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The parent of a child hospitalized with acute glomerulonephritis asks the nurse, "Why are blood pressure readings being taken so often?" What is the best explanation by the nurse? "Blood pressure fluctuations are a common side effect of antibiotic therapy." "Blood pressure fluctuations are a sign that the condition has become chronic." "Elevated blood pressure needs to be detected quickly if it happens." "Hypotension can lead to sudden shock can develop at any time."
"Elevated blood pressure needs to be detected quickly if it happens." Vital signs, in particular blood pressure, provide information about the severity of the disease and early signs of complications. Acute hypertension is anticipated and requires frequent monitoring for early intervention. Hypertension is quite likely with glomerulonephritis. Blood pressure does not commonly fluctuate with antibiotic therapy. Blood pressure fluctuations are not indicative of chronic disease. Most children with glomerulonephritis fully recover.
The nurse is preparing to administer timolol eye drops for treatment of glaucoma. What statement made by the patient would cause the nurse to hold the medication and report to the health care provider? "I have sinusitis." "I have migraine headaches a lot." "I have chronic obstructive pulmonary disease." "I have a history of chronic urinary tract infections."
"I have chronic obstructive pulmonary disease Timolol is a nonselective β-adrenergic blocker that could lead to bronchoconstriction and bronchospasm. For this reason, it should not be used in patients with COPD. Timolol may be used to treat migraine headaches, and it does not affect sinusitis or chronic urinary tract infections.
The nurse is teaching a patient about timolol eye drops for the treatment of glaucoma. What statement made by the patient demonstrates that teaching was effective? "I may feel some palpitations after instilling these eye drops." "I should withhold this medication if my blood pressure becomes elevated." "I should keep my eyes closed for 15 minutes after instilling these eye drops." "I may have some temporary blurring of vision after instilling these eye drops.
"I may have some temporary blurring of vision after instilling these eye drops." It is common for patients to have a temporary blurring of vision for a few minutes after instilling eye drops. This should not cause concern to the patient. Because timolol is a β-blocker, heart rate may slow, and blood pressure is more likely to decrease if absorbed systemically.
The nurse is teaching a patient with glaucoma about administration of pilocarpine. What statement is important for the nurse to include during the instructions? "Prolonged eye irritation is an expected adverse effect of this medication." "This medication will help to raise intraocular pressure to a near normal level." "This medication needs to be continued for at least 5 years after your initial diagnosis." "It is important not to do activities requiring visual acuity immediately after administration."
"It is important not to do activities requiring visual acuity immediately after administration." Correct Pilocarpine causes blurred vision and difficulty in focusing, so it is important not to engage in any activities requiring visual acuity until the vision clears. It should not cause prolonged eye irritation, and this should be immediately reported to the prescribing care provider. This medication will decrease intraocular pressure.
When teaching a patient about the pathophysiology related to open-angle glaucoma, which statement is most appropriate? "The retinal nerve is damaged by an abnormal increase in the production of aqueous humor." "There is decreased draining of aqueous humor in the eye, causing pressure damage to the optic nerve." "The lens enlarges with normal aging, pushing the iris forward, which then covers the outflow channels of the eye." "There is a decreased flow of aqueous humor into the anterior chamber by the lens of the eye blocking the papillary opening."
"There is decreased draining of aqueous humor in the eye, causing pressure damage to the optic nerve. With primary open-angle glaucoma, there is increased intraocular pressure because the aqueous humor cannot drain from the eye. This leads to damage to the optic nerve over time. Primary angle-closure glaucoma is caused by the lens bulging forward and blocking the flow of aqueous humor into the anterior chamber.
The patient has been diagnosed with benign paroxysmal positional vertigo. The nurse knows that which anatomic area of the ear contributes to this disturbance? mc015-1.jpg 1 2 3 4
1 Benign paroxysmal positional vertigo occurs when the organ of balance (the three semicircular canals) have debris or excessive pressure within the lymphatic fluid. The oval window is in the middle ear and receives the vibrations of the ossicles. The facial nerve (cranial nerve VII) traverses above the oval window in the middle ear and may be damaged by chronic ear infection or trauma that causes problems related to voluntary facial movements. The cochlea is the coiled structure in the inner ear that is the receptor organ for hearing
You are caring for a patient receiving D5W at a rate of 125 mL/hr. During the 4:00 PM assessment of the patient, you determine that 500 mL is left in the present IV bag. At what time should the nurse anticipate hanging the next bag of D5W? __________
100 PM Divide the 500 mL left in the IV bag by the hourly rate of 125 mL to calculate that the present solution will remain infusing for another 4 hours. If you made this notation at 4:00 PM, the bag is due to be changed at 8:00 PM.
When planning the care of a patient with dehydration, what urine output would the nurse instruct the unlicensed assistive personnel to report? 60 mL in 90 minutes 1200 mL in 24 hours 300 mL per 8-hour shift 20 mL for 2 consecutive hours
20 mL for 2 consecutive hours he minimal urine output necessary to maintain kidney function is 30 mL/hr. If the output is less than this for 2 consecutive hours, the nurse should be notified so that additional fluid volume replacement therapy can be instituted
When planning care for stable adult patients, the oral intake that is adequate to meet daily fluid needs is 500 to 1500 mL. 1200 to 2200 mL. 2000 to 3000 mL. 3000 to 4000 mL.
2000 to 3000 mL. Daily fluid intake and output is usually 2000 to 3000 mL. This is sufficient to meet the needs of the body and replace both sensible and insensible fluid losses. These would include urine output and fluids lost through the respiratory system, skin, and GI tract.
A patient was admitted for a paracentesis to remove ascites fluid. Five liters of fluid was removed. Which IV solution may be used to pull fluid into the intravascular space after the paracentesis? 0.9% sodium chloride 25% albumin solution Lactated Ringer's solution 5% dextrose in 0.45% saline
25% albumin solution After a paracentesis of 5 L or greater of ascites fluid, 25% albumin solution may be used as a volume expander. Normal saline, lactated Ringer's solution, and 5% dextrose in 0.45% saline will not be effective for this action
The nurse has measured the urinary output for the 12-hour shift and has 340 mL for a 12-kg toddler. What is the normal range of urinary output for this child for a 12-hour shift so the nurse can evaluate the output obtained? 238 to 366 mL 246 to 398 mL 274 to 416 mL 288 to 432 mL
288 to 432 mL The normal urinary output for infants and toddlers is greater than 2 to 3 mL/kg/hr, so the calculation would be: 12 kg × 2 mL/hr and 12 kg × 3 mL/hr → 24 to 36 mL/hr. Since the output is for 12 hours, 24 mL/hr would be multiplied by 12 hours, and 36 mL/hr would also be multiplied by 12 hours. The answer is 288 to 432 mL for the 12-hour shift. The amount the toddler urinated falls within the range.
