CAT 7

A postpartum client tells the nurse they are constipated. Which response by the nurse is best?

"Add more fruits, vegetables and fluid to each meal"

A client wants to avoid methods of birth control that contain estrogen. Which method would be the nurse recommend?

"Although it varies, a gain of 25 to 35 lb (11.4 to 14.5 kg) is about average."

A client has just given birth to a stillborn baby at 39 weeks gestation. What is the most appropriate response to the client the nurse would make at this time?

"I am sorry for your loss."

A client has a cerclage placed at 16 weeks' gestation. The client has had no contractions and their cervix is dilated 2 cm. The nurse is preparing the client for discharge. Which statement by the client should indicate to the nurse that the client needs further instruction?

"I can have sex again in about 2 weeks."

A client just experienced spontaneous bleeding at 11 weeks gestation, which resulted in the loss of the fetus. The couple wonders if the bleeding could have been caused from the client working long hours in a stressful work environment. What is the most appropriate response from the nurse?

"I can understand your need to find an answer to what caused this. Let's talk about this further."

After the nurse instructs a primigravid client at 8 weeks' gestation about measures to overcome early morning nausea and vomiting, which client statement indicates the need for additional teaching?

"I will eat two large meals daily with frequent protein snacks."

A client who tells the nurse that they would like to use the basal body temperature method for family planning receives instructions about the method. Which client statement indicates to the nurse that the teaching has been successful?

"It's important to take my temperature at about the same time every morning before arising."

A primigravid client at 28 weeks' gestation tells the nurse that they and their spouse wish to drive to visit relatives who live several hours away. Which recommendation by the nurse would be best?

"Taking the trip is okay if you stop every 1 to 2 hours and walk."

While changing the newborn's diaper, a client states: "there is some bleeding from the vagina." Which is the nurse's appropriate response?

"This is in response to your hormones and will stop within a week."

A 15-year-old primipara who gave birth to a term neonate vaginally tells the nurse, "My parent started feeding me rice cereal when I was only 2 weeks old." What would be the most appropriate response to the client?

"Wait until the infant is at least 4 months of age before using cereal."

A certified nurse-midwife places a neonate under the radiant heat unit for the nurse's initial assessment. The initial assessment includes a heart rate of 110 beats/minute and an irregular respiratory effort. The neonate is moving all extremities and the body is pink. The neonate responds to gentle stimulation by withdrawing. The nurse notes copious amounts of clear mucus present both orally and nasally. Based on these assessment findings, what should the nurse do next?

Assign an Apgar score of 9, place the neonate in modified Trendelenburg position, and suction the neonate's nose and oropharynx.

When planning a class for primigravid clients about the common physiologic changes of pregnancy, the nurse should include which information in the teaching plan?

Cardiac output increases by 25% to 50% during pregnancy.

Which instruction should a nurse give to a client who's 26 weeks pregnant and reports of constipation?

Encourage the client to increase the intake of roughage and to drink at least six glasses of water per day.

During a home visit 4 days after birth, the breastfeeding primiparous client tells the nurse that their breasts are hard and tender. The nurse determines the client has breast engorgement and should instruct the client to perform which measure?

Express a small amount of breast milk before breastfeeding.

The nurse is caring for a laboring client fluent in English, but the client defers to a family member when asked to sign the hospital consent forms. Which of the following factors contributes to the challenges the nurse faces in obtaining consent?

Influence of the extended family

While preparing to provide neonatal care instructions to a primiparous client who gave birth to a term neonate 24 hours ago, what should the nurse include in the client's teaching plan?

Milia are white papules from plugged sebaceous ducts that disappear by age 2 to 4 weeks.

During the assessment, the nurse observes a gray-pigmented nevus on the neonate's buttocks. The nurse documents this as which finding?

Mongolian spots

When assessing a neonate, the nurse observes a vaguely outlined area of scalp edema that is most likely caput succedaneum. What is the most appropriate nursing action based on this finding?

Note the finding on the assessment record.

The nurse assesses a 15-hour-old infant and finds jaundice. What is the priority action the nurse needs to take?

Notify the health care provider of the finding.

While assessing the fundus of a multiparous client on the first postpartum day, the nurse performs handwashing and puts on clean gloves. What should the nurse do next?

Place the nondominant hand above the symphysis pubis and the dominant hand at the umbilicus.

Which action by the nurse would be most appropriate after assessing a neonate's cry as infrequent, weak, and very high pitched?

Request that the health care provider evaluate the neonate's neurologic status.

A nurse is assisting with a circumcision. After the health care provider has started the procedure, the nurse reviews the neonate's medical record and notices that an informed consent form hasn't been signed. What should the nurse do?

Tell the health care provider to stop the procedure immediately because an informed consent form hasn't been signed.

A client who is Rh-factor negative has given birth to a healthy infant who is Rh-factor positive. What teaching will the nurse provide to the client?

The client will need Rh immunoglobulin injection within 72 hours.

A nurse is teaching a group of clients about birth control methods. When providing instruction about subdermal contraceptive implants, the nurse should cite which feature as the main advantage of this method?

The implants provide effective, continuous contraception that isn't user dependent.

While the nurse is caring for a neonate born at 32 weeks' gestation, which finding would mostsuggest the infant is developing necrotizing enterocolitis (NEC)?

abdominal distention

A primigravid client visits the clinic for a routine examination at 35 weeks' gestation. The client's blood pressure is near the baseline of 120/74 mm Hg with no proteinuria or evidence of facial edema. The client asks the nurse, "What should I take if I get an occasional headache after looking at my computer at work all day?" Which over-the-counter medicine does the nurse consider to be safest for occasional use by a pregnant client with no known risks?

acetaminophen

A nurse is developing a teaching plan for a primigravid client who's 2 months pregnant. The nurse should tell the client that fetal movement can be felt beginning at which time?

between 18 and 20 weeks' gestation

The nurse develops a teaching plan for the parent of an infant about introducing solid foods into the diet. The nurse should expect to include which measure in the plan to help prevent obesity?

decreasing the amount of formula or breast milk intake as solid food intake increases

A nurse is assessing a neonate. When maternal estrogen has been transferred to the fetus which sign will the nurse see in the neonate?

enlarged breast tissue

Which nursing intervention is most important when working with neonates who are suspected of having congenital hypothyroidism?

identifying the disorder early

A nurse is providing care for a pregnant client with gestational diabetes. The client asks the nurse if gestational diabetes will affect the birth. The nurse should know that:

labor may need to be induced early.

A nurse is performing a neurologic assessment on a neonate. Which assessment finding would be normal for a neonate?

positive Babinski's reflex

A pregnant parent who has brought their toddler to the clinic for a checkup asks the nurse how they can keep their next baby from becoming obese. The parent plans to bottle-feed the next child. Which information should the nurse include in the teaching plan to help the parent avoid over nourishing the infant?

recognizing clues indicating that the baby is full

Assessment of a term neonate at 2 hours after birth reveals a heart rate of less than 100 bpm, periods of apnea approximately 25 to 30 seconds in length, and mild cyanosis around the mouth. The nurse notifies the health care provider (HCP) based on the interpretation that these findings may lead to which condition?

respiratory arrest

A nurse is teaching the birth parent of an infant about the importance of immunizations. The nurse should teach that active immunity

results from exposure of an antigen through immunization or disease contact.

After circumcision with a Plastibell, the nurse should instruct the neonate's parent to cleanse the circumcision site with which agent?

warm water

Which finding is considered normal in the neonate during the first few days after birth?

weight loss then return to birth weight

The nurse assesses a postterm neonate. Which finding is considered normal for a postterm infant?

wrinkled, peeling skin

A client who has tested positive for the human immunodeficiency virus (HIV) gives birth. When the client asks whether the baby has acquired immunodeficiency syndrome (AIDS), how should the nurse respond?

"Your child may have acquired HIV in utero, but we won't know for sure until the child is older."

When teaching a primiparous client who used cocaine during pregnancy how to comfort their fussy neonate, the nurse can advise the client to use which intervention?

Tightly swaddle the neonate.

After a vaginal birth of a term neonate, the nurse observes that the neonate has one artery and one vein in the umbilical cord. The nurse notifies the health care provider (HCP) based on the analysis that this may be indicative of which anomalies?

cardiovascular anomalies

A client with hemolysis, elevated liver enzymes, and low platelet count (HELLP) syndrome is admitted to the labor and delivery unit. The client's condition rapidly deteriorates and despite efforts by the staff, the client dies. After the client's death, the nursing staff displays many emotions. With whom should the nurse-manager consult to help the staff cope with this unexpected death?

chaplain, because their educational background includes strategies for handling grief

A client in the second stage of labor who planned an unmedicated birth is in severe pain because the fetus is in the right occiput posterior position. The nurse should place the client in which position for pain relief?

hands and knees

During the initial assessment of a laboring client, the nurse notes the following: blood pressure 160/110 mm Hg, pulse 88 beats/minute, respiratory rate 22 breaths/minute, reflexes +3/+4 with 2 beat clonus. Urine specimen reveals +3 protein, negative sugar and ketones. Based on these findings, a nurse should expect the client to have which complaints?

headache, blurred vision, and facial and extremity swelling

A nurse is monitoring a premature neonate for development of neonatal sepsis. Which assessment finding is an early sign of neonatal sepsis?

temperature instability

After instructing a primigravid client about the functions of the placenta, the nurse determines that the client needs additional teaching when they say that which hormone is produced by the placenta?

testosterone

A client is concerned that their 2-day-old, breast-feeding neonate isn't getting enough to eat. The nurse should teach the client that breast-feeding is effective if:

the neonate latches onto the areola and swallows audibly.

A multigravid client visits the clinic because they suspect that they are pregnant. The client, however, is unable to tell the nurse when their last menstrual period began. The client has a history of preterm birth. The nurse instructs the client that the gestational age of the fetus can be estimated by which procedure?

ultrasonography

During the first feeding, the nurse observes that the neonate becomes cyanotic after gagging on mucus. What action should the nurse take first?

Clear the neonate's airway with suction or gravity.

During a visit to the clinic, a pregnant 25-year-old client who began prenatal care at 10 weeks' gestation and is now in the third trimester reports frequent constipation. Which suggestion by the nurse would be most helpful?

Eat at least four pieces of fruit daily.

Which instructions should the nurse give to the parents of a neonate diagnosed with hyperbilirubinemia who is receiving phototherapy?

Keep the neonate's eyes completely covered.

A pregnant client states that they frequently ingest laundry starch. The nurse should assess the client for which condition?

anemia

During a prenatal visit, a pregnant client with cardiac disease and slight functional limitations reports increased fatigue. To help combat this problem, the nurse should advise the client to:

divide daily food intake into five or six meals.

A nurse assesses a 1-day-old neonate. Which finding indicates respiratory distress?

nasal flaring

Which common characteristics should the nurse include in the teaching plan for a multiparous client after giving birth to a neonate diagnosed with Down Syndrome? Select all that apply

webbed neck, congenital heart defects, epicanthal folds, and hypotonia

A pregnant client arrives in the emergency department and states, "My baby is coming." The nurse sees a portion of the umbilical cord protruding from the vagina. What should the nurse do first?

Hold pressure on the fetal head.

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

A preterm infant born 2 hours ago at 34 weeks' gestation is experiencing rapid respirations, grunting, no breath sounds on one side, and a shift in location of heart sounds. The nurse should prepare to assist with which procedure?

insertion of a chest tube into the neonate

The neonate of a client with type 1 diabetes is at high risk for hypoglycemia. An initial sign the nurse should recognize as indicating hypoglycemia in a neonate is

lethargy

Sick and preterm neonates who experience continuity of nursing care directly benefit from

nursing recognition of subtle changes in high-risk neonates' conditions.

A 32-year-old client visits the family planning clinic and requests an intrauterine device for contraception. When the nurse is assessing the client, a history of which problem would be mostimportant to determine?

pelvic inflammatory disease

What would the nurse expect to find during the physical examination of a preterm male neonate born at 28 weeks' gestation?

thin, wasted appearance

While the nurse is caring for a neonate at 32 weeks' gestation in an isolette with continuous oxygen administration, the neonate's parent asks why the baby's oxygen is humidified. What should the nurse should tell the parent?

"Oxygen is drying to the mucous membranes unless it is humidified."

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

On the second postpartum day, the nurse enters the room and notices that the client is holding a crying baby and lightly rubbing the infant's back. The client states, "I don't know why my baby won't stop crying all the time." Which of the following is the most appropriate nursing intervention?

Demonstrate ways that the client can comfort the baby.

A primiparous client who will be bottle-feeding their neonate asks, "What is the best position for the baby to nap after feeding?" What should the nurse recommend?

Hold the baby upright for 15 to 20 minutes before placing them down for a nap.

