anorexia, abdominal distension, and difficulty defecating. The parents should be instructed to contact the PHCP immediately if an incarcerated hernia is suspected. These signs may lead to a complete intestinal obstruction and gangrene. Diarrhea, increased flatus and constipation are not associated with an incarcerated hernia.
An oriented client is scheduled to have aversion therapy to change behavior. Before initiating any aversive protocol, the therapist, treatment team, or society must answer which questions? Select all that apply.
Aversion therapy, also known as aversion conditioning or negative reinforcement, is a technique used to change behavior. In this therapy, a stimulus attractive to the client is paired with an unpleasant event in hopes of associating the stimulus with negative properties. Before beginning this therapy, the following questions must be answered by the therapist, treatment team, or society: (1) Is the therapy in the best interest of society? (2) Does it violate the client's rights? (3) Is it in the best interest of the client? The following questions are not related to beginning this therapy: (1) Is it covered by the client's insurance? (2) How long will it take for positive results? (3) Has the client's family given permission for this therapy? If aversion therapy is chosen as the most appropriate treatment, ongoing supervision, support, and evaluation of those administering it must occur.