A preschooler with vomiting and diarrhea lost 0.5 kg of weight since being weighed in the pediatrician's office prior to admission to the hospital. How much fluid would the nurse calculate that this child has lost? 250 mL 500 mL 750 mL 1000 mL
500 mL
Which finding related to primary open-angle glaucoma would the nurse expect to find when reviewing a patient's history and physical examination report? Absence of pain or pressure Blurred vision in the morning Seeing colored halos around lights Eye pain accompanied with nausea and vomiting
Absence of pain or pressure Primary open-angle glaucoma is typically symptom free, which explains why patients can have significant vision loss before a diagnosis is made unless regular eye examinations are being performed. Primary angle-closure glaucoma manifestations include sudden, excruciating pain in or around the eye, seeing colored halos around lights, and nausea and vomiting.
When using the otoscope, the nurse is unable to see the landmarks or light reflex of the tympanic membrane. The tympanic membrane is bulging and red. What does the nurse determine is most likely occurring in the patient's ear? Swimmer's ear Acute otitis media Impacted cerumen Chronic otitis media
Acute otitis media The manifestations of inability to see the landmarks or light reflex of the tympanic membrane and the bulging and redness of the tympanic membrane are those of acute otitis media. With swimmer's ear and chronic otitis media, there is frequently drainage in the external auditory canal. Impacted cerumen would block the visualization of the tympanic membrane.
The nurse is caring for a child with nephrotic syndrome who is confined to bed. What is the best way to promote this child's developmental needs? Restrain the child only when necessary. Discourage parents from holding the child. Adjust activities to child's tolerance level. Perform passive range-of-motion exercises daily.
Adjust activities to child's tolerance level. The child will have a variable level of tolerance for activity because of the illness and the medications, such as steroids. Provide activities that are energy conserving but enjoyable for the child. The child should be encouraged to move all extremities while in bed. There is no indication for the use of restraints. Parents should be encouraged to hold the child.
When assessing the patient with a multi-lumen central line, the nurse notices that the cap is off one of the lines. On assessment, the patient is in respiratory distress and the vital signs show hypotension and tachycardia. What is the nurse's priority action? Administer oxygen Notify the health care provider Rapidly administer more IV fluid Reposition the patient on the right side
Administer oxygen The cap off the central line could allow entry of air into the circulation, causing an air embolus. To manage an air embolus, oxygen is administered; the catheter is clamped, and the patient is positioned on the left side with the head down. Then the health care provider is notified.
The nurse is teaching the mother of a child with a new corneal abrasion how to take care of the affected eye at home. Discharge instructions by the nurse are correct if which instructions are given? "Administer the eye drops as directed for 1 to 2 days, and remind your child to keep his hands away from his eyes." "Keep the patch on his eye except when instilling the antibiotic eye medication." "Rinse the affected eye two to three times daily for 1 to 2 days." "Wear sunglasses even in the house to decrease any sensitivity."
Administer the eye drops as directed for 1 to 2 days, and remind your child to keep his hands away from his eyes." If the abrasion is small, treatment consists only of the instillation of an appropriate antibiotic ointment or drops four times a day for 1 to 2 days with a follow-up evaluation to check healing. Referral to an ophthalmologist should be considered with any eye injury but particularly for a large abrasion or with the suspicion of a penetrating injury. Many authorities now recommend no patching unless the wound is large. Patching is not recommended unless the abrasion is large. If the eye is patched, advise the parents not to remove the patch for 24 hours, even to instill ointment. Rinsing is not done at home after evaluation. The eye should be left alone except for antibiotic medications in the eye. Sunglasses are not recommended for this condition. The major care includes use of antibiotic medication in the eye and not touching the eye because the abrasion can be made worse.
A preschooler with severe vomiting and diarrhea was admitted to the hospital. The vomiting has stopped, and rehydration was begun intravenously. When should the nurse begin feeding the child solid food? When the parents give their permission to feed their child After the child has been rehydrated After the diarrhea has stopped for 24 hours When the IV rehydration can be stopped
After the child has been rehydrated Feeding of solids or formula is started as soon as the child is rehydrated. Children should be encouraged to eat frequently—every 3 to 4 hours. Parents should be instructed that although stool output may increase, feeding will not prolong diarrhea, and the child will be absorbing necessary nutrients and calories. Parents should be instructed that although stool output may increase, feeding will not prolong diarrhea, and the child will be absorbing necessary nutrients and calories. The intravenous solutions may run a little longer to ensure that the child remains hydrated. It is not up to the parents to decide when resumption of solid food begins.
Which term should the nurse use when documenting reduced visual acuity in one eye despite appropriate optical correction? Myopia Hyperopia Amblyopia Astigmatism
Amblyopia, or "lazy eye," one of the most common causes of diminished vision in children, results from a variety of eye alterations seen in children whose visual acuity is impaired. Astigmatism is an alteration in vision caused by unequal curvature in the eyes' refractive apparatus. Myopia is nearsightedness, the ability to see objects up close but not clearly at a distance. Hyperopia is farsightedness, the ability to see distant objects clearly but not those up close.
The triage nurse at an ambulatory clinic receives a call from an individual with possible metal fragments in both eyes. Which instructions would the nurse provide for emergency care of this possible eye injury? "Remove any visible metal fragments." "Apply a loose dressing over your eyes." "Rinse your eyes immediately with water." "Keep your eyes open to allow tears to form."
Apply a loose dressing over your eyes. An initial intervention for a penetrating eye injury includes covering the eye(s) with a dry, sterile patch and protective shield. The fragments should not be removed by the individual or others. Penetrating eye injuries should not be irrigated (only irrigate for chemical eye injuries).
A 4-year-old has had diarrhea for several days, and her perineum is inflamed and almost excoriated. What nursing actions are indicated? (Select all that apply.) Gently wash the perineum with cold water and mild soap after each stool. Apply an ointment to the inflamed area to provide a moisture barrier. Place the child without underwear for brief periods to allow air to the area. Turn the child at least every 2 hours.
Apply an ointment to the inflamed area to provide a moisture barrier. Turn the child at least every 2 hours Applying an ointment to the inflamed area to provide a moisture barrier is important. Placing the child without underwear for brief periods to allow air to the area often helps heal the area. Turning the child at least every 2 hours keeps pressure off the skin and facilitates circulation to the affected area. Gently wash the perineum with warm water and mild soap after each stool.
A patient with poor visual acuity is diagnosed with age-related macular degeneration (AMD). Which nursing action should be the nurse's priority? Teach about visual enhancement techniques. Teach nutritional strategies to improve vision. Assess coping strategies and support systems. Assess impact of vision on normal functioning.
Assess impact of vision on normal functioning. The most important nursing intervention is to assess the patient's ability to function with the visual impairment. The nurse will use this information to plan nursing care, including assessment of the patient's coping strategies and teaching about vision enhancement techniques and nutrition.