A full-term neonate is admitted to the newborn nursery. When lifting the baby out of the crib the nurse notes the baby's arms move sideways with the palms up and the thumbs flexed. What should the nurse do next?

Identify this reflex as a normal finding.

While assisting the health care provider with an amniocentesis on a multigravid client at 38 weeks' gestation, the nurse observes that the fluid is very cloudy and thick. The nurse interprets this finding as indicating which of the following?

Intrauterine infection.

While caring for a neonate 2 days after birth, the nurse observes a swelling on the neonate's head that does not cross the cranial suture line. What should the nurse tell the client about the swelling?

The swelling will resolve without treatment by 6 weeks of age.

At 24 hours of age, assessment of the neonate reveals the following: eyes closed, skin pink, no sign of eye movements, heart rate of 120 bpm, and respiratory rate of 35 breaths/min. What is this neonate most likely experiencing?

a state of deep sleep

A newborn was discharged from the hospital before receiving the newborn metabolic screening (NMS) test. The community health nurse is scheduling the home visit for the infant. Which time would be the most critical time to perform the heel stick on this infant?

at least 24 hours after birth

During an assessment of a neonate born at 33 weeks' gestation, a nurse finds and reports a heart murmur. An echocardiogram reveals patent ductus arteriosis, for which the neonate received indomethacin. What is the expected outcome after the administration of indomethacin to a neonate with patent ductus arteriosis?

closure of a patent ductus arteriosus

A dilatation and curettage (D&C) is scheduled for a primigravid client admitted to the hospital at 10 weeks' gestation with abdominal cramping, bright red vaginal spotting, and passage of some of the products of conception. The nurse should assess the client further for the expression of which feeling?

guilt

A client gives birth to a neonate prematurely at 28 weeks' gestation. The neonate's Apgar score is 5 at 1 minute. What is the nurse's most important intervention for this premature neonate?

Administer oxygen.

A primigravid client at 16 weeks' gestation visits the clinic for a routine examination. The client tells the nurse that they knows someone whose baby was born with congenital toxoplasmosis. What should the nurse instruct the client to do to prevent transmission of the toxoplasmosis protozoan?

Cook all meats, such as beef and pork, thoroughly.

During an annual checkup, a client tells the nurse that they and their partner have decided to start a family. Ideally, when should the nurse plan for childbirth education to begin and end?

It should begin before conception and end 3 months after childbirth.

After a long labor process, a primigravid client gives birth to a healthy newborn with a moderate amount of skull molding. What information would the nurse include when explaining to the client about this condition?

It usually lasts a day or two before resolving.

A primigravid with severe gestational hypertension has been receiving magnesium sulfate IV for 3 hours. The latest assessment reveals deep tendon reflexes (DTR) of +1, blood pressure of 150/100 mm Hg, a pulse of 92 beats/minute, a respiratory rate of 10 breaths/minute, and a urine output of 20 ml/hour. Which action should the nurse perform next?

Stop the magnesium sulfate infusion.

Twenty-four hours after giving birth to a term neonate, a primipara receives acetaminophen with codeine for perineal pain. One hour after the nurse administers the medication, which finding should alert the nurse to the development of a possible side effect?

dizziness

A client at 42 weeks of gestation is 3 cm dilated and 30% effaced, with membranes intact and the fetus at 12 station. Fetal heart rate (FHR) is 140 beats/minute. After 2 hours, the nurse notes that, for the past 10 minutes, the external fetal monitor has been displaying an FHR of 190 beats/minute. The client states that the baby has been extremely active. Uterine contractions are strong, occurring every 3 to 4 minutes and lasting 40 to 60 seconds. Which piece of data would indicate fetal hypoxia?

excessive fetal activity and fetal tachycardia

A client who is breastfeeding tells the nurse that they plan to return to work in 6 months and will probably wean their baby then. The client asks the nurse, "How will I stop producing milk when I want to wean the baby?" What information should the nurse give the client?

gradual decrease in milk supply as the baby nurses less

A client makes a routine visit to the prenatal clinic. Although the client is 14 weeks pregnant, the size of their uterus approximates an 18- to 20-week pregnancy. The health care provider diagnoses gestational trophoblastic disease and orders ultrasonography. The nurse expects ultrasonography to reveal:

grapelike clusters.

A 30-year-old multigravida client has missed three periods and now visits the prenatal clinic because they assume they are pregnant. The client is experiencing enlargement of the abdomen, a positive pregnancy test, and changes in the pigmentation on the face and abdomen. These assessment findings reflect this client is experiencing a cluster of which signs of pregnancy?

probable

A newborn baby has developed physiologic jaundice. The parents are concerned about the appearance of the newborn and ask the nurse about their concerns. Which of the following would be the most appropriate response by the nurse?

"I can tell you are worried about your baby. Let's talk about this change in your baby's skin color."

During a health-teaching session, a pregnant client asks the nurse how soon the fertilized ovum becomes implanted in the endometrium. Which answer should the nurse supply?

7 days after fertilization

A client is admitted for an amniocentesis. Initial assessment findings include 16 weeks' gestation, vital signs within normal limits, hemoglobin 12.2 g/dL (122 g/L), hematocrit 35% (0.35), and type O-negative blood. Which action would the nurse complete first after amniocentesis has been completed?

Assess fetal heart rate and compare to pre-procedure baseline.

Assessment of a client in active labor reveals the following: moderate discomfort; cervix dilated 3 cm, 0 station, and completely effaced; and fetal heart rate of 136 bpm. What should the nurse plan to do next?

Assist the client with comfort measures and breathing techniques.

A nurse has been providing care to a client in labor for the past 9 hours. The partner remains at the bedside while the laboring client is sleeping with the epidural block in situ. Which is the most appropriate nursing action?

Offer to remain with the client while the partner takes a short break.

The nurse is teaching the parent of a newborn to develop their baby's sensory system. To further improve the infant's most developed sense, the nurse should instruct the parent to perform which action?

Stroke the newborn's cheek with the nipple to direct the baby's mouth to the nipple.

The parent of a neonate diagnosed with gastroschisis tells the nurse that their spouse had planned on breastfeeding the neonate. Which information should the nurse include in the preoperative teaching plan about feeding the neonate?

The neonate will remain on nothing-by-mouth (NPO) status until after surgery.

A primigravid client at 8 weeks' gestation tells the nurse that since having had sexual relations with a new partner 2 weeks ago, the client has noticed flu-like symptoms, enlarged lymph nodes, and clusters of vesicles on their vagina. The nurse refers the client to a primary health care provider (HCP) because the nurse suspects which sexually transmitted infection?

herpes genitalis

The nurse is admitting a newborn to the nursery. Report reveals that the newborn was slow to crown and delivery of the head and chin was difficult. For which complication would the nurse need to assess?

shoulder dystocia

A nurse is teaching parents of a neonate the proper position for the neonate's sleep. The nurse stresses the importance of placing the neonate on their back to reduce the risk of which concern?

sudden unexplained infant death syndrome (SUIDS)

The nurse makes a home visit to a 3-day-old full-term neonate who weighed 3912 g (3.91 kg) at birth. Today the neonate, who is being bottle-fed, weighs 3572 g (3.57 kg). Which instruction should the nurse give the parent?

Continue feeding every 3 to 4 hours since the weight loss is normal.

A client who is 14 weeks' pregnant mentions that they have been having difficulty moving their bowels since they became pregnant. Which hormone is responsible for this common discomfort during pregnancy?

progesterone

Parents who bring a 3-week-old neonate to the hospital report that the infant has been "throwing up after every feeding." A nurse notes projectile vomiting while assessing the neonate. X-rays confirm

pyloric stenosis.

The client who is breastfeeding asks the nurse if they should supplement breastfeeding with formula feeding. The nurse bases the response on which principle?

Formula feeding should be avoided to prevent interfering with the breast milk supply.

A client has obtained levonorgestrel as emergency contraception. After unprotected intercourse, the client calls the clinic to ask questions about taking this contraceptive. The nurse realizes the client needs further explanation when they make which statement?

"I can wait up to 4 days after intercourse to start taking these to prevent pregnancy."

A client two days postpartum was given a shot of RhoGAM. At the postpartum home visit, the client asks the nurse why they needed RhoGAM. What is the most appropriate response by the nurse?

"RhoGAM suppresses antibody formation in clients with Rh negative blood after giving birth to an Rh positive baby."

A couple is inquiring about vasectomy as a permanent method of contraception. Which teaching statement would the nurse include in the teaching plan?

"Another method of contraception is needed until the sperm count is 0."

Which statement indicates a client understands teaching about the purified protein derivative (PPD) test for tuberculosis?

"Because I had a previous reaction to the test, this time I need to get a chest X-ray."

The nurse teaches the parents of a 2-year-old child how to instill antibiotic eardrops. Which statement about the direction to pull on the earlobe indicates that the child's parent has understood the teaching?

"I should pull the earlobe down and backward."

The nurse has been instructing the client about how to prepare meals that are low in fat. Which comment would indicate the client needs additional teaching?

"I will eat more liver with onions."

After diagnosing a client with pulmonary tuberculosis, the health care provider tells family members that they must receive isoniazid (INH) as prophylaxis against tuberculosis. The client's family asks the nurse how long the drug must be taken. What is the usual duration of prophylactic isoniazid therapy?

6 to 12 months

Forty-eight hours after undergoing a ventriculoperitoneal shunt placement, an infant is irritable and vomits a large amount. Assessment reveals a bulging fontanel. Using the SBAR (Situation-Background-Assessment-Recommendation) technique for communication, the nurse calls the primary health care provider with a recommendation for:

A computerized tomography scan.

A client with chronic renal failure receives hemodialysis treatments through a mature arteriovenous (AV) fistula. What intervention will the nurse include in the care plan?

Auscultate the AV fistula for a bruit.

A client presents to the emergency department (ED) with suicidal thoughts and a long-standing history of major depression. The nurse completes a mental status assessment and deems that the health care provider needs to see the client immediately. Which action would be most appropriate for the nurse to take next?

Call the health care provider from a phone in the examining room.

A nurse is providing in-home management instructions to the parents of a child who is receiving desmopressin acetate (DDAVP). What is the most important instruction for the nurse to include?

Call the health care provider if the child has an upper respiratory infection or allergic rhinitis.

When performing a postoperative assessment on a client who has undergone surgery to manage increased intracranial pressure (ICP), a nurse notes an ICP reading of 0 mm Hg. Which action should the nurse perform first?

Check the equipment.

When assessing a 2-month-old infant, the nurse feels a "click" when abducting the infant's left hip. What should the nurse do next?

Check the lengths of the femurs to determine if they are equal.

A nurse is caring for a client receiving a dopamine receptor agonist for treatment of extrapyramidal symptoms caused by antipsychotic medications. What evaluation would indicate a therapeutic response to this drug?

Client experiences a decrease in dystonia.

A client is admitted with a diagnosis of chronic hydronephrosis. Which assessment finding requires immediate action or will assist the nurse in planning care?

Client's blood urea nitrogen (BUN) is 32 mg/dL.

The nurse plans care for a child with sickle cell disease in vasoocclusive crisis. What rationale does the nurse use for increasing the child's fluid intake?

Decreased blood viscosity prevents the sickling process.

A nurse is preparing for the discharge of a neonate born 7 weeks premature. The neonate has had several apneic episodes and will need a home apnea monitor but will require no other specialized care. Which nursing diagnosis is most appropriate for the neonate's parents?

Deficient knowledge related to lack of exposure to apnea monitor.

A client receiving total parenteral nutrition (TPN) is ordered to undergo a 24-hour urine test for creatinine clearance. Which actions should the client take to initiate this collection?

Discard the first morning void, then continue the collection for exactly 24 hours.

The parents of a child on sulfamethoxazole and trimethoprim for a urinary tract infection report that the child has a red, blistery rash. What instruction should the nurse give the parents?

Discontinue the medicine and come for immediate further evaluation.

Following a simple mastectomy, the nurse is totaling the amount of drainage in 24 hours from a suction drain in the incision. The nurse notes there is 200 mL of serosanguineous drainage for the first 24 hours. What should the nurse do?

Document the findings.

A nurse is assessing a newborn with the following findings: respiratory rate of 40 breaths per minute, heart rate of 145 beats per minute, and a temperature of 97.3° F (36.2° C). Which are appropriate nursing interventions? Select all that apply.

Double wrap the newborn with blankets., Place a hat on the newborn, and Reduce the newborn's exposure to drafts.

A client has a chest tube and water-seal drainage system. What should the nurse do to ensure safe and effective use of the drainage system?

Make sure that the drainage apparatus is always below the client's chest level

A client has a chest tube and water-seal drainage system. What should the nurse do to ensure safe and effective use of the drainage system?

Make sure that the drainage apparatus is always below the client's chest level.

The nurse is caring for a client with acute renal failure and edema. Which actions should the nurse delegate to an experienced unlicensed assistive personnel (UAP)? Select all that apply.