A patient with Ménière's disease had decompression of the endolymphatic sac to reduce the frequent and incapacitating attacks being experienced. What should the nurse include in the discharge teaching for this patient? Airplane travel will be more comfortable now. Avoid sudden head movements or position changes. Cough or blow the nose to keep the Eustachian tubes clear. Take antihistamines, antiemetics, and sedatives for recovery.
Avoid sudden head movements or position changes After ear surgery, the patient should avoid sudden head movements or position changes. The patient should not cough or blow the nose because this increases pressure in the Eustachian tube and middle ear cavity and may disrupt healing. Airplane travel should be avoided at first as increased pressure and ear popping is normally experienced, which will disrupt healing. Antihistamines, antiemetics, and sedatives are used to decrease the symptoms of acute attacks of Ménière's disease.
The patient informs the nurse that he has a "sty" that has been present for some time on the upper eyelid and reports using warm moist compresses with no improvement. What is the best response by the nurse? "Go to the pharmacy to get some eye drops." "Come in so the ophthalmologist can assess the lesion." "The health care provider will need to inject it with an antibiotic." "Wash the eyelid margins with baby shampoo to remove the crusting."
Come in so the ophthalmologist can assess the lesion." chalazion may evolve from a "sty" or hordeolum as it did for this patient. Initial treatment is with warm compresses, but when they are ineffective, the lesion may be surgically removed or injected with corticosteroids. Washing the eyelid margins with baby shampoo is done with blepharitis.
A 2-month-old breastfed infant is successfully rehydrated with oral rehydration solutions (ORS) for acute diarrhea. What instructions to the mother about breastfeeding should be included by the nurse? Continue breastfeeding. Stop breastfeeding until breast milk is cultured. Stop breastfeeding until diarrhea is absent for 24 hours. Express breast milk, and dilute with sterile water before feeding.
Continue breastfeeding.
A school-age child with acute diarrhea and mild dehydration is being given oral rehydration solutions (ORS). The child's mother calls the clinic nurse to report the child has occasional vomiting. What is the appropriate recommendation by the nurse? Bring the child to the hospital for intravenous fluids. Alternate giving the child ORS and carbonated drinks. Continue to give the child ORS frequently in small amounts. Maintain the child on NPO for 8 hours and resume ORS if vomiting subsides.
Continue to give the child ORS frequently in small amounts. Vomiting is not a contraindication to the use of ORS unless it is severe. The mother should continue to give the ORS in small amounts and at frequent intervals. NPO status is not indicated. Frequent intake of ORS in small amounts is recommended. A school-age child with mild dehydration can be rehydrated safely at home with oral solutions. Carbonated drinks should not be given to the child. They may have a high carbohydrate content and contain caffeine, which is a diuretic.
A 22-yr-old man is admitted to the emergency department with a stab wound to the abdomen. The patient's vital signs are blood pressure 82/56 mm Hg, pulse 132 beats/min, respirations 28 breaths/min, and temperature 97.9° F (36.6° C). Which fluid, if ordered by the health care provider, should the nurse question? D5W 0.9% saline Packed red blood cells Lactated Ringer's solution
D5W IV administration of 0.45% saline is hypotonic and is used for maintenance fluid replacement and dilutes the extracellular fluid. IV solutions used for volume expansion for hypovolemic shock include lactated Ringer's solution and 0.9% saline. If hypovolemia is due to blood loss, blood may be administered.
A 4-year-old male is continuing to have periodic daytime and nocturnal enuresis. His mother is very worried and calls the pediatrician's office nurse for advice. What information would be appropriate for the nurse to give? (Select all that apply.) He needs evaluation by a psychiatrist before having a medical workup to determine if there are anxiety issues present. Diet modifications can be made including avoidance of extraneous sugar and caffeine intake after late afternoon. Reassure the mother that the cause will be found through testing. It's important to limit the child's interactions with others until the situation is corrected. The child needs to realize that he can control the enuresis if he wants to. Urinary tract infections can cause enuresis.
Diet modifications can be made including avoidance of extraneous sugar and caffeine intake after late afternoon. Reassure the mother that the cause will be found through testing. Urinary tract infections can cause enuresis.
The nurse is providing discharge instructions for a patient using contact lenses who is diagnosed with bacterial conjunctivitis. What is most important for the nurse to include in the instructions? Discard all opened or used lens care products. Disinfect contact lenses by soaking in a cleaning solution for 48 hours. Put all used cosmetics in a plastic bag for 1 week to kill any bacteria before reusing. Disinfect all lens care products with the prescribed antibiotic drops for 1 week after infection.
Discard all opened or used lens care products The patient who wears contact lenses and develops infections should discard all opened or used lens care products and cosmetics to decrease the risk of reinfection from contaminated products. The risk of conjunctivitis is increased with not disinfecting lenses properly, wearing contact lenses too long, or using water or homemade solutions to store and clean lenses.
Which action is most important for the nurse to take when caring for a patient with a subclavian triple-lumen catheter? Change the injection cap after the administration of IV medications. Use a 5-mL syringe to flush the catheter between medications and after use. During removal of the catheter, have the patient perform the Valsalva maneuver. If resistance is met when flushing, use the push-pause technique to dislodge the clot.
During removal of the catheter, have the patient perform the Valsalva maneuver. The nurse should withdraw the catheter while the patient performs the Valsalva maneuver to prevent an air embolism. Injection caps should be changed at regular intervals but not routinely after medications. Flushing should be performed with at least a 10-mL syringe to avoid excess pressure on the catheter. If resistance is encountered during flushing, force should not be applied. The push-pause method is preferred for flushing catheters but not used if resistance is encountered during flushing.
An acoustic neuroma is removed from a patient. The nurse instructs the patient about tumor recurrence. What should the nurse instruct the patient to monitor (select all that apply.)? Lack of coordination Episodes of dizziness Worsening of hearing Inability to close the eye Clear drainage from the nose
Episodes of dizziness Correct Worsening of hearing Correct Inability to close the eye An acoustic neuroma is a unilateral benign tumor that occurs where the vestibulocochlear nerve (cranial nerve [CN] VIII) enters the internal auditory canal. Clinical manifestations of tumor recurrence including facial nerve (CN VII) paralysis can be manifested by intermittent vertigo, hearing loss, and inability to close the eye. Lack of coordination and clear nasal drainage do not manifest with acoustic neuroma.
An infant is being fitted for a hearing aid. Which type of hearing aid would the nurse expect would be used for this infant and for young children? Behind-the-ear Eyeglass Ear-level Body
Ear-level Infants and young children often do better with ear-level hearing aids, not body or behind-the-ear. There's no data that says the infant has a visual problem as well.
The parents of a toddler ask why the nurse why their son's hypospadias needs to be repaired as early as possible. Which explanation by the nurse is best? Early repair helps to prevent separation anxiety. It's important that their son's genitalia looks like his father's. It's most likely he won't remember the surgery or hospitalization. Early repair helps to promote development of normal body image.