Make sure the urinal is within the client's reach, Remind the client that all urine is to be saved for intake and output measurement. Weigh the client every morning using the standing scale.Measure and record vital signs.

A client returns from a laryngectomy and begins to cough violently, dislodging the tracheostomy tube. What is the priority action of the nurse?

Mask ventilate the client and prepare for orotracheal intubation when the health care provider arrives

A client is admitted to the hospital with a diagnosis of renal calculi. The client is experiencing severe flank pain and nausea; their temperature is 100.6°F (38.1°C). Which goal is a priority for this client?

Relieve pain.

A nurse is caring for a 9-year-old child who is shy and fearful. The nurse asks the child a question, but the child does not answer immediately. What is the best approach by the nurse to develop a therapeutic relationship with the child?

Remain silent after asking a question.

The nurse is supervising a student nurse who is performing tracheostomy care for a client. Which action performed by the student would require nurse intervention?

Remove inner cannula and clean using universal precautions.

The nurse is reviewing the lab report for a client in hospice care with breast cancer and brain metastasis. According to the information in the chart, what should the nurse do next?

Report the elevated calcium level immediately.

A toddler is hospitalized with multiple injuries. Although the parent states that the child fell down the stairs, the child's history and physical findings suggest abuse as the cause of the injuries. What is the nurse's first responsibility in caring for this child?

Report the incident to the proper authorities.

The nurse is giving rescue breaths to a client who just had a cardiac arrest while a team member performs chest compressions. The chest wall fails to rise after the team has been performing cardiopulmonary resuscitation for 30 seconds. What should the nurse do next?

Reposition the airway.

What is the most important nursing intervention when caring for a child with a newly applied wet hip spica cast?

Reposition the child every 1 to 2 hours.

The client and their partner are very distressed and state that they feel the nurse has been negligent in providing care during labor. What is the nurse's best defense against an accusation of negligence?

The national standards of practice were met when providing care.

A nurse hears a client state, "I've had it with this marriage. It would be so much easier to just hire someone to kill my spouse!" What action should the nurse take?

The nurse must start the process to warn the client's spouse.

A client with hepatitis B is visiting with a sibling when the client's I.V. catheter dislodges and bleeds onto the surface of the bedside table. Which action, if observed, would cause the nurse to intervene?

The unlicensed assistive personnel (UAP) uses tissue to blot up the blood.

The nurse is explaining the long-term toxic effects of cancer treatments on the immune system to a client who is receiving chemotherapy and radiation therapy for colon cancer. What should the nurse tell the client?

The use of radiation and combination chemotherapy can result in more frequent and more severe immune system impairment.

Which assessment finding supports the administration of protamine sulfate?

aPTT 3.5-5 times normal

Which toy should the nurse give to a toddler to use in the hospital playroom?

blocks

At an emergency shelter, a client who has experienced an earthquake that damaged their home tells the nurse that they are going to spend the night in their own bed at home. Which defense mechanism is the client exhibiting?

denial

A 25-year-old client who is in the first stage of labor receives a continuous lumbar epidural block when the cervix is 6-cm dilated. After administration of this anesthesia, which assessment would be most important?

fetal heart rate

A client on mechanical ventilation is receiving pancuronium I.V. as needed. Which assessment finding indicates that the client needs another pancuronium dose?

fighting the ventilator

A nursery nurse just received the shift report. Which neonate should the nurse assess first?

four-hour-old term neonate with jaundice

A nurse is caring for a client who's had surgery to repair a hip fracture. The client says their left hand and arm are numb and they can't move the extremity. The nurse contacts the health care provider, who suspects brachial plexus nerve damage. What additional priority assessment does the nurse need?

function of the client's left hand before the operation

The nurse has taught a client about preventing the recurrence of cystitis. Which statement indicates that further teaching is needed? "I can:

go 8 to 10 hours without emptying my bladder."

The nurse is caring for a client with asthma. The nurse should conduct a focused assessment to detect:

inspiratory and expiratory wheezing.

A client requires long-term ventilator therapy. The client has a tracheostomy in place and requires frequent suctioning. Which technique should the nurse use?

intermittent suction while withdrawing the catheter

A client with cancer is being evaluated for possible metastasis. What is one of the most common metastasis sites for cancer cells?

liver

A client has the following arterial blood gas (ABG) values: pH, 7.12; partial pressure of arterial carbon dioxide (PaCO2), 40 mm Hg; and bicarbonate (HCO3-), 15 mEq/L. These ABG values suggest which disorder?

metabolic acidosis

A client with influenza is admitted to an acute care facility. The nurse monitors the client closely for complications. What is the most common complication of influenza?

pneumonia

A nurse is interviewing a client about their past medical history. Which preexisting condition may lead the nurse to suspect that a client has colorectal cancer?

polyps

A nurse is caring for a client in addisonian crisis. Which medication order should the nurse question?

potassium chloride

A nurse should assess the maturity of enzyme systems (kidney and liver) in which pediatric population before administering medications?

premature infants

The client with histrionic personality disorder is melodramatic and responds to others and situations in an exaggerated manner. The nurse should recommend which activity for this client?

role-playing

A client is prescribed phenelzine. Which food should the nurse tell the client to avoid while taking the medication?

salami

The client with a diagnosis of bipolar disorder, manic phase, states to the nurse, "I am the Queen of England. Bow before me." The nurse interprets this statement as important to document in which area of the mental status examination?

thought content

A health care provider (HCP) placed a direct fetal scalp electrode on the fetus. What information should a nurse include when documenting direct fetal scalp electrode placement?

time of fetal scalp electrode placement, name of the HCP who applied the electrode, and the fetal heart rate (FHR)

A client with benign prostatic hyperplasia doesn't respond to medical treatment and is admitted to the facility for prostate gland removal. Before providing preoperative and postoperative instructions to the client, the nurse asks the surgeon which prostatectomy procedure will be done. What is the most widely used procedure for prostate gland removal?

transurethral resection of the prostate (TURP)

The nurse is teaching a client about the pathophysiology of asthma. Place in chronological order the sequence of an asthma attack. All options must be used.

trigger by stimulus inflammation mucous production airflow limitation breathlessness acute asthma attack

After instructing a parent about normal reflexes of term neonates, the nurse determines that the parent understands the instructions when they describe the tonic neck reflex as occurring when the neonate displays which behavior?

turns head to the left, extends the left extremities, and flexes the right extremities

A parent says that their family will soon be traveling abroad and asks why the drinking water in many regions must be boiled. The nurse should explain that, in addition to various types of dysentery, contaminated drinking water is most commonly responsible for the transmission of which disease?

typhoid fever

Which clinical finding should a nurse look for in a client with chronic renal failure?

uremia

The nurse is assessing a young adult male client who has pain when urinating. The client states they think they have a sexually transmitted infection. When obtaining a health history, the nurse should ask the client if they are experiencing which symptom?

urethral discharge

A nurse is reviewing a report of a client's routine urinalysis. Which value requires further investigation?

urine pH of 3.0

During the discharge planning teaching process, a client who has been prescribed tranylcypromine states that they enjoy a beer or two in the evenings. Which is the nurse's most appropriate response?

"Beer contains tyramine which must be avoided when on this medication."

After the nurse explains to a primiparous client the causes of the neonate's cranial molding, which statement by the client indicates the need for further instruction?

"Brain damage may occur if the molding does not resolve quickly."

The nurse in a psychiatric unit has formed a therapeutic relationship with a client with a borderline personality disorder. When the client is readmitted to the unit for a suicide attempt, the nurse exclaims to another staff nurse, "Why? Everything was going well. How could they do this to me?" What response by the staff nurse reflects an understanding of the client's borderline disorder?

"Clients with borderline disorder act out to relieve anxiety, and something must have provoked a great deal of anxiety."

A client is scheduled for an intravenous pyelogram (IVP). In preparation for the procedure, what should the nurse ask the client?

"Do you have any allergies?"

A nurse is explaining electroconvulsive therapy (ECT) to members of a depression support group. Which statement would indicate understanding?

"ECT treatments are given for severe depression when other meds have failed."

An unlicensed assistive personnel (UAP) approaches the nurse and states, "The client doesn't know what caused them to be so depressed. They must not want to tell me because they don't trust me yet." In responding to this staff member, which statement by the nurse will help the UAP understand the client's illness?

"Endogenous depression is biochemical and isn't caused by an outside stressor or problem. The client can't tell you why they're depressed because they really don't know."

The nurse is taking a client's mental health history and assessment. The client with depression has been diagnosed with anergia. The nurse teaches a client how to increase the levels of the neurotransmitter serotonin. Which statement made by the nurse educator is best?

"Exercise daily for at least 30 minutes."

A client undergoes a total laryngectomy and tracheostomy formation. On discharge, the nurse should give which instruction to the client and family?

"Family members should continue to talk to the client."

A school-age client has a fever, joint inflammation, and a nonpruritic rash. Knowing that these are signs of rheumatic fever, the nurse should ask the parents

"Has your child had strep throat recently?"

As a first step in teaching a female client with a spinal cord injury and quadriplegia about their sexual health, the nurse assesses the client's understanding of their current sexual functioning. Which statement by the client indicates they understand their current ability?

"I can participate in sexual activity but might not experience orgasm."

The nurse is teaching a G2P1 client about upcoming labor. Which response would indicate to the nurse that further teaching is necessary?

"I can wait until my contractions are every 2 minutes to contact the health care provider because my first labor was so long."

The nurse is teaching a young adult female who has a severe gonorrheal infection about the disease. The client understands the implications of the disease when they make which statement?

"I could have trouble getting pregnant."

After several months of taking olanzapine, the client reports that they are no longer hearing voices of any kind. Which statement would confirm that the client is developing insight into their illness?

"I didn't realize how sick I could get from a chemical brain imbalance."

The nurse is caring for a client on the psychiatric unit. The client states, "The voices are bothering me. They are yelling and telling me stuff. They are really bad." Which responses by the nurse would be most appropriate?

"I do not hear any voices. What are you hearing?"

A client who is experiencing hallucinations asks if a nurse hears the voices saying that the client should never have been born. The nurse's most appropriate response would be:

"I don't hear any voices, but I believe you can hear them."

A nurse is caring for a client who is receiving chemotherapy and has a platelet count of 30,000/mm3. Which statement by the client indicates a need for additional teaching?

"I floss my teeth every morning."

The nurse is explaining the concept of poor personal boundaries to a client. Which statement by the client requires priority action by the nurse?

"I know that it is okay to expect others to fulfill my needs."

After the nurse teaches a client and family about lithium therapy, which client statement would indicate the need for further teaching?

"I need to eliminate salt in my diet."

An adolescent is receiving chemotherapy for lymphoma. Which statement by the adolescent supports a nursing diagnosis of Deficient knowledge related to mouth care?

"I remove white patches from my tongue and cheeks with my toothbrush."

A nurse is caring for a client who has a history of sleep apnea. The client understands the disease process when they say

"I should become involved in a weight loss program."

After the nurse has taught a client who is being discharged on lithium about the drug, which client statement would indicate that the teaching has been successful?

"I'll call my health care provider right away for any vomiting or muscle weakness."

A client who has been sexually assaulted is admitted to the emergency department (ED). Which is the most important initial statement by the nurse?

"I'll stay with you while you're here."

A bottle-fed infant, age 3 months, is brought to the pediatrician's office for a well-child visit. During the previous visit, the nurse taught the parent about infant nutritional needs. Which statement by the parent during the current visit indicates effective teaching?

"I'm giving the baby iron-fortified formula and a fluoride supplement because our water isn't fluoridated."

A 9-year-old client is brought to the emergency department with a sutured wound with purulent drainage. The area around the wound is red and warm to the touch, and the child is febrile. The parents want to know the significance of the purulent drainage. What is the best response by the nurse?

"If a wound heals on the surface but infection remains, it will open and drain."

A nurse recognizes that a client with tuberculosis needs further teaching when the client states:

"It will be necessary for the people I work with to take medication."

Which statement indicates that the parents understand the need for their child to receive long-term antibiotic therapy after an episode of rheumatic fever?

"It will prevent recurring acute rheumatic fever."

During a home visit to a primiparous client 1 week postpartum who is bottle-feeding the neonate, the client tells the nurse that their parent has suggested that they feed the neonate cereal so the neonate will sleep through the night. What would be the nurse's best response?

"It's better to continue feeding only formula until about 4 to 6 months of age."

A school-age child loses their appetite secondary to side effects of chemotherapy. What will the nurse teach the parents about nutritional choices for the child?

"Let your child eat any foods that appeal to them right now."

A nurse on the geropsychiatric unit receives a call from the caregiver of a recently discharged client. The caregiver reports that the client just got a prescription for memantine to take "on top of their donepezil." The caregiver then asks, "Why do they have to take extra medicines?" What should the nurse tell the caregiver?

"Memantine and donepezil are commonly used together to slow the progression of dementia."

After teaching a group of students who are volunteering for a local crisis hotline, the nurse judges that further education about crisis and intervention is needed when a student makes which statement?

"Most people in crisis will be calling the line once every day for at least a year."

The nurse assesses the progress of a client who has behavioral manifestations of stress. Which client statement indicates that the client has gained insight into the use of the defense mechanism of displacement?

"Now when I am mad at my spouse, I talk to them instead of taking it out on the kids."

An older adult client is brought to the outpatient clinic by their caregiver for a routine medication evaluation. The caregiver reports that the client is quite stable and has no adverse effects from the risperidone they are taking. Then, the caregiver says, "I just think the client could be even better if they were on a larger dosage. My child takes 1 mg of risperidone every day and the client is only on 0.5 mg." What is the most helpful response by the nurse?

"Older clients generally need a lesser dose than younger people."

A client diagnosed with schizophrenia is being switched to risperidone long-acting injection. The client is told that they will remain on an oral dose of risperidone daily for approximately 1 month. The client says, "I didn't have to take pills when I was on fluphenazine shots in the past." What should the nurse tell the client?

"Risperidone initially takes a little longer to reach the ideal blood level."

The nurse documents the initial care of a client who the nurse suspects is a victim of intimate partner violence. Which information would be most helpful for others to know when caring for the client?

"Seems fearful to discuss how bruises on their body were caused."

Parents of a school-age child with asthma express concern about letting the child participate in sports. What will the nurse instruct the parents about the relationship between exercise and asthma?

"Taking prophylactic medication before the activity can prevent asthma attacks, making exercise safer."

The parents of a 20-year-old client admitted 4 days ago with a diagnosis of paranoid schizophrenia are attending a family psychoeducation group in the hospital. Which statement indicates that the parents understand their child's illness and management?

"Tasks as simple as getting out of bed and showering in the morning may be difficult."

An adolescent is to receive radioactive iodine for Graves disease. Which statement by the client reflects the need for more teaching?

"The advantage of radioactive iodine is that I will not need future medication for my disease."

A client with benign prostatic hypertrophy is being transferred from the emergency department to a surgery unit. Which information should be included in the report from the nurse in the emergency department to the nurse responsible for admitting the client?

"The client was catheterized, and 1100 mL of urine was obtained. The urine appeared cloudy, and a specimen was sent to the laboratory."

The parent of a newborn witnesses the nurse give the baby a vitamin K injection and asks why the baby received it. What is the nurse's most appropriate response?

"The medication is given to promote synthesis of clotting factors."

A nurse is instructing a client with an ileal conduit about skin care around the stoma. What should the nurse tell the client about stoma care? Select all that apply.

"The stoma will shrink to a normal size in 4 to 6 weeks.", You can take a shower or a bath with the appliance on or off.", and "You can use an electric razor to remove the hair around the stoma."

According to the antenatal record, a newborn is 12 days post-mature. A nurse completes the initial assessment of the newborn and notes increased amounts of vernix. The parent asks why the nurse seems concerned about the presence of the vernix. Which of the following statements by the nurse is most appropriate?

"The vernix indicates a different gestational age than expected."

The parent of a client with schizophrenia calls the visiting nurse in the outpatient clinic to report that their child has not answered the phone in 10 days. "They were doing so well for months. I don't know what's wrong. I'm worried." Which response by the nurse is most appropriate?

"They may have stopped taking their medications. I'll check on them."

While performing an assessment, a nurse observes a 6-month-old infant transferring an object from one hand to another and reaching for the nurse's stethoscope. The parent tells the nurse this is new behavior and asks if it is normal. The nurse educates the parent about growth and development parameters for a 6-month-old infant. What do they tell the parent?

"This behavior is typical for a 6-month-old infant."

A nurse is providing health teaching to a group of adolescent females. The focus is on urinary tract infections. One of the adolescents tells the nurse that they want to know more about cystitis. Which statement by the nurse is the most appropriate response?

"This condition can result from irritation and inflammation from sexual activity."

The nurse has completed teaching a client about alprazolam. Which statement by the client will the nurse document as evidence of successful teaching?

"This medication carries a risk of dependence."

A client who is incoherent and agitated comes to the emergency department. The client reports visual and auditory hallucinations. The health care provider orders haloperidol, 5 mg IM. When educating the client on this medication, which statement by the nurse is correct?

"This medication will help decrease your tension and agitation."

A child is admitted to the emergency department and diagnosed with a suspected ruptured appendix. The parents are anxious about the child's condition and ask the nurse what to expect for immediate treatment. What is the best response by the nurse?

"We will be preparing your child for emergency surgery."

A 74-year-old client receiving fluphenazine decanoate therapy develops pseudoparkinsonism, and is ordered amantadine hydrochloride. With the addition of this medication, the client reports feeling dizzy when standing. Which response by the nurse is best?

"When you change positions, do so slowly."

As the nurse stands near the window in the client's room, the client shouts, "Come away from the window! They will see you!" Which response by the nurse would be best?

"Who are 'they'?"

A client in a group therapy setting is very demanding. The client repeatedly interrupts others and monopolizes most of the group time. The nurse's best response would be:

"Will you briefly summarize your point? Others also need time."

A client tells the nurse at the outpatient clinic that they do not need to attend groups because they are "not a regular like these other people here." How should the nurse respond to the client?

"You say you're not a regular here, but you're experiencing what others are experiencing."

An older adult has asthma and asks the nurse about taking the pneumonia vaccine. The should the nurse tell the client?

"You should receive the vaccine."

During the admission assessment, a client with a panic disorder begins to hyperventilate and says, "I'm going to die if I don't get out of here right now!" What is the nurse's best response?

"You're having a panic attack. I'll stay here with you."

A client who is dying from AIDS is admitted to the inpatient psychiatric unit because they attempted suicide. Their close friend recently died from AIDS. The client states to the nurse, "What's the use of living? My time's running out." What is the nurse's best response?

"You're in a lot of pain. What are you feeling?"

A child admitted to the hospital with an elevated serum sodium level is receiving 5% dextrose with 0.45 normal saline solution. The parent asks the child's nurse why the child is receiving sodium. What is the nurse's best reply?

"Your child's sodium is high; but if the serum sodium level is decreased too rapidly, it may cause seizures."

The client with pyelonephritis asks the nurse, "How will I know whether the antibiotics are treating my infection?" What should the nurse tell the client?

"Your health care provider will take a urine culture."

A client admitted with pneumonia has a history of lung cancer and heart failure. A nurse caring for this client recognizes that they should maintain adequate fluid intake to keep secretions thin for ease in expectoration. The amount of fluid intake this client should maintain is

1.4 L.

After receiving an oral dose of codeine for an intractable cough, a client asks the nurse, "How long will it take for this drug to work?" How should the nurse respond?

30 minutes

A client has given birth to an 8 lb 2.5 oz (3,700 g) infant. A newborn infant requires 110 to 120 cal/kg/day. What is the minimum number of calories per day this neonate requires? Record your answer using a whole number.

407

Prior to discharging a client diagnosed with tuberculosis, the nurse is determining if others in the home are at risk for contracting the disease. Which of these family members who have been exposed to tuberculosis would be at highest risk for contracting the disease?

76-year-old grandparent

After receiving a report, the nurse is making out assignments. Which client would be appropriate to assign to unlicensed assistive personnel?

8-month-old with pneumonia who will be discharged today

The nurse is reviewing the arterial blood gas values of a client with emphysema. Which PaCO2 value indicates the need for immediate action?

80 mm Hg

A nurse is administering a purified protein derivative (PPD) test to a client. Which statement concerning PPD testing is true?

A positive reaction indicates that the client has been exposed to the disease.

Which situations should a supervisor consider in making assignments for nurses in the neonatal unit?

A pregnant nurse shouldn't care for a neonate with cytomegalovirus (CMV).

The nurse is caring for a client with bacterial pneumonia. The effectiveness of the client's oxygen therapy can be best determined by which indicator of oxygenation?

ABG

The nurse is caring for a client who has experienced severe multiple trauma. The client's arterial blood gases reveal low arterial oxygen levels that are not responsive to high concentrations of oxygen. This finding is an indicator of the development of which of the following conditions?

Acute respiratory distress syndrome (ARDS).

A client is admitted with a diagnosis of viral gastroenteritis. The client has an elevated blood urea nitrogen and creatinine and is oliguric with a blood pressure of 74/30 mmHg. Which order from the health care provider should the nurse carry out first?

Administer intravenous fluids.

A newly admitted client diagnosed with paranoid schizophrenia is pacing rapidly and wringing their hands. They state that another client is out to get them. Then they say, "Protect me, select me, reject me." What action should the nurse take next?

Administer oral lorazepam and haloperidol as needed.

A 7-year-old has had an appendectomy on November 12. They have had pain for the last 24 hours. There is a prescription to administer acetaminophen with codeine every 3 to 4 hours as needed. The nurse is beginning the shift, and the child is requesting pain medication. The nurse reviews the chart below for pain history. Based on the information in the medical record, what should the nurse do next?

Administer the acetaminophen with codeine.

Which intervention can the nurse delegate to a licensed practical/vocational nurse (LPN/LVN) working on a medical-surgical unit?

Administer zolpidem 5 mg as needed for sleep.

the nurse is caring for an adolescent client who sustained a head injury in a motor vehicle crash. The client begins to experience extreme thirst and excretes 4 L of urine in a 24-hour period with a specific gravity of 1.002. What pharmacological intervention does the nurse anticipate performing?

Administration of desmopressin.

A nurse is admitting an older adult female client to the gynecology surgical unit. When the nurse asks the client what medication they are taking at home, the client responds that they are taking a little red pill in the morning and a white capsule at night for their blood pressure. What should the nurse do next?

Ask a family member to bring the medications from home in the original vials for proper identification and administration times.

A client of Asian descent has been laboring for 3 hours. The nurse notes that a laboring client's temperature is elevated and mucous membranes are becoming dry. The client has been refusing sips of water and ice that have been offered. Which is the most appropriate nursing action at this time?

Ask the client what fluids they prefer to drink.

A nurse is preparing a client for an intravenous pyelography. Which action is the priority?

Assess allergies to iodine.

A client has a transurethral resection of the prostate to treat benign prostatic hyperplasia. The client returns to the room with continuous bladder irrigation and reports bladder pain. What is the priority nursing action?

Assess irrigation catheter for patency and drainage.

A school-age child is admitted to the hospital with newly diagnosed insulin-dependent diabetes mellitus. On admission at 1000, the child's blood glucose is elevated, and they receive 2 units of regular insulin subcutaneously at 1030. What should the nurse include in the plan of care?

Assess the child beginning at 1230 for shakiness, feelings of anxiety, or decreased level of consciousness.

A 45-year-old client had a complete abdominal hysterectomy with bilateral salpingo-oophorectomy 2 days ago. The client's abdominal dressing is dry and intact. While sitting up in the chair, the client has severe pain and numbness in their left leg. What should the nurse do first?

Assess the color and temperature of the left leg.

A client who had transurethral resection of the prostate (TURP) 2 days earlier has lower abdominal pain. What should the nurse do first?

Assess the patency of the urethral catheter.

A client with chronic obstructive pulmonary disease (COPD) has developed tachypnea, dyspnea, and oxygen saturation (SaO2) of 90%. Which action by the nurse is most appropriate?

Assist the client to sit in a chair and lean slightly forward with hands on the knees.

A client is ready for discharge after surgery for a deviated septum. Which instruction would be appropriate?

Avoid activities that elicit the Valsalva maneuver.

A school-age child with leukemia is taking immunosuppressive drugs. What health maintenance recommendation should the nurse include in the teaching plan?

Avoid any live attenuated vaccines.

A health care provider (HCP) has just inserted nasal packing for a client with epistaxis. The client is taking ramipril for hypertension. What should the nurse instruct the client to do?

Avoid rigorous aerobic exercise.

A client with acute pyelonephritis receives a prescription for co-trimoxazole P.O. twice daily for 10 days. Which finding best demonstrates that the client has followed the ordered regimen?

Bacteria are absent on urine culture.

During hemodialysis treatment, a client is restless and reports a headache and nausea. Which action should the nurse implement?

Bolus the client with 500 mL of normal saline.

A client with paranoid schizophrenia is recently admitted to the psychiatric unit. The client is hesitant to eat the food provided and states "I know they poisoned this food before putting it on my plate." What is the priority nursing action?

Bring the client food in unopened containers.

A 13-year-old female presents to the emergency department with their parents and reports abdominal pain of 8 on a 0-10 scale and a low-grade fever. The nurse knows that which of these is the most serious assessment finding in this client?

Client has a rigid, boardlike abdomen.