Early repair helps to promote development of normal body image. Correct This is extremely important. Surgery involving sexual organs can be very upsetting to children, especially preschoolers who fear mutilation and castration. Separation anxiety can be avoided if one of the parents stays with the child. The urinary functioning is more important than the physical appearance. Proper preparation can facilitate coping with these issues.
When planning care for a patient with disturbed sensory perception related to increased intraocular pressure caused by primary open-angle glaucoma, what nursing action would be a priority? Recognizing that eye damage caused by glaucoma can be reversed in the early stages Giving anticipatory guidance about the eventual loss of central vision that will occur Encouraging compliance with drug therapy for the glaucoma to prevent loss of vision Managing the pain experienced by patients with glaucoma that persists until the optic nerve atrophies
Encouraging compliance with drug therapy for the glaucoma to prevent loss of vision Drug therapy is necessary to prevent the eventual vision loss that may occur as a consequence of glaucoma. For this reason, encourage the patient to remain compliant with drug therapy.
The nurse is assessing a child who has just been diagnosed with primary nephrotic syndrome. Which signs would the nurse expect to see during the assessment? Facial edema, edema in genital area, puffy ankles Anorexia, abdominal edema, periorbital edema Pitting edema in the upper extremities, abdominal pain, sneezing Fatigue, wheezing, puffy hands
Facial edema, edema in genital area, puffy ankles Manifestations of primary nephrotic syndrome include edema, anorexia, fatigue, abdominal pain, respiratory infection, and increased weight. Anorexia is a symptom, not a sign. Abdominal pain but not edema can occur, and periorbital edema is common. Pitting edema is seen in the lower extremities and not the upper. Abdominal pain can occur from the presence of extra fluid in the peritoneal area. Fatigue can be present but not wheezing or puffy hands.
When planning care for a patient with dehydration related to nausea and vomiting, the nurse would anticipate which fluid shift to occur because of the fluid volume deficit? Fluid movement from the blood vessels into the cells Fluid movement from the interstitial spaces into the cells Fluid movement from the blood vessels into interstitial spaces Fluid movement from the interstitial space into the blood vessels
Fluid movement from the interstitial space into the blood vessels In dehydration, fluid is lost first from the blood vessels. To compensate, fluid moves out of the interstitial spaces into the blood vessels to restore circulating volume in that compartment. As the interstitial spaces then become volume depleted, fluid moves out of the cells into the interstitial spaces.
The nurse is conducting a class on emergency childhood problems for a group of preschool parents. What should the nurse stress as the first action the caregiver should take if a child splashes bleach in the eyes? Call 9-1-1. Take the child to an eye doctor. Take the child to an emergency clinic. Flush the eye with lots of cool water.
Flush the eye with lots of cool water. Correct Flush with lots of cool water or normal saline. Plain water will most likely be what a parent would use for this type of emergency. The priority is to get the chemical away from the child's eye. 9-1-1 can then be called. The child will need to be seen by an eye doctor after an initial flushing is done. The child could be seen in an emergency clinic if it was staffed with a doctor who is well versed on eye injuries, but the eye must be flushed first while the child is at home.
When administering eye drops to a patient with glaucoma, which nursing measure is most appropriate to minimize systemic effects of the medication? Apply pressure to each eyeball for a few seconds after administration. Have the patient close the eyes and move them back and forth several times. Have the patient put pressure on the inner canthus of the eye after administration. Have the patient try to blink out excess medication immediately after administration.
Have the patient put pressure on the inner canthus of the eye after administration Systemic absorption can be minimized by applying pressure to the inner canthus of the eye. The other options will not minimize systemic effects of the medication.
A patient is prescribed intravenous (IV) gentamicin after repair of an intestinal perforation. The nurse should assess for which adverse effect of this medication? Hearing loss Exophthalmos Conjunctivitis Recurrent fever
Hearing loss minoglycosides such as gentamicin are drugs that are potentially ototoxic and may cause damage to the auditory nerve. When this drug is used, careful monitoring for hearing and balance problems (e.g., hearing loss, tinnitus, vertigo) is essential. Exophthalmos is related to a symptom of hyperthyroidism. Conjunctivitis is a bacterial or a viral infection of the conjunctiva. Recurrent fever can be related to many issues and is not related to the use of IV gentamicin.
A 2-month-old infant has been brought to the emergency department because of diarrhea and vomiting for the past 48 hours. Why should the pediatric nurse expect the infant to be at a greater risk for fluid and electrolyte imbalances than older children? Infants have a lower metabolic rate than older children. Infants have a decreased surface area. Immature renal function is common in infants. The infants' daily exchange of extracellular fluid is decreased
Immature renal function is common in infants.
An 11-month-old infant is being seen in the pediatric ophthalmologist's office for strabismus. What questions would the nurse ask the mother for the infant's health history? (Select all that apply.) How much did your baby weigh at birth? At how many weeks' gestation was he born? Does anyone in your family have this condition? Do either you or the baby's father smoke? Does your baby bang his head against the wall or the crib? Does your baby tilt his head when he is playing?
How much did your baby weigh at birth? At how many weeks' gestation was he born? Does anyone in your family have this condition? Does your baby tilt his head when he is playing?
The nurse is caring for a child with possible nephrosis. In addition to presenting symptoms, which laboratory finding would the nurse expect to see? Hypoalbuminemia Low specific gravity Decreased hemoglobin level Decreased hematocrit
Hypoalbuminemia is a result of the large amounts of protein that leak through the glomerular membrane into the urine. Specific gravity is increased because of the large amount of protein. The hemoglobin level would be elevated as a result of the hypovolemia. Hematocrit would be elevated as a result of the hypovolemia.
A toddler is hospitalized with severe dehydration. The nurse should assess the child for which possible complication? Hypertension Hypokalemia A rapid, bounding pulse Decreased specific gravity
Hypokalemia is a concern in severe dehydration. A rapid, thready pulse would be seen in severe dehydration. The urine would be concentrated, so the specific gravity would increase. The child needs to be monitored for hypotension.
The nurse is providing discharge teaching to a patient with type 2 diabetes after a scleral buckling procedure. Which statement, if made by the patient, indicates that the discharge teaching is effective? "I doubt my other eye will ever be affected." "I can expect severe pain after this procedure." "I should avoid lifting heavy objects and straining." "The procedure will correct my vision immediately."
I should avoid lifting heavy objects and straining." Patients should avoid heavy lifting (more than 20 lb) and straining. A patient with a detached retina is at risk for detachment of the other retina. Patients usually have little to no discomfort after scleral buckling. Severe, persistent pain should be reported immediately to the health care provider. Vision is restored in about 90% of retinal detachments. Vision will not be restored immediately and takes days to weeks to improve.