A nurse assessing a client who underwent cardiac catheterization finds the client lying flat on the bed. The client's temperature is 99.8° F (37.7° C). Their blood pressure is 104/68 mm Hg. Their pulse rate is 76 beats/minute. The nurse assesses the limb and detects weak pulses in the leg distal to the puncture site. Skin on the leg is cool to the touch. The puncture site is dry, but swollen. What is the most appropriate action for the nurse to take?

Contact the health care provider and report the findings.

A client who is taking lithium carbonate is going home on a 3-day pass. What is the best health teaching the nurse should provide for this client?

Continue to maintain normal sodium intake while at home.

A nurse assesses an 8-year-old child and obtains a heart rate of 80 beats/minute. Which of the following is the appropriate action by the nurse?

Continue with the assessment; this is a normal finding.

The nurse is teaching a client with allergic rhinitis about the use of nasal decongestants. What information should the nurse to include in the teaching plan?

Continuous use for more than 3 days can result in worsening of symptoms.

A client has been hospitalized with pancreatitis for 3 days. The nurse assesses the client and documents the accompanying results. The nurse realizes these findings are a manifestation of what sign?

Cullen sign

After surgery to create a urinary diversion, the client is at risk for a urinary tract infection. What should the nurse do to prevent a urinary tract infection?

Empty the urinary appliance before it is one-third to one-half full.

A nurse is caring for a 10-year-old child with cystic fibrosis. The parents tell the nurse that the child needs to placed in a facility that can provide more care. What action will the nurse take?

Encourage the parents to discuss what is causing the need for placement.

After months of counseling, a client abused by their spouse tells the nurse that they have decided to stop treatment. There has been no abuse during this time, and they feel better able to cope with the needs of their spouse and children. How should the nurse begin the discussion of the decision with the client?

Find out more about the client's rationale for their decision to stop treatment.

A client's admitting diagnosis is schizophrenia with an episodic delusional disorder. The nurse applies what intervention strategy while working with the client in this pronounced delusional state?

Focus on the client's underlying feelings, and redirect inappropriate responses

A nurse is counseling a married client who has two children under 4 years of age and is experiencing intimate partner violence. Before the client leaves the clinic, what is the mostimportant thing the nurse should do?

Help the client develop a safety plan.

The nurse developed a plan of care for an adolescent who is receiving chemotherapy for lymphoma and has developed stomatitis. What statement made by the adolescent demonstrates understanding of the education provided from the plan of care?

I will rinse my mouth every 2-4 hours with baking soda and water."

A client with an exacerbation of chronic obstructive pulmonary disease (COPD) is admitted to the hospital. Which nursing diagnosis requires the nurse to collaborate with other health team members to achieve the best outcome for the client?

Impaired gas exchange

A client is admitted to a health care facility for treatment of chronic obstructive pulmonary disease. Which nursing diagnosis is most important for this client?

Impaired gas exchange related to airflow obstruction

The nurse is planning discharge teaching for a client who will continue taking the prescribed warfarin at home. What early symptoms of occult blood loss should the nurse teach the client?

Increasing fatigue and shortness of breath.

After the nurse informs the surgeon that a chest tube is malfunctioning, the health care provider asks the nurse to reposition the tube and obtain a chest radiograph. What should the nurse do?

Inform the surgeon this is not within the scope of nursing practice.

A client is diagnosed with diabetes mellitus. The health care provider orders 15 units of U-100 regular insulin and 35 units of U-100 isophane insulin suspension (NPH) to be taken before breakfast. The nurse checks the medication order, assembles equipment, washes their hands, rotates the NPH insulin vial, puts on disposable gloves, and cleans the stoppers. To draw the two insulin doses into the single U-100 insulin syringe, which sequence should the nurse use?

Inject 35 units air into NPH vial; inject 15 units air into regular insulin vial, withdraw 15 units regular insulin; withdraw 35 units NPH.

A client with suspected severe acute respiratory syndrome (SARS) comes to the emergency department. Which health care provider order should the nurse implement first?

Institute isolation precautions.

A nurse is assisting the health care provider (HCP) with the removal of a central venous access device (CVAD). What should the nurse do to prepare the client?

Instruct the client to take a deep breath and hold it.

The nurse, along with the treatment team for the client, uses critical pathways of care. Which statement regarding critical pathways is correct?

It is a care plan that provides outcome-based guidelines with a designated length of stay.

A client with lung cancer has developed an intractable, nonproductive cough that is unrelieved by nonopioid antitussive agents. The health care provider orders codeine, 10 mg PO every 4 hours. Which statement accurately describes codeine?

It's a centrally-acting antitussive and can cause dependence.

The nurse is caring for an infant with a congenital heart defect. What priority health teaching should the nurse offer to the parents of this infant?

Keep feedings small, but frequent.

A child is admitted to the hospital with a febrile seizure. What action should the nurse take?

Keep the room temperature low and bedclothes to a minimum.

A nurse, who witnesses an adolescent being thrown from a motorcycle, stops to help. The adolescent reports that they are unable to move their legs. While waiting for the emergency medical service to arrive, what should the nurse do?

Leave the adolescent as they are, staying close by.

The nurse is assessing a client who has a chest tube connected to a water-seal chest tube drainage system. According to the illustration shown, what should the nurse do?

Lower the drainage system to maintain gravity flow.

An adolescent presents with a large round ring with a swollen border on the left arm. The adolescent often plays ball games in a field behind the school. What condition does the nurse suspect?

Lyme disease

The client has a continuous bladder irrigation after a transurethral resection. Which is a nursing goal related to maintaining the irrigation?

Maintain catheter patency.

A client has just returned from the postanesthesia care unit after undergoing a laryngectomy. Which intervention should the nurse include in the plan of care?

Maintain the head of the bed at 30 to 40 degrees.

The director of an outpatient rehab program tells the nurse that a client with schizophrenia had done well for 6 months until last week, when a new person started the program. This new person worked faster than the client did and took their place as leader of the group. Based on this information, which intervention is most appropriate?

Make an appointment to meet the client at the mental health center, and ask them about the situation.

What is the most important information for the nurse to include when teaching a client about metronidazole?

Mixing this drug with alcohol causes severe nausea and vomiting.

A nurse is caring for an 8-year-old client with multiple, chronic urinary tract infections. While the nurse helps the child's parent provide morning care, the child states, "My uncle doesn't clean me that way." The parent becomes visibly upset and gives the child a stern warning not to discuss the matter. What is the priority action for the nurse?

Notify the nursing supervisor and the authorities of the possibility of abuse.

A family member of a resident in a long-term care facility reports to the nurse that their mother's diamond ring is missing. Another resident reported a day earlier that a twenty-dollar bill was missing from their night table. What should the nurse do in this situation?

Notify the supervisor and call the police.

A client doesn't make eye contact with the nurse during an interview. The nurse suspects that the client's behavior has a cultural basis. What should the nurse do first?

Observe how the client and the client's family and friends interact with one another and with other staff members.

The nurse is working in a community mental health clinic. A client who is diagnosed with schizophrenia is taking clozapine and reports of a sore throat. What is the most appropriate action for the nurse to take?

Obtain an order for the client to have a white blood cell count drawn.

A client with cancer of the throat had a tracheostomy tube inserted 2 days ago. The client has moderate secretions and can take deep breaths without pain. When suctioning a client's tracheostomy tube, the nurse should take which action?

Oxygenate the client before suctioning.

Which laboratory test should the nurse monitor when the client is receiving warfarin sodium therapy?

PT

A newborn who is 20 hours old has a respiratory rate of 66 breaths/min, is grunting when exhaling, and has occasional nasal flaring. The newborn's temperature is 98°F (36.6°C); the baby is breathing room air and is pink with acrocyanosis. The birth parent had membranes that were ruptured 26 hours before birth. What nursing action is most indicated?

Place a pulse oximeter, and request a prescription to draw blood cultures.

During the initial assessment, the nurse notes that the neonate's hands and feet appear blue while the neonate's torso appears pale pink. What action should the nurse take next?

Place the infant skin to skin with the birth parent.

A client with a history of a substance use disorder gives birth to a low-birth-weight neonate who is experiencing drug withdrawal. Which intervention is helpful for this neonate?

Place the isolette in a quiet area of the nursery.

A 12-year-old has a fractured femur and is immobilized in traction as shown in the figure. What should the nurse do?

Provide opportunities for age-appropriate activities.

A client diagnosed with conversion disorder has a paralyzed arm. A staff member states, "I would just tell the client their arm is paralyzed because they had an affair and neglected their baby's care to the point where the baby had to be hospitalized for dehydration." Which response by the nurse is best?

Pushing insight will increase the client's anxiety and the need for physical symptoms."

The nurse is teaching a client who had a lobectomy for lung cancer and the client's partner how to promote comfort and optimal respiratory expansion during sexual intimacy. What can the nurse suggest the couple do?

Raise the affected partner's head and upper torso on pillows.

A client is diagnosed with genital herpes (herpes simplex virus type 2, or HSV-2). What information should the nurse give to the client about managing this health problem?

Reducing stressful life events may decrease the incidence of herpetic outbreaks.

A 26-week gestation pregnant client has completed a 1-hour glucose screening test. What action should the nurse take first if the glucose level is 150 mg/dL (8.3 mmol/L)?

Refer the client for a 3-hour glucose test.

A nurse in a psychiatric care unit finds that a client with psychosis has become violent and has struck another client in the unit. What action should the nurse take in this case?

Restrain the client, as they are harmful to the other clients.

The nurse is caring for a client with a nasogastric tube who is receiving intermittent tube feedings by gravity every 4 hours. The nurse aspirates 75 mL of residual prior to the next feeding. What action should the nurse take next?

Return the residual and begin the feeding.

The nurse is conducting a health assessment of an older adult. The client tells the nurse about cramping leg pain that occurs when walking for 15 minutes; the pain is relieved with rest. The lower extremities are slightly cool to touch, and pedal pulses are palpable +1. What should the nurse instruct the client to do?

Seek consultation from the health care provider.

A client is disruptive to other clients and constantly walks about the unit interrupting others. Which plan should the nurse institute first?

Set limits on the client's behavior; explain what is expected and what the consequences will be if limits are violated.

An appropriate nursing diagnosis for a bedridden and hospitalized client who tells the nurse that they are upset because they haven't missed a Methodist church service in 50 years is

Spiritual distress related to inability to attend church services evidenced by verbal states of guilt.

A nurse is about to admit a client to the medical surgical unit directly from the health care provider's office. Upon assessment, the nurse notes that the client has significant periorbital edema. Laboratory values indicate the presence of proteinuria and hypoproteinemia. Which action is the nurse's priority?

Strict intake and output assessment and documentation

A client undergoes a tracheostomy after many failed attempts at weaning them from a mechanical ventilator. Two days after tracheostomy, while the client is being weaned, the nurse detects a mild air leak in the tracheostomy tube cuff. What should the nurse do first?

Suction the client, withdraw residual air from the cuff, and reinflate it.

A 23-year-old pregnant client diagnosed with schizophrenia cheerfully announces, "My parents and I are so excited that I'm pregnant. They're willing to help us take care of the baby too." Which reason should cause the nurse to be concerned about this situation?

Symptom management will be difficult in early pregnancy without medications.

The nurse is planning to teach a client with chronic obstructive pulmonary disease (COPD) how to cough effectively. Which instruction should be included?

Take a deep abdominal breath, bend forward, and cough three or four times on exhalation.

An older adult client asks the nurse how to treat chronic constipation. What is the best recommendation the nurse can make?

Take a stool softener such as docusate sodium daily.

A 10-year-old client has arrived to sleepover summer camp. The child's parent states that the client has just been diagnosed with insulin-dependent diabetes mellitus but does not perform self-injections. The child is nervous, cries, and jerks away when the nurse initially attempts to give insulin. Which is the best nursing action?

Teach the child to self-administer the insulin injections.

A client with rib fractures and a pneumothorax has a chest tube inserted that is connected to a water-seal chest tube drainage system. The nurse notes that the fluid in the water-seal column is fluctuating with each breath that the client takes. What is the significance of this fluctuation?

The chest tube system is functioning properly.

When attempting to check the pupils of a client scheduled to receive general anesthesia, the nurse notices that the client has trouble tilting their head back. What is the primary concern related to this finding?

The client is at risk for difficult intubation.

A client has aggressive cancer with only a few months to live. The nurse observes the client is sitting in the bed with legs crossed, hands on knees, head bowed, eyes closed, and taking slow, deep breaths. What does this observation indicate to the nurse?

The client is using a form of relaxation.

After having transurethral resection of the prostate (TURP), a client returns to the unit with a three-way indwelling urinary catheter and continuous closed bladder irrigation. Which finding suggests that the client's catheter is occluded?

The client reports bladder spasms and the urge to void.

A nurse is caring for a client with schizophrenia. Which outcome requires revising the client's care plan?

The client spends more time alone.

Oxygen at the rate of 2 liters per minute through nasal cannula is prescribed for a client with chronic obstructive pulmonary disease (COPD). Which of the following statements best describes why the oxygen therapy is maintained at a relatively low concentration?

The client's respiratory center is so used to high carbon dioxide and low oxygen levels that changing these levels may eliminate their stimulus for breathing.

The nurse is reviewing the client's lab values. On admission, the client's arterial blood gas (ABG) values were pH, 7.20; PaO2, 64 mm Hg (8.5 kPa); PaCO2, 60 mm Hg (8 kPa); and HCO3-, 22 mEq/L (22 mmol/L). A chest tube is inserted, and oxygen at 4 L/min is started. Thirty minutes later, repeat ABG values are pH, 7.30; PaO2, 76 mm Hg (10.1 kPa); PaCO2, 50 mm Hg (6.7 kPa); and HCO3-, 22 mEq/L (22 mmol/L). Which judgment should the nurse make about the changes in the client's blood gases?

The client's respiratory status is improving.

During inspiration, which action occurs?

The diaphragm descends.

A laboring client smiles pleasantly at the nurse when asked simple questions. The client speaks only Mandarin, and the interpreter is busy with an emergency situation. At the client's last vaginal examination, the client was 5 cm dilated, 100% effaced, and at 0 station. While working with this client, the nurse understands that which response indicates the client may be approaching birth?

The fetal monitor strip shows early decelerations.

A client arrives at a public health clinic worried that they have breast cancer after finding a lump in their breast. When assessing the breast, which assessment finding provides an indication that the lump is more typical of fibrocystic breast disease?

The lump is round and movable.

A nurse is helping a client who is suspected of choking. When should the nurse perform the Heimlich maneuver?

The victim cannot speak due to airway obstruction.

The nurse is developing a teaching plan with a client diagnosed with genital herpes. What is the most important information for the nurse to include in the teaching plan?

Use condoms at all times during sexual intercourse.

A client in acute kidney injury has an external cannula inserted in the forearm for hemodialysis. Which nursing measure is appropriate for the care of this client?

Use the unaffected arm for blood pressure measurements

A client has just undergone a bronchoscopy. Which nursing interventions are appropriate after this procedure? Select all that apply.

Withhold food and fluids until the client's gag reflex returns, Assess for hemoptysis and frank bleeding, and Monitor the client's vital signs.

A client with a tentative diagnosis of psychosis is admitted to the psychiatric unit. A health care provider orders the phenothiazine thioridazine 50 mg by mouth three times per day. Phenothiazines differ from central nervous system (CNS) depressants in their sedative effects by producing:

a calming effect from which the client is easily aroused.

An inpatient psychiatric nurse has received a report on the nurse's assigned clients. Which client should the nurse see first?

a client with schizophrenia who is suspicious of staff

The parents of a teenager recently diagnosed with schizophrenia ask the nurse about whether their other children will be susceptible as well. The nurse explains that schizophrenia is caused by:

a combination of biological, psychologic, and environmental factors.

The client asks the nurse, "How can I tell whether my baby is spitting up or vomiting?" The nurse explains that, in contrast to regurgitated material, vomited material has which characteristic?

a curdled appearance

A client periodically has acute panic attacks. These attacks are unpredictable and have no apparent association with a specific object or situation. During an acute panic attack, the client may experience:

a decreased perceptual field.

An infant is admitted to the hospital with dehydration secondary to viral gastroenteritis. Which room assignment is the most appropriate for this infant?

a private room

The nurse manager on a psychiatric unit is reviewing the outcomes of staff participation in an aggression management program. What indicator would the nurse use to evaluate the effectiveness of such a program?

a reduction in the total number of restraint procedures

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 needed when the parents put the infant in which position?

abdomen, with legs pulled up under the body

The health care provider prescribes intravenous (IV) fluid replacement therapy with potassium chloride to be added for a child with severe gastroenteritis. Before the nurse hangs the IV fluids with potassium chloride, which assessment would be most important?

ability to void

The nurse is assessing a client with a right pneumothorax. Which assessment findings would be expected? Select all that apply.

absence of breath sounds in the right thorax and chest pain on inspiration

A client has refused to take a shower since being admitted 4 days earlier and tells a nurse, "There are poison crystals hidden in the showerhead. They'll kill me if I take a shower." Which nursing action is most appropriate?

accepting these fears and allowing the client to take a sponge bath

A pregnant client late in the first trimester comes to the clinic for a follow-up visit. The client tells the nurse that they have been having morning sickness, but they "tried using this band on their wrist," and it helped cut down on the number of episodes they were having. The nurse interprets this therapy as an example of

acupuncture

A client comes to the emergency department reporting severe pain in the right flank, nausea, and vomiting. The health care provider tentatively diagnoses right ureterolithiasis (renal calculi). When planning this client's care, the nurse should assign the highest priority to which nursing diagnosis?

acute pain

A client, diagnosed with asthma, is experiencing an anaphylactic reaction to a medication. Which action should the nurse take after administering initial emergency care?

administer bronchodilators

When prioritizing a client's care plan based on Maslow's hierarchy of needs, a nurse's first priority would be

administering pain medication.

A nurse documents, "The client described the partner's abuse in an emotionless tone and with a flat facial expression." This statement describes the client's:

affect.

An older adult is admitted to the hospital with a diagnosis of bacterial pneumonia. While obtaining the client's health history, the nurse learns that the client has osteoarthritis, follows a vegetarian diet, and is very concerned with cleanliness. Which client information would most likely be a predisposing factor for the diagnosis of pneumonia?

age

A client on the behavioral health unit reports palpitations, trembling, and nausea while traveling alone, outside the home. These symptoms have severely limited the client's ability to function and have caused the client to avoid leaving home whenever possible. The nurse recognizes that this client has symptoms of what disorder?

agoraphobia

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

An adult recently diagnosed with Hodgkin's disease is admitted for staging by undergoing a bone marrow aspiration and biopsy. To obtain more information about the client's nutritional status, the nurse should review the results of which test?

albumin level

At 2300, a client is admitted to the emergency department with a respiratory rate of 44 breaths/minute and audible wheezes. Oxygen and methylprednisolone IV are administered. At 2330, the client's oxygen saturation is 86%, with wheezing present. Which medication will the nurse plan to administer next?

albuterol (salbutamol) nebulizer

A client experiencing a severe asthma attack has the following arterial blood gas results: pH 7.33 partial pressure of arterial carbon dioxide (PaCO2) 48 mm Hg (6.4 kPa) partial pressure of arterial oxygen (PaO2) 58 mm Hg (7.7 kPa) bicarbonate (HCO3−) 26 mEq/L (26 mmol/L) Which prescription should the nurse implement first?

albuterol nebulizer

A small-for-gestational-age infant is born with facial abnormalities and vision abnormalities. These abnormalities are likely caused by which maternal factor?

alcohol consumption

A nurse is caring for a client on antipsychotic medication who reports muscle weakness, slurred speech, and involuntary twitching. Which medication is most important for the nurse to administer?

amantadine

While caring for a term neonate just born, the nurse observes that the neonate's clitoris is enlarged and there is some fusion of the posterior labia majora. The nurse should notify the health care provider because these findings are associated with which problem?

ambiguous genitalia

A client who is paraplegic cannot feel the lower extremities and has been positioned on the side. The nurse should inspect which area that is a potential pressure point when the client is in a side-lying position?

ankles

A client is diagnosed with a chronic respiratory disorder. After assessing the client's knowledge of the disorder, the nurse prepares a teaching plan. This teaching plan is most likely to include which nursing diagnosis?

anxiety

A client diagnosed with acute pancreatitis 5 days ago is experiencing respiratory distress. Which finding should the nurse report to the health care provider (HCP)?

arterial oxygen level of 46 mm Hg (6.1 kPa)

A nurse is preparing a client with a pleural effusion for a thoracentesis. The nurse should

assist the client to a sitting position on the edge of the bed, leaning over the bedside table.

A client with end-stage pulmonary hypertension tells the health care provider they don't want any heroic measures should their heart stop, and don't want to be placed on a ventilator. The health care provider enters a do-not-resuscitate order into the hospital's computer system. Which ethical principle is the nurse upholding by supporting the client's decision?

autonomy

A client receiving external radiation to the left thorax to treat lung cancer has a nursing diagnosis of Risk for impaired skin integrity. Which intervention should be part of this client's care plan?

avoiding using deodorant soap on the irradiated areas

The nurse teaches a child with leukemia about a scheduled bone marrow aspiration, The nurse determines that the teaching has been successful when the child identifies which place as the site for the aspiration?

back of the hipbone

After a vaginal birth, a preterm neonate is to receive oxygen via mask. While administering the oxygen, the nurse would place the neonate in which position?

back, with the neck slightly extended

Before weaning a client from a ventilator, which assessment parameter is the most important for the nurse to obtain?

baseline arterial blood gas (ABG) levels

A nurse is providing anticipatory guidance to the family of a school-age child with acute lymphocytic leukemia. Which recommendation should the nurse make?

being treated as "normal" as much as possible

A client with benign prostatic hypertrophy (BPH) is being treated with terazosin 2 mg at bedtime. What should the nurse tell the client to monitor regularly?

blood pressure

The nurse is preparing to administer vitamin K to a 1-hour-old newborn. Which newborn would have the highest potential for hemorrhage?

born to a birth parent who took phenytoin during pregnancy and is breastfeeding

A client who is receiving chemotherapy is not eating well but otherwise feels healthy. What should the nurse suggest the client eat?

broiled chicken, green beans, and cottage cheese

Which finding would the nurse most expect to find in a neonate born at 28 weeks' gestation who is diagnosed with intraventricular hemorrhage (IVH)?

bulging fontanelles

The nurse assesses an infant with an undescended testis. The nurse should be alert for which symptom?

bulging in the inguinal area

The nurse teaches a parent about feeding an infant with colic. The nurse determines that the parent has understood the teaching when the nurse observes the parent doing which action?

burping the infant during and after the feeding

In the emergency department, a client with facial lacerations states that the spouse beat the client with a shoe. After the lacerations are repaired, the client waits to be seen by the crisis intake nurse, who will evaluate the continued threat of violence the spouse represents. Suddenly the client's spouse arrives, shouting a desire to "finish the job." What is the first priority of the nurse who witnesses this scene?

calling a security guard and another staff member for assistance

The nurse is planning for home care with a client after transurethral resection of the prostate (TURP). What should the nurse tell the client about the dribbling of urine after this surgery? Dribbling of urine:

can persist for several months.

A client undergoes a biopsy of a suspicious lesion. The biopsy report classifies the lesion according to the TNM staging system as follows: TIS, N0, M0. What does this classification mean?

carcinoma in situ, no abnormal regional lymph nodes, and no evidence of distant metastasis

A client with chronic kidney disease (CKD) has a blood urea nitrogen (BUN) of 100 mg/dL, serum creatinine of 6.5 mg/dL, potassium of 6.1 mEq/L, and lethargy. What is the priority nursing assessment?

cardiac rhythm

A client with human papillomavirus (HPV) infection is being treated by a colposcopy. The client asks the nurse if this procedure is really necessary. The nurse can tell the client that if the HPV infection is not treated which health problem is likely to occur?

cervical cancer

A client with emphysema is at a greater risk for developing what acid-base imbalance?

chronic respiratory acidosis

The nurse is facilitating a group of clients with schizophrenia when one client says, "I like to drive my car, bar, tar, far." This client is exhibiting:

clang association.

A nurse is assigned to triage the care of four clients. Which client should the nurse assess first?

client with a sore throat who now has a muffled voice and is drooling

One of the myths about sexual abuse of young children is that it usually involves physically violent acts. Which behavior is more likely to be used by the abusers?

coercion as a result of the trusting relationship

A client admitted with tuberculosis reports concerns about paying for needed medications. The nurse should:

collaborate with the social worker to investigate possible availability of funds

A nurse enters a client's room and finds that the client is lying on the floor. The nurse makes the client comfortable on the bed and completes an assessment. The nurse then informs the health care provider and the nursing supervisor about this incident and also completes an incident report. Which actions by the nurse indicates correct knowledge of handling an incident report?

completes a full incident report

An 11-month-old infant is admitted to the hospital with severe diarrhea. To determine the severity of the diarrhea, the nurse should assess which stool characteristic?

consistency

A client reports experiencing vulvar pruritus. Which assessment factor may indicate that the client has an infection caused by Candida albicans?

cottage cheese-like discharge

A client has undergone a left hemicolectomy for bowel cancer. Which combination of activities is most effective in preventing the occurrence of postoperative pneumonia in this client?

coughing, breathing deeply, frequent repositioning, and using an incentive spirometer

A client develops decreased renal function and requires a change in antibiotic dosage. On which factor should the health care provider base the dosage change?

creatinine clearance

The nurse receives the preoperative blood work report for a client who is scheduled to undergo surgery. Which laboratory finding should the nurse report to the surgeon and anesthesiologist?

creatinine, 2.6 mg/dL (230 µmol/L)

A client in the rehabilitation unit eloped in the morning and has not returned. The nurse manager is conducting a post-elopement huddle. What information should be included in the huddle? Select all that apply.

data collection on the incident brainstorming to prevent future elopement updating staff on the status of the search

The nurse is assessing a client with kidney failure. Which finding is concerning?

decreased urine output

The nurse assesses a child with ketoacidosis. What manifestation is supportive of the diagnosis of ketoacidosis?

deep, rapid respirations

The nurse is conducting a home visit with a school-age child with a physical disability. What behaviors by the child alert the nurse to overprotective parenting?

dependency, fearfulness, and lack of outside interests

A child, age 6, is anxious and upset before a scheduled bone marrow aspiration. During client preparation, the nurse should keep in mind that:

describing what the child will hear, see, smell, and feel will help the child cope with the procedure.