The nurse is teaching a parents' class about when to call the pediatrician's office if vomiting and diarrhea in their toddlers. Instruction by the nurse is correct if the nurse includes which information? (Select all that apply.) If their child doesn't urinate for longer than 4 hours If their child's fontanel appears sunken If crying produces no tears When the diarrhea has been present for 24 hours If the toddler has a fever (>39° C [102° F]) If severe abdominal cramps occur
If crying produces no tears Correct When the diarrhea has been present for 24 hours Correct If the toddler has a fever (>39° C [102° F]) Correct If severe abdominal cramps occur If crying produces no tears, the pediatrician should be notified. When the diarrhea has been present for 24 hours, the pediatrician should be notified. If the toddler has a fever >39° C (102° F), the pediatrician should be notified. If severe abdominal cramps occur, the pediatrician should be notified. If their toddler doesn't urinate for longer than 6 hours, the pediatrician should be notified. The fontanels disappear by 18 months of age.
You are caring for an older patient who is receiving IV fluids postoperatively. During the 8:00 AM assessment of this patient, you note that the IV solution, which was ordered to infuse at 125 mL/hr, has infused 950 mL since it was hung at 4:00 AM. What is the priority nursing intervention? Slow the rate to keep vein open until next bag is due at noon. Notify the health care provider and complete an incident report. Listen to the patient's lung sounds and assess respiratory status. Asses the patient's cardiovascular status by checking pulse and blood pressure.
Listen to the patient's lung sounds and assess respiratory status After 4 hours of infusion time, 500 mL of IV solution should have infused, not 950 mL. This patient is at risk for fluid volume excess, and you should assess the patient's respiratory status and lung sounds as the priority action and then notify the health care provider for further orders.
You are caring for a patient admitted with heart failure. The morning laboratory results reveal a serum potassium level of 2.9 mEq/L. Which classification of medications should you withhold until consulting with the health care provider? Antibiotics Loop diuretics Bronchodilators Antihypertensives
Loop diuretics Loop diuretics are contraindicated during episodes of hypokalemia because these medications cause the kidneys to excrete sodium and potassium. Thus administration of this type of medication at this time would worsen the hypokalemia, putting the patient at risk for dysrhythmias. The prescribing physician should be consulted for potassium replacement therapy, and the drug should be withheld until the potassium has returned to normal range.
When administering a scheduled dose of pilocarpine, in which area should the nurse place the drops? Inner canthus Outer canthus Center of the eyeball Lower conjunctival sac
Lower conjunctival sac Correct Ocular medications such as pilocarpine should be instilled into the lower conjunctival sac. Never apply eye drops directly to the cornea. Applying the drops to the inner canthus will cause them to be distributed systemically.
A dehydrated patient is receiving a hypertonic solution. Which assessments must be done to avoid adverse risks associated with these solutions (select all that apply.)? Lung sounds Bowel sounds Blood pressure Serum sodium level Serum potassium level
Lung sounds Correct Blood pressure Correct Serum sodium level Correct Blood pressure, lung sounds, and serum sodium levels must be monitored frequently because of the risk for excess intravascular volume with hypertonic solutions.
A school-age child with a severe hearing loss who is able to read lips well is scheduled for surgery. What nursing action will best support the child's needs during the preoperative period? Have a sign language interpreter available in the pre-op holding area. Make sure the child is asleep before the surgical masks are pulled up. Show the child pictures of the operating room and people who work there. Give the child a coloring book with crayons for distraction before surgery.
Make sure the child is asleep before the surgical masks are pulled up Making sure the child is asleep before the surgical masks are pulled up by the staff would enable the child to continue lip-reading until receiving the anesthesia. Showing the child pictures of the operating room and people who work there is helpful but is not best. It does not promote communication with the child. Distraction is going to be neither best at this time nor necessarily possible for a school-age child. There's no data that says the child can sign.
The nurse is providing care for a patient with loss of hearing acuity over the past several years. Which statement by the nurse is most accurate? "This is often due to an infection that will resolve on its own." "Many people experience an age-related decline in their hearing." "This is likely an effect of your medications. Try stopping them for a few days." "You can likely accommodate for your hearing loss with a few small changes in your routine."
Many people experience an age-related decline in their hearing." Presbycusis is a loss of hearing that is both common and age-related. Infections are most often accompanied by different symptoms. It would be inappropriate to counsel the patient to stop his medications. It would be simplistic to advise the patient to accommodate the hearing loss rather than seek intervention.
The nurse is caring for a child who has nephrotic syndrome and has not yet been toilet trained. What is the best way for the nurse to detect fluid retention in this child? Weigh the child daily. Check the urine for blood. Measure the abdominal girth weekly. Count the number of wet diapers.
Measuring weight at the same time each day is the most accurate way to determine fluid gains and losses. The presence or absence of blood in the urine will not help with the determination of fluid retention. Abdominal girth will be reflective of edema, but weekly measure is too infrequent. The number of wet diapers reflects how often they have been changed. The diapers should be weighed to reflect fluid balance.
You are admitting a patient with complaints of abdominal pain, nausea, and vomiting. A proximal bowel obstruction is suspected. Which acid-base imbalance do you anticipate in this patient? Metabolic acidosis Metabolic alkalosis Respiratory acidosis Respiratory alkalosis
Metabolic alkalosis Because gastric secretions are rich in HCl acid, the patient who is vomiting will lose a significant amount of gastric acid and be at an increased risk for metabolic alkalosis.
Which nursing intervention is most appropriate when caring for a patient with dehydration? Monitor skin turgor every shift. Auscultate lung sounds every 2 hours. Monitor daily weight and intake and output. Encourage the patient to reduce sodium intake.
Monitor daily weight and intake and output. Measuring weight is the most reliable means of detecting changes in fluid balance. Weight loss would indicate the dehydration is worsening, whereas weight gain would indicate restoration of fluid volume.
A 5-year-old child has bilateral eye patches that were put in place after surgery yesterday morning and is allowed out of bed today while still patched. Which is the most important nursing intervention? Speak to her when entering the room. Allow her to assist in feeding herself. Orient her to her immediate surroundings. Reassure the child that her parents can stay with her.
Orient her to her immediate surroundings. Because the child is being allowed to move about while both eyes are patched, the immediate safety concern for her is ensuring her familiarity with her immediate surroundings. In Maslow's hierarchy, safety needs have priority over love and belonging. Throughout her hospitalization, she should be reassured and her parents should be allowed to stay with her. Orientation to the room now that she is out of bed is essential. Speaking to the child should always be done so the child can verify who is entering her room. There is no reason why she should not be allowed to feed herself with assistance as needed; however, ambulatory safety is the primary concern at this time.
You are caring for a patient admitted with a diagnosis of chronic obstructive pulmonary disease (COPD) who has the following arterial blood gas results: pH 7.33, PaO2 47 mm Hg, PaCO2 60 mm Hg, HCO3 32 mEq/L, and O2 saturation of 92%. What is the correct interpretation of these results? Fully compensated respiratory alkalosis Partially compensated respiratory acidosis Normal acid-base balance with hypoxemia Normal acid-base balance with hypercapnia
Partially compensated respiratory acidosis A low pH (normal, 7.35-7.45) indicates acidosis. In a patient with respiratory disease such as COPD, the patient retains carbon dioxide (normal, 35-45 mm Hg), which acts as an acid in the body. For this reason, the patient has respiratory acidosis. The elevated HCO3 indicates a partial compensation for the elevated CO2.