A recent immigrant is diagnosed with pulmonary tuberculosis (TB). Which intervention is the most important for the nurse to implement with this client?

developing a list of people with whom the client has had contact

A nurse is assessing whether a 6-year-old child has received all required immunizations. Which immunizations does the nurse expect to be documented?

diphtheria, tetanus, and acellular pertussis (DTaP); measles, mumps, and rubella (MMR); and inactivated polio virus (IPV)

A nurse must assess a client's judgment to determine the client's mental status. To best accomplish this, the nurse should have the client:

discuss hypothetical ethical situations.

A client becomes angry and belligerent toward the nurse after speaking on the phone with the client's parent. The nurse recognizes this as what defense mechanism?

displacement

A nurse and a nursing student are leading a group counseling session for clients with depression who have attempted suicide in the past. Which topic, if selected by the student, would indicate to the nurse that the student needs further education on this group's discussion topics?

dramatization of suicidal behavior in society

Which instruction should the nurse give to a client with prostatitis who is receiving double strength co-trimoxazole?

drink six to eight glasses of fluid daily while taking this medication

The nurse cares for a child in the immediate postoperative period after cleft palate repair. Which type of restraints is best for the nurse to use?

elbow restraints

The health care provider suspects tracheoesophageal fistula in a 1-day-old neonate. Which nursing intervention is most appropriate for this child?

elevating the neonate's head and giving nothing by mouth

According to Erikson, the psychosocial task of adolescence is the development of a sense of identity. A nurse can best promote the development of a hospitalized adolescent by:

encouraging peer visitation.

A nurse is caring for a client with schizoaffective disorder. The client is currently experiencing auditory hallucinations. Which nursing actions would take first priority for this client?

engaging the client in reality-based conversations

A client is transferred from the emergency department to the locked psychiatric unit after attempting suicide by taking 200 acetaminophen tablets. The client is now awake and alert but refuses to speak with the nurse. In this situation, the nurse's first priority is to:

ensure safety by initiating suicide precautions.

30-year-old multigravid client pregnant with dizygotic twins at 37 weeks' gestation is being continuously monitored with electronic fetal monitoring. After giving instruction about the purpose of the electronic monitoring, the nurse determines that the client needs further instruction when they say that an electronic monitor performs which function?

ensures a more comfortable atmosphere for the client and labor

The nurse is working with a client with depression in a mental health clinic. During the interaction, the nurse uses the technique of self-disclosure. In order for this technique to be therapeutic, which step must be a priority for the nurse?

ensuring relevance to, and quickly refocusing upon, the client's experience

A client with type 2 diabetes mellitus who is taking metformin is scheduled for a computed tomography (CT) with contrast of the abdomen tomorrow. Which priority nursing assessment is done before the procedure?

ensuring that the metformin has been withheld for 48 hours prior to the scan

When preparing for the discharge of a newborn after surgery to correct tracheoesophageal fistula (TEF), the nurse teaches the parents about the need for long-term health care because their child has a high probability of developing which complication?

esophageal stricture

A client with schizophrenia comes to the outpatient mental health clinic 5 days after being discharged from the hospital. The client was given a 1-week supply of clozapine. The client tells the nurse that they have too much saliva and frequently need to spit. The nurse interprets the client's statement as being consistent with which factor?

expected adverse effect of clozapine

A nurse is using drawing, puppetry, and other forms of play therapy while treating a terminally ill, school-age child. The purpose of these techniques is to help the child:

express feelings that the child can't articulate.

Which action is the best precaution against transmission of infection?

eye prophylaxis with antibiotics for a neonate whose birth parent has gonorrhea infection

An adolescent is brought to the hospital emergency department in a state of unconsciousness after having swallowed "a bottle of pain pills" 45 minutes earlier. The pills are identified as oxycodone. A suicide note is found that asks for forgiveness. Which measure should the nurse be prepared to carry out when this client is admitted?

giving naloxone IV

A client begins clozapine therapy after several other antipsychotic agents fail to relieve psychotic symptoms. The nurse instructs the client to return for weekly white blood cell (WBC) counts to assess for which adverse reaction?

granulocytopenia

A client with schizophrenia is admitted to the psychiatric unit of a local hospital. During the next several days, the client is seen laughing, yelling, and talking out loud to no one. This behavior is characteristic of:

hallucination.

A nurse knows that a health care provider has ordered the liquid form of the drug chlorpromazine rather than the tablet form because the liquid:

has a more predictable onset of action.

A nurse is assessing the growth and development of a 10-year-old. What is the expected behavior of this child?

has a strong sense of justice and fair play

The nurse is instructing a client with acute asthma who is taking short-term corticosteroid therapy. The nurse should tell the client that steroids will have which expected outcome?

have an anti-inflammatory effect

Several former clients from a mental health facility have recently collected their stories to corroborate that a nurse working there has attempted to befriend them. The clients state that during their therapy, the nurse encouraged them to invest in a new business. The nursing supervisor, upon hearing of the clients' reports, begins an investigation. How can the nursing supervisor best describe the nurse's behavior with these former clients?

having poor boundaries

The health care provider (HCP) has determined that a preterm labor client at 34 weeks' gestation has no fetal fibronectin present. Based on this finding, the nurse would anticipate which other finding within the next week?

he client will not develop preterm labor.

The nurse assesses a child with meningitis. Which finding would lead the nurse to suspect that the child has developed disseminated intravascular coagulation?

hemorrhagic skin rash

A client with human immunodeficiency virus (HIV) infection gives birth to a neonate. When assessing the neonate, the nurse is most likely to detect

hepatosplenomegaly.

The nurse is teaching the client with chronic obstructive pulmonary disease (COPD) about obtaining the best nutrition. Which diet would be best for this client?

high-calorie, high-protein diet

While assessing a neonate weighing 3175 g (3.2 kg) who was born at 39 weeks' gestation to a primiparous client who reports opiate use during pregnancy, the nurse understands that which finding would indicate possible opiate withdrawal?

high-pitched cry

A nurse consulting with a nutrition specialist knows it's important to consider a special diet for a client with chronic obstructive pulmonary disease (COPD). Which diet is appropriate for this client?

high-protein

An older adult client's lithium level is 1.4 mEq/L. The client reports diarrhea, tremors, and nausea. The nurse should:

hold the lithium and notify the health care provider.

The nurse enters a child's room to administer medications and notices that the child is missing. The nurse cannot find the child in the immediate area, including the playroom. Who does the nurse notify first?

hospital security

The nurse evaluates the care of an adolescent with a recent spinal cord injury. Which finding should lead the nurse to determine that spinal shock was resolving?

hyperactive reflexes

The nurse is admitting a client with a history of bipolar mania. Which assessment finding is the priority when developing a plan of care?

hyperactivity, ignoring eating, and sleeping

The client with depression has been hospitalized for 3 days on the psychiatric unit. This is the second hospitalization during the past year. The health care provider prescribes tranylcypromine sulfate because the client did not respond positively to a tricyclic antidepressant. If the client's diet includes foods containing tyramine, the nurse should teach the client about which possible reaction?

hypertensive crisis

A 31-year-old multigravid client at 39 weeks' gestation admitted to the hospital in active labor is receiving intravenous lactated Ringer's solution and a continuous epidural anesthetic. During the first hour after administration of the anesthetic, the nurse should monitor the client for which adverse reaction?

hypotension

A home health nurse is visiting a home care client with advanced lung cancer. Upon assessing the client, the nurse discovers wheezing, bradycardia, and a respiratory rate of 10 breaths/minute. These signs are associated with which condition?

hypoxia

A child has discomfort and swelling around the IV insertion site. Which assessment should the nurse make first?

if the intravenous catheter has come out of the vein

After teaching a client about the neonate's positive Babinski reflex, the nurse determines that the birth parent understands the instructions when they say that a positive Babinski reflex indicates which condition?

immaturity of the central nervous system

The nurse is caring for a hospitalized client who has a disorder of the amygdala. Which symptom can the nurse anticipate the client will have?

impulsive acts of aggression

Upon analysis of a client's arterial blood gas results, the nurse determines that the concentration of carbon dioxide and hydrogen ions are elevated and the oxygen in the arterial blood is decreased. What respiratory assessment findings would the nurse anticipate in a client with these arterial blood gas results?

increase in rate and depth of respirations

A nurse is caring for a client with acute pyelonephritis. Which nursing intervention is the mostimportant?

increasing fluid intake to 3 L/day

A client with multiple trauma and acute respiratory insufficiency is admitted to the intensive care unit (ICU). The health care provider's orders arterial blood gas (ABG) analysis to determine the client's ventilatory and gas exchange status. Because the client's arms are in casts from above the elbow to the fingertips, the ABG sample is taken from the femoral artery. After the sample is drawn, the nurse should make a recommendation to the health care provider for which priorityintervention?

indwelling arterial catheter

A nurse is caring for a 9-year-old child with a grave prognosis after sustaining a closed-head injury. The child is on mechanical ventilation without spontaneous respirations. What is the nurse's highest priority related to the potential for organ donation?

initiating referral to a transplant coordinator as soon as possible

The nurse cares for an adolescent after an appendectomy. Which client action would the nurse judge to be a healthy coping behavior?

insisting on wearing a T-shirt and gym shorts rather than pajamas

Erikson described the psychosocial tasks of the developing person in their theoretical model. They proposed that the primary developmental task of the young adult (ages 18 to 25) is:

intimacy versus isolation.

A nurse is planning care for an adolescent client who is 12 weeks' gestation. The nurse will monitor this client closely for the development of which complication during this stage of the pregnancy?

iron-deficiency anemia

A client is prescribed metaproterenol via a metered-dose inhaler, two puffs every 4 hours. The nurse should instruct the client to report which adverse effect?

irregular heartbeat

A client who used heroin during the pregnancy gives birth to a neonate. When assessing the neonate, the nurse expects to find

irritability and poor sucking.