A patient is diagnosed with severe myopia. Which type of correction is the patient planning to have if they state, "I can't wait to be able to see after they implant a contact lens over my lens"? Photorefractive keratectomy (PRK) Phakic intraocular lenses (phakic IOLs) Refractive intraocular lens (refractive IOL) Laser-assisted in situ keratomileusis (LASIK)
Phakic intraocular lenses (phakic IOLs) Phakic intraocular lenses (phakic IOLs) is the implantation of a contact lens in front of the natural lens. PRK is used with low to moderate amounts of myopia, and the epithelium is removed and the laser sculpts the cornea to correct the refractive error. Refractive IOL is also for patients with a high degree of myopia or hyperopia and involves removing the natural lens and implanting an intraocular lens. LASIK surgery is similar to PRK except that the epithelium is replaced after surgery.
You are caring for a patient receiving calcium carbonate for the treatment of osteopenia. Which serum laboratory result would you identify as an adverse effect related to this therapy? Sodium falling to 138 mEq/L Potassium rising to 4.1 mEq/L Magnesium rising to 2.9 mg/dL Phosphorus falling to 2.1 mg/dL
Phosphorus falling to 2.1 mg/dL Calcium has an inverse relationship with phosphorus in the body. When phosphorus levels fall, calcium rises, and vice versa. Because hypercalcemia rarely occurs as a result of calcium intake, the patient's phosphorus falling to 2.1 mg/dL (normal, 2.4-4.4 mg/dL) may be a result of the phosphate-binding effect of calcium carbonate.
A young child is diagnosed with vesicoureteral reflux. What would the nurse expect to read in the medical history that the child had been experiencing? Incontinence Hypotension Recurrent kidney infections Increased renal arterial perfusion
Recurrent kidney infections Reflux allows urine flow to be forced back to the kidneys. When the urine is infected, this contributes to kidney infections. Pyelonephritis occurs as a result of reflux. Scarring occurs because of inflammation from pyelonephritis, which then causes decreased renal arterial perfusion. Incontinence may be associated with urinary tract infections, but it is not a direct result of reflux. Hypertension results from the cycle of infection/inflammation/scarring/decreased perfusion. Renin-angiotensin is released, which ultimately elevates blood pressure.
While performing patient teaching regarding hypercalcemia, which statements are appropriate (select all that apply.)? Have patient restrict fluid intake to less than 2000 mL/day. Renal calculi may occur as a complication of hypercalcemia. Weight-bearing exercises can help keep calcium in the bones. The patient should increase daily fluid intake to 3000 to 4000 mL. Any heartburn can be managed with an as needed calcium-containing antacid.
Renal calculi may occur as a complication of hypercalcemia. Correct Weight-bearing exercises can help keep calcium in the bones. Correct The patient should increase daily fluid intake to 3000 to 4000 mL A daily fluid intake of 3000 to 4000 mL is necessary to enhance calcium excretion and prevent the formation of renal calculi, a potential complication of hypercalcemia. Tums are a calcium-based antacid that should not be used in patients with hypercalcemia. Weight-bearing exercise does enhance bone mineralization.
A patient is admitted with metabolic acidosis. Which system is not functioning normally? Renal system Buffer system Endocrine system Respiratory system
Renal system When the patient has metabolic acidosis, the kidneys are not combining H+ with ammonia to form ammonium or eliminating acid with secretion of free hydrogen into the renal tubule. The buffer system neutralizes HCl acid by forming a weak acid. The hormone system is not directly related to acid-base balance. The respiratory system releases CO2 that combines with water to form hydrogen ions and bicarbonate. The hydrogen is then buffered by the hemoglobin.
When assessing a patient admitted with nausea and vomiting, which finding best supports the nursing diagnosis of deficient fluid volume? Polyuria Bradycardia Restlessness Difficulty breathing
Restlessness Restlessness is an early cerebral sign that dehydration has progressed to the point where an intracellular fluid shift is occurring. If the dehydration is left untreated, cerebral signs could progress to confusion and later coma.
A newborn was found to have kidney problems while in utero; this has been confirmed several hours after birth. The pediatrician has scheduled a hearing test to be performed on the baby and the mother wants to know why. What explanation by the physician might the nurse need to reinforce? "Since the kidneys and ears are formed at the same time, there is a chance your baby may having a hearing problem as well." "It's a routine procedure we do on all infants because the earlier the problem is picked up, the better prognosis your child has." "I understand your concern, but all new parents are worried about their baby so let us handle it until we know something." "I really think you need some rest and food before we have a major discussion about what we might be anticipating."
Since the kidneys and ears are formed at the same time, there is a chance your baby may having a hearing problem as well. Ear and kidney development occurs at the same time so malformation in one system may indicate problems in the other. Hearing tests are not routinely done on all infants. Stating that all parents worry or encouraging the parent to rest before speaking about the issue are non-therapeutic responses because they ignore the parent's concern.
A 6-year-old child has difficulty hearing faint or distant speech. His speech is normal, but he is having problems with his school performance. How should this hearing loss be classified in the child's medical record? Slight Severe Moderate Moderately severe
Slight Slight hearing loss is defined as hearing faint or distant speech. With severe loss, a child may hear a loud voice if nearby and may be able to identify loud environmental noises. Moderate hearing loss results in symptoms of being able to understand conversation at a distance of only 3 to 5 feet. With a moderately severe hearing loss, he would be unable to understand conversation unless it was very loud.
You receive a physician's order to change a patient's IV from D5½ NS with 40 mEq KCl/L to D5NS with 20 mEq KCl/L. Which serum laboratory values on this same patient best support the rationale for this IV order change? Sodium, 136 mEq/L; potassium, 3.6 mEq/L Sodium, 145 mEq/L; potassium, 4.8 mEq/L Sodium, 135 mEq/L; potassium, 4.5 mEq/L Sodium, 144 mEq/L; potassium, 3.7 mEq/L
Sodium, 135 mEq/L; potassium, 4.5 mEq/L The normal range for serum sodium is 135 to 145 mEq/L, and the normal range for potassium is 3.5 to 5.0 mEq/L. The change in the IV order decreases the amount of potassium and increases the amount of sodium. Therefore, for this order to be appropriate, the potassium level must be near the high end and the sodium level near the low end of their respective ranges.
Early detection of a hearing impairment is critical because of its effect on the following areas of a child's life. Which aspect of development should the parents be told would be most affected when a child has a hearing impairment? Reading Speech Relationships with peers Performance at school
Speech he ability to hear sounds is essential for the development of speech. Babies imitate the sounds that they hear. Relationships with peers will be affected by the child's lack of hearing. The effect will be augmented by difficulties with oral communication. Performance at school will be affected by the child's lack of hearing. The effect will be augmented by difficulties with oral communication. The child will have greater difficulty in learning to read, but the primary issue of concern is the effect on speech.
A 50-yr-old woman with hypertension has a serum potassium level that has acutely risen to 6.2 mEq/L. Which type of order, if written by the health care provider, should the nurse question? Limit foods high in potassium Calcium gluconate IV piggyback Spironolactone (Aldactone) daily Administer intravenous insulin and glucose
Spironolactone (Aldactone) daily Spironolactone (Aldactone) is a potassium-sparing diuretic that inhibits the exchange of sodium for potassium in the distal renal tubule and helps to prevent potassium loss. Spironolactone is contraindicated in a patient with hyperkalemia (serum potassium >5.0 mEq/L). Management of patients with hyperkalemia may include limiting foods high in potassium, administering IV insulin and glucose, administering IV calcium gluconate, changing to potassium-wasting diuretics (e.g., furosemide [Lasix]), hemodialysis, administering sodium polystyrene sulfonate (Kayexalate), and IV fluid administration.
A nurse is evaluating an infant brought to the clinic with severe diarrhea. What signs and symptoms should the nurses identify as indicating the infant has severe dehydration? Tachycardia, decreased tears, 5% weight loss and skin tenting Normal pulse rate, decreased blood pressure, intense thirst, and increased crying Irritability, moderate thirst, a flat fontanel, and sucking on his hands Tachycardia, capillary refill greater than 3 seconds, and sunken eyes and fontanel
Tachycardia, capillary refill greater than 3 seconds, and sunken eyes and fontanel Correct Tachycardia, capillary refill greater than 3 seconds, and sunken eyes and fontanel are the symptoms of severe dehydration. In severe dehydration, tachycardia, decreased tears, a 15% weight loss, and skin tenting are present. Tachycardia, orthostatic hypotension and shock, and intense thirst would be expected. Crying may or not be present or increased due to lack of energy. The infant would be extremely irritable, with sunken eyes and fontanel.
A 5-year-old female has been sent to the school nurse for urinary incontinence three times in the past 2 days. What nursing action should be taken first? Talking with the parents about a possible school phobia Determining if there are emotional causes Talking with the parents about a possible urinary tract infection Asking the parents if there is a possible structural defect of the urinary tract
Talking with the parents about a possible urinary tract infection Incontinence in a previously toilet-trained child can be an indication of a urinary tract infection. This would also be using Maslow's hierarchy in determining physical issues first. Structural defects would be explored after a urinary tract infection is confirmed. A physical cause of the problem needs to be eliminated before a psychological cause is considered. A physical cause of the problem needs to be eliminated before a psychological cause is considered.
A 7-year-old girl born with a myelomeningocele has a neurogenic bladder. Her parents have been performing clean intermittent catheterization. Based on the knowledge of child development and chronic disability, what action should the nurse implement? Teach the child to do self-catheterization. Teach the child appropriate bladder control. Continue having the parents do the catheterization. Encourage the family to consider urinary diversion.
Teach the child to do self-catheterization. At 7 years of age, this child should be able to perform the intermittent catheterization herself. This will give her more control and mastery over her disability. Bladder control cannot be taught in a child with a neurogenic bladder. This would be a good time to have the child begin caring for herself. A urinary diversion is not necessary at this time.
You are caring for a patient admitted with diabetes mellitus, malnutrition, and a massive GI bleed. In analyzing the morning lab results, the nurse understands that a potassium level of 5.5 mEq/L could be caused by which factors in this patient (select all that apply.)? The potassium level may be increased if the patient has nephropathy. The patient has been eating excessive amounts of foods that increase potassium levels. The patient may be excreting extra sodium and retaining potassium secondary to malnutrition. There may be excess potassium being released into the blood as a result of massive blood transfusion. The potassium level may be increased because of dehydration that accompanies high blood glucose levels.
The potassium level may be increased if the patient has nephropathy. There may be excess potassium being released into the blood as a result of massive blood transfusion. The potassium level may be increased because of dehydration that accompanies high blood glucose levels. Hyperkalemia may result from hyperglycemia, renal insufficiency, or cell death. Diabetes mellitus, along with the stress of hospitalization and illness, can lead to hyperglycemia. Renal insufficiency is a complication of diabetes. Because malnutrition does not cause sodium excretion accompanied by potassium retention, it is not a contributing factor to this patient's potassium level. Stored hemolyzed blood can cause hyperkalemia when large amounts are transfused rapidly. The patient with a massive GI bleed would have an nasogastric tube and not be eating.
A teenager who needs dialysis decides to use continuous cycling peritoneal dialysis (CCPD) or continuous ambulatory peritoneal dialysis (CAPD) with her physician's blessing. What information can the nurse explain to the teenager's parents to help them understand the advantage for their child? Dietary restrictions are no longer necessary. The teenager can carry out the procedure herself after training. Hospitalization is only required several nights per week. Insertion of the catheter does not require surgical placement.
The teenager can carry out the procedure herself after training. The procedure can be done at home and often during the hours the child is sleeping. This type of dialysis provides the most independence for adolescents with end-stage renal disease and their families. Hospitalization is needed for catheter placement and only if the teenager runs into difficulty. The catheter is surgically implanted in the abdominal cavity. Dietary restrictions are still required but are less strict.
A patient is scheduled for a corneal transplant and is concerned regarding the difficulty with vision that may last for up to 12 months after the transplant. What is the best response by the nurse? If the transplant is done soon after the donor dies, there will not be as much trouble recovering vision. The astigmatism the patient is experiencing may be corrected with glasses or rigid contact lenses. Increasing the amount of light and using a magnifier to read will be helpful if a transplant is not wanted. There are newer procedures in which only the damaged cornea epithelial layer is replaced, and they have a faster recovery.
There are newer procedures in which only the damaged cornea epithelial layer is replaced, and they have a faster recovery. Correct The new procedures are called Descemet's stripping endothelial keratoplasty (DSEK) and Descemet's membrane endothelial keratoplasty (DMEK). Corneal transplants should be done as soon as possible, but this does not affect the rate of visual recovery. Astigmatism is not experienced with corneal scars and opacities requiring a corneal transplant. Increasing light and magnification helps a person with cataracts to read.
After hearing from the physician that their infant has sensorineural hearing loss, the parents ask the nurse to explain what that term means. Which explanation by the nurse is correct? This serious type of hearing loss is the result of damage from heredity or environmental effects. Sensorineural hearing loss is a minor type that is easily corrected with tiny hearing aids. Sensorineural hearing loss leads to intellectual disability by the age of 7. Since sensorineural hearing loss is reversible in most children, don't worry.