A client with early dementia exhibits disturbances in mental awareness and orientation to reality. The nurse should expect to assess a loss of ability in which other area?

judgment

A nurse is working with a student nurse who is caring for a client with an acute bleeding cerebral aneurysm. Which action by the student nurse requires further intervention?

keeping the client in one position to decrease bleeding

A client suffers acute respiratory distress syndrome as a consequence of shock. The client's condition deteriorates rapidly, and endotracheal (ET) intubation and mechanical ventilation are initiated. When the high-pressure alarm on the mechanical ventilator sounds, the nurse starts to check for the cause. Which condition triggers the high-pressure alarm?

kinking of the ventilator tubing

The nurse assesses the development of a 1-month-old infant. Which skills should the nurse ask the parent if the infant is able to demonstrate?

lift their head from the prone position

A client with schizoaffective disorder is brought to the hospital by a family member. The family member states that the client is having an increase in auditory hallucinations and is becoming significantly more withdrawn. The nurse reviewing the admission blood work expects which blood level to be subtherapeutic?

lithium carbonate

Which group of characteristics should a nurse expect to see in the client with schizophrenia?

loose associations, grandiose delusions, and auditory hallucinations

The nurse is developing a care plan for a client with chronic obstructive pulmonary disease (COPD). What is the priority goal of this care plan?

maintaining functional ability

During therapy, a client on the mental health unit is restless and is starting to make sarcastic remarks to others in the therapy session. The nurse responds by saying, "you look angry." Which communication techniques is the nurse using?

making observations

For a client who has a chest tube connected to a closed water-seal drainage system, the nurse should include which action in the care plan?

measuring and documenting the drainage in the collection chamber

Which is the appropriate nursing intervention for a client with pruritus caused by medications used to treat cancer?

medicated cool baths

A client with a chronic mental illness who does not always take their medications is separated from their spouse and receives public assistance funds. The client lives with their parent and older sibling and manages their own medication. The client's parent is in poor health and also receives public assistance benefits. The client's sibling works outside the home, and the client's other parent is dead. Which issue should the nurse address first?

medication compliance

After being seen in the oncology clinic, a client with severe bone marrow suppression is admitted to the hospital. The client's cancer therapy consisted of radiation and chemotherapy. When developing the care plan for this client, the nurse prioritizes which nursing intervention?

monitoring temperature and blood cell count

A client diagnosed with cancer of the cervix in situ is scheduled to have a conization. Which is a priority during the first 24 postoperative hours?

monitoring vaginal bleeding

A client who is a painter recently fractured a tibia and can't work. The client worries about finances. To treat the client's anxiety, the health care provider orders buspirone, 5 mg by mouth three times per day. Which drugs interact with buspirone?

monoamine oxidase (MAO) inhibitors

The nurse is assessing a client with a darker-skin tone in need of emergency care for acute respiratory distress. Which area would the nurse inspect when assessing for cyanosis in this client?

mucous membranes

The nurse assesses an aggressive client. Which behavior warrants the nurse's prompt reporting and use of safety precautions?

naming another client as their adversary

The nurse managers of a home health care office wish to maximize nurses' freedom to characterize and record client conditions and situations in the nurses' own terms. Which documentation format is most likely to promote this goal?

narrative notes

The health care provider (HCP) has determined that a primigravid client in active labor requires a cesarean birth because of cephalopelvic disproportion. After the birth of a healthy neonate, which assessment should the nurse make first?

nasopharyngeal secretions

A client who's taking antipsychotic medication develops a very high temperature, severe muscle rigidity, tachycardia, and rapid deterioration in mental status. What complication of antipsychotic therapy does the nurse suspect?

neuroleptic malignant syndrome

A client with schizophrenia started risperidone 2 weeks ago. Today, the client reports feeling flu-like symptoms. The nurse's assessment reveals the following: temperature 104.4° F (40.2° C), respirations 24 breaths/minute, blood pressure 130/102 mm Hg, pulse rate 120 beats/minute. The nurse also notes muscle stiffness and pain, excessive sweating and salivation, and changes in mental status. The nurse suspects the client is experiencing:

neuroleptic malignant syndrome.

The nurse is planning care with a client with acute leukemia who has mucositis. What should the nurse advise the client to use for mouth care?

normal saline

A person calls the neonatal intensive care unit stating that their child is receiving care there. They tell the nurse that they and their spouse "aren't together," and requests information about their child's condition. The nurse should

obtain more data before giving the caller any confidential information.

A nurse is caring for a newly admitted client on the psychiatric unit. The nurse would most hinder therapeutic communication by performing what action?

offering advice and opinions

A nurse is teaching a community class about how to decrease the risk of cancer. What is the bestfood for the nurse to recommend?

oranges

A health care provider has entered orders for a client with chronic obstructive pulmonary disease (COPD). Which order should the nurse question?

oxygen increased to 3 L/minute if oxygen saturation is less than 94% on room air

A neonate receives an Apgar score of 6 at 5 minutes of age. What additional assessment will the nurse prioritize for this 5-minute Apgar score?

oxygen saturation

A nurse assesses arterial blood gas results for a client in acute respiratory failure (ARF). Which result is consistent with this disorder?

pH 7.28, PaO2 50 mm Hg

A client with acute diarrhea is requesting an as-needed medication for loose, watery stools. After reviewing the health care provider's orders, which medication should the nurse administer?

paregoric 5 ml P.O.

A nurse is obtaining a history from a client. The client reports being a waiter. When asked about the work environment, the client says, "If customers confront me for not being attentive enough, I just spit on their food." The nurse suspects the client is prone to which type of behavior?

passive-aggressive

A pregnant client is diagnosed with group B streptococcus chorioamnionitis. The nurse should expect to administer which medication to prevent fetal transmission?

penicillin G potassium I.V. to the client

The nurse is teaching a client with chronic obstructive pulmonary disease (COPD) to assess for signs and symptoms of right-sided heart failure. Which sign/symptom should be included in the teaching plan?

peripheral edema

A 3-year-old child has arrived in the emergency department. The nurse documents the following assessment findings in the client's chart, knowing that they are consistent with which disease process?

pneumonia

A 9-year-old child is admitted to the pediatric unit for treatment of cystic fibrosis. A nurse assessing the child's respiratory status should expect to identify:

production of thick, sticky mucus.

A postoperative client is receiving heparin after developing thrombophlebitis. The nurse monitors the client carefully for bleeding and other adverse effects of heparin. If the client starts to exhibit signs of excessive bleeding, the nurse should expect to administer an antidote that is specific to heparin. Which agent fits this description?

protamine sulfate

A client with a cocaine use disorder is irritable, anxious, highly sensitive to stimuli, and overreacting to clients and staff on the unit. Which action is most therapeutic for this client?

providing the client with frequent "time-outs"

A client is scheduled for a renal arteriogram. No allergies are recorded in the client's medical record, and the client is unable to provide allergy information. During the arteriogram, the nurse should be alert for which assessment finding that may indicate an allergic reaction to the dye used?

pruritus

Parents who bring a 3-week-old neonate to the hospital report that the infant has been "throwing up after every feeding." A nurse notes projectile vomiting while assessing the neonate. X-rays confirm

pyloric stenosis

A client diagnosed with a cognitive disorder is showing signs of confusion, short-term memory loss, and a short attention span. Which therapy group would be best suited for this client?

reality orientation

The nurse needs to assess an infant's height to determine if the infant is meeting appropriate growth and development parameters. To obtain the most accurate measurement of an infant's height (length), the nurse measures the:

recumbent height with the infant supine.

A client with acquired immunodeficiency syndrome is receiving zidovudine. Which laboratory value indicates an adverse reaction to zidovudine?

red blood cell (RBC) count of 1.8 million/μl (1.8 million x 10 to the 12th/L)

A nurse is admitting a client with possible borderline personality disorder. The client has called the nurse every 15 minutes with one request or another. Which behavior should the nurse give priority to when planning care?

regression

When upset, a client curls into a fetal position in bed. The nurse judges the client to be exhibiting which condition?

regression

The nurse is administering theophylline ethylenediamine to a client with chronic obstructive pulmonary disease. Which is an expected outcome of administering this drug?

relaxed bronchial smooth muscle

A client refuses the evening dose of haloperidol and then becomes extremely agitated in the day room while other clients are watching television. The client begins cursing and throwing furniture. The nurse's first action is to:

remove all other clients from the day room.

The nurse is teaching a client who will be undergoing a lung resection. The client is told that two chest tubes will be placed during surgery. When the nurse is evaluating the effectiveness of the tube placed lowest in the pleural cavity, what is the purpose of this chest tube?

removing fluid

A nurse is developing a care plan for a client who has undergone electroconvulsive therapy (ECT). The nurse should include which intervention?

reorienting the client to time and place

A client had surgery for a deviated nasal septum. Which finding would indicate that bleeding is occurring even if the nasal drip pad remains dry and intact?

repeated swallowing

Which term refers to the primary unconscious defense mechanism that blocks intense, anxiety-producing situations from a person's conscious awareness?

repression

A neonate weighing 1870 g (4.1 lb) with a respiratory rate of 46 breaths/minute, a pulse rate of 175 bpm, and a serum pH of 7.11 (reference range 7.35 to 7.45) has received sodium bicarbonate intravenously. The drug has been effective if the neonate exhibits which finding?

resolves the metabolic acidosis

A nurse is caring for a client after an open lung biopsy. Which assessment finding requires immediate intervention?

respiratory rate of 44 breaths/minute

The health care provider (HCP) has prescribed pseudoephedrine. The nurse should instruct the client about which possible adverse effect of this drug?

restlessness

A client with renal failure is undergoing continuous ambulatory peritoneal dialysis. Which nursing diagnosis is the most appropriate for this client?

risk for infection

The nurse assesses an adolescent's musculoskeletal system. According to the figure, the nurse should note that the adolescent has which condition?

scoliosis

What is a generally accepted criterion of mental health?

self-acceptance

A 28-year-old client is diagnosed with acute epididymitis. What should the nurse assess the client for when conducting a focused assessment?

severe tenderness and swelling in the scrotum

A 30-year-old client is being treated for epididymitis. What information should the nurse include in the teaching plan about the likely cause of epididymitis?

sexually transmitted infection

A client has a history of schizophrenia. Because of a history of noncompliance with antipsychotic therapy, the client will receive fluphenazine decanoate injections every 4 weeks. Before discharge, what should the nurse include in the teaching plan?

sitting up for a few minutes before standing to minimize orthostatic hypotension

A client seeking help at a community mental health center reports fatigue, sensitivity to criticism, decreased libido, and feeling self-conscious. The client also has aches and pains. A nursing diagnosis for this client might include:

situational low self-esteem.

The nurse obtains a health history from the parent of a 7-year-old child diagnosed with acute rheumatic fever. It is most important for the nurse to determine if the child has recently had which illness?

sore throat

A college foreign exchange student is living with a family in England and is confused about the family's Catholic prayers and rituals. The student longs for their Protestant practices and reports to the campus nurse for direction. The nurse recognizes the student is experiencing which type of spiritual distress?

spiritual alienation

A client is 41 weeks gestation and is admitted to the hospital in true labor. The client has an external fetal monitor in place. What does the nurse recognize as a reassuring fetal heart rate (FHR) pattern?

spontaneous accelerations; FHR increases by 15 beats per minute (bpm) lasting at least 15 seconds

A client with bacterial pneumonia is to be started on intravenous antibiotics. The nurse should verify that which diagnostic test has been completed before administering the antibiotic?

sputum culture

A nurse is caring for a client receiving chemotherapy. Which assessment finding places the client at the greatest risk for an infection?

stage 3 pressure injury on the left heel

At the 2-week well-child visit, a parent states, "My baby seems to keep their head tilted to the right." Which area should the nurse further assess?

sternocleidomastoid muscle

A female client reports to a nurse that they experience a loss of urine when they jog. The nurse's assessment reveals no nocturia, burning, discomfort when voiding, or urine leakage before reaching the bathroom. The nurse explains to the client that this type of problem is called:

stress incontinence.

When positioned properly, the tip of a central venous catheter should lie in the

superior vena cava.

Twenty-four hours after cesarean birth, a neonate at 30 weeks' gestation is diagnosed with respiratory distress syndrome (RDS). When explaining to the parents about the cause of this syndrome, the nurse should include a discussion about an alteration in the body's secretion of which substance?

surfactant

A 12-year-old child with asthma wants to exercise. Which activity should the nurse suggest to improve breathing?

swimming

A client has become increasingly afraid to ride in elevators. While in an elevator one morning, the client experiences shortness of breath, palpitations, dizziness, and trembling. A health care provider can find no physiological basis for these symptoms and refers the client to a psychiatric clinical nurse specialist for outpatient counseling sessions. Which type of therapy is most likely to reduce the client's anxiety level?

systematic desensitization

A client with hypothyroidism (myxedema) is receiving levothyroxine, 25 mcg P.O. daily. Which finding should the nurse recognize as an adverse reaction to the drug?

tachycardia

After working multiple shifts in the psychiatric intensive care unit, a nurse is becoming more distant and, at times, even irritable. The best action for the nurse to take would be to:

talk with the charge nurse and seek support from peers on the unit.

The nurse is caring for a client with suicidal ideation on an inpatient unit. Which activity should the nurse recommend when the client has thoughts of suicide?

talking with the nurse

The client with tuberculosis is to be discharged home with nursing follow-up. Which aspect of nursing care will have the highest priority?

teaching the client about the disease and its treatment

The nurse is working the night shift and needs to collect urine from four clients for routine urinalysis. Which client collection can be delegated to the unlicensed assistive personnel (UAP)?

the client ordered a voided urine

A client is admitted to the hospital because of threatening, aggressive behavior toward their family. Which factor is most important for the nurse to consider when assessing the angry client's potential for violence?

the client's past history of violent behavior

A nurse assesses a client's respiratory status. Which observation indicates that the client is having difficulty breathing?

use of accessory muscles

A client at risk for lung cancer asks about the reason for having a computed tomography (CT) scan as part of the initial examination. What is the nurse's best response? "A CT scan is:

useful for distinguishing small differences in tissue density and detecting nodal involvement."

A nurse is caring for a client admitted with an exacerbation of asthma. The nurse knows the client's condition is worsening when the client:

uses the sternocleidomastoid muscles.

A 2-month-old infant is seen in the emergency department for symptoms of infection. The health care provider has prescribed an antibiotic via the IM route. In which location should the nurse administer the injection?

vastus lateralis

A client with cholelithiasis has a gallstone lodged in the common bile duct. When assessing this client, the nurse expects to note

yellow sclerae.