This serious type of hearing loss is the result of damage from heredity or environmental effects. such as infection or viral invasion. Sensorineural hearing loss is major and not reversible, but it can be corrected using ear-level hearing aids. Sensorineural hearing loss does not lead to intellectual disability. The amount the child can learn depends upon hearing so the child can be behind if not diagnosed, but this does not cause a permanent disability. Sensorineural hearing loss is not reversible but can be treated even with a cochlear implant.
The nurse is examining a patient's ear in the clinic to determine if recent treatment for acute otitis media has been effective. Which assessment finding indicates resolution of the middle ear infection? Fenestrations are visible in the tympanic membrane. Tympanic membrane is gray, shiny, and translucent. Cone of light is not visible on the tympanic membrane. Tympanic membrane is blue and bulging with no landmarks.
Tympanic membrane is gray, shiny, and translucent. The tympanic membrane (TM) is normally pearly gray, white or pink, shiny, and translucent. Perforation of the TM that has not healed will appear as open areas of the tympanic membrane. The absence of the cone of light indicates a retracted TM. A bulging red or blue eardrum and lack of landmarks indicates a fluid-filled middle ear. The fluid may be pus or blood.
A patient with septic shock is receiving multiple medications. Which intravenous (IV) medication is most likely to cause a hearing loss? Dopamine Ampicillin Aspirin Vancomycin
Vancomycin Correct The IV medication in use that is most likely to cause a hearing loss is vancomycin (Vancocin) because it is an ototoxic medication. For that reason, serum drug levels are monitored to maintain therapeutic levels and reduce the risk of ototoxicity. Aspirin can also cause hearing loss, but it is not administered IV. Neither dopamine nor ampicillin is likely to cause hearing loss.
A patient is recovering from a motor vehicle crash that resulted in blindness. The patient is withdrawn and refuses to get out of bed. What is the nurse's priority goal for this patient? Use suitable coping strategies to reduce stress. Identify patient's strengths and support system. Verbalize feelings related to visual impairment. Transition successfully to the sudden vision loss.
Verbalize feelings related to visual impairment The nurse's priority is to help the patient express his feelings about the vision loss resulting from the lack of coping effectively with the situation. Until the patient expresses how they feel, they will be unable to progress in the rehabilitation process.
While caring for a patient with metastatic bone cancer, which clinical manifestations would alert the nurse to the possibility of hypercalcemia in this patient (select all that apply.)? Weakness Paresthesia Facial spasms Muscle tremors Depressed reflexes
Weakness Depressed reflexes Signs of hypercalcemia are lethargy, fatigue, weakness, depressed reflexes, muscle flaccidity, heart block, anorexia, nausea, and vomiting. Paresthesia, facial spasms, and muscle tremors are symptoms of hypocalcemia.
An infant is born with ambiguous genitalia. Tests are being done to assist in gender assignment. The parents tell the nurse that family and friends are asking what caused the baby to be this way. What is the most appropriate approach by the nurse? Help parents understand that no one knows how this occurs. Explain the disorder so that parents can explain it to others. Encourage parents not to worry while the tests are being done. Suggest that parents avoid family and friends until the gender is assigned.
explaining the disorder so that the parents can explain it to others is the most therapeutic approach while the parents await the gender assignment of their child. The parents will be concerned. Telling the parents not to worry without giving them specific alternative actions would not be effective. It is impractical for parents to avoid family and friends and would isolate the family from their support system while awaiting test results. Telling the parents that no one knows how this occurs will increase parents' anxiety and is non-therapeutic.
Which serum potassium result best supports the rationale for administering a stat dose of IV potassium chloride 20 mEq in 200 mL of normal saline over 2 hours? 3.1 mEq/L 3.9 mEq/L 4.6 mEq/L 5.3 mEq/L
he normal range for serum potassium is 3.5 to 5.0 mEq/L. This IV order provides a substantial amount of potassium. Thus the patient's potassium level must be low. The only low value shown is 3.1 mEq/L.
The nurse is caring for a 76-yr-old woman admitted to the medical unit with hypernatremia and dehydration after prolonged fever. The best beverage to offer the patient is malted milk. orange juice. tomato juice. hot chocolate.
orange juice. Orange juice would be the safest option because it has the least amount of sodium (~2 mg in 8 oz). Hot chocolate has approximately 75 mg sodium in 8 ounces. Tomato juice has approximately 650 mg sodium in 8 oz. Malted milk has approximately 625 mg sodium in 8 oz.
The nurse on a medical-surgical unit identifies which patient as having the highest risk for metabolic alkalosis? A patient with a traumatic brain injury A patient with type 1 diabetes mellitus A patient with acute respiratory failure A patient with nasogastric tube suction
patient with nasogastric tube suction Excessive nasogastric suctioning may cause metabolic alkalosis. Brain injury may cause hyperventilation and respiratory alkalosis. Type 1 diabetes mellitus (diabetic ketoacidosis) is associated with metabolic acidosis. Acute respiratory failure may lead to respiratory acidosis.
he nurse is reviewing urine test results. About which value should the nurse alert the physician? pH: 4.0 Specific gravity: 1.020 Protein level: absent Glucose level: absent
ph 4.0 The expected pH is 4.8 to 7.8. A specific gravity of 1.020 is within the normal specific gravity range of 1.010 to 1.030. Protein should not be present in the urine. It would indicate an abnormality in glomerular filtration. Glucose should not be present. If present, it could indicate diabetes mellitus, glomerulonephritis, or a response to infusion of fluids with high glucose concentrations.
The nurse instructs a patient prescribed dipivefrin eye drops to manage chronic open-angle glaucoma. Which statement, if made by the patient to the nurse, indicates that further teaching is needed? "The eye drops could cause a fast heart rate and high blood pressure." "I will need to take the eye drops twice a day for at least 2 to 3 months." "I may experience eye discomfort and redness from the use of these eye drops." "I will apply gentle pressure on the inside corner of my eye after each eye drop."
will apply gentle pressure on the inside corner of my eye after each eye drop. To avoid systemic reactions such as tachycardia and hypertension, the patient should apply punctual occlusion after instillation of the eye drops. Dipivefrin will control chronic open-angle glaucoma but will not cure the disease. Side effects associated with dipivefrin include ocular discomfort and redness, tachycardia, and hypertension.
You are caring for a patient admitted with an exacerbation of asthma. After several treatments, the ABG results are pH 7.40, PaCO2 40 mm Hg, HCO3 24 mEq/L, PaO2 92 mm Hg, and O2 saturation of 99%. You interpret these results as metabolic acidosis. respiratory acidosis. respiratory alkalosis. within normal limits
within normal limits. The normal pH is 7.35 to 7.45. Normal PaCO2 levels are 35 to 45 mm Hg, and HCO3 is 22 to 26 mEq/L. Normal PaO2 is >80 mm Hg. Normal oxygen saturation is >95%. Because the patient's results all fall within these normal ranges, the nurse can conclude that the patient's blood gas results are within normal limits.