Don't Hate--Remediate (NCLEX PREP)

A nurse is performing a physical examination of a primigravid client who's 8 weeks pregnant. At this time, the nurse expects to assess: Hegar's sign. fetal outline. ballottement. quickening.

Hegar's sign. When performing a vaginal or rectovaginal examination, the nurse may assess Hegar's sign (softening of the uterine isthmus) between the 6th and 8th weeks of pregnancy. The fetal outline may be palpated after 24 weeks. Ballottement isn't elicited until the fourth or fifth month of pregnancy. Quickening typically is reported after 16 to 20 weeks.

What is the approximate time that the blastocyst spends traveling to the uterus for implantation? 2 days 7 days 10 days 14 weeks

7 days

A nurse is developing a care plan for bone marrow suppression, the major dose-limiting adverse reaction to floxuridine (FUDR). How long after drug administration does bone marrow suppression become noticeable? 24 hours 2 to 4 days 7 to 14 days 21 to 28 days

7 to 14 days Bone marrow suppression becomes noticeable 7 to 14 days after floxuridine administration. Bone marrow recovery occurs in 21 to 28 days.

A nurse is caring for a client with type 1 diabetes who is light headed, begins sweating profusely, and loses consciousness. Which action should the nurse take? Raise the client's legs. Give the client 240 mL of orange juice. Administer 10 units of fast-acting insulin. Administer an IV bolus of 50% dextrose.

Administer an IV bolus of 50% dextrose. The client is most likely experiencing hypoglycemia and needs glucose. Giving fluids to an unconscious client is contraindicated. Insulin will further decrease glucose levels. Raising the client's legs will not reverse hypoglycemia.

A competent client in a long-term care facility refuses to take his oral diuretic medication. The nurse informs him that if the medication isn't taken, restraints will be applied, and the medication will be given by injection. Which legal tort best describes this nurse's statement? Assault Battery Negligence Autonomy

Assault Assault occurs when one person puts another in fear of harmful or threatening contact. Battery is physical contact with another person. Negligence involves actions that are below the standard of care. Autonomy is an ethical principle of self-determination, and does not constitute a legal issue.

Which assessment finding is expected in a client receiving bicalutamide and leuprolide for advanced prostate cancer? Abdominal distention Acromegaly Colicky pain Hot flashes

Hot flashes Bicalutamide, a nonsteroidal antiandrogen, and leuprolide, a gonadotropin-releasing hormone agonist, decrease the production of testosterone. This helps decrease the production of cancer cells involved in prostate cancer. Because androgens are responsible for the development of male genitalia and secondary male sex characteristics, low androgen levels can cause genital atrophy, breast enlargement, and hot flashes. Abdominal distention, acromegaly, and colicky pain aren't caused by bicalutamide and leuprolide therapy.

A client with chronic pancreatitis should be assessed for which finding? Nausea and vomiting Confusion and agitation Fever and tachycardia Muscle twitching and tremors

Nausea and vomiting Common manifestations of chronic pancreatitis include nausea, vomiting, and intermittent pain. Chronic pancreatitis does not cause confusion or agitation. There is no change in vital signs, and there are no musculoskeletal manifestations such as muscle twitching.

What is the most common assessment finding in a child with ulcerative colitis? Intense abdominal cramps Profuse diarrhea Anal fissures Abdominal distention

Profuse diarrhea Ulcerative colitis causes profuse diarrhea. Intense abdominal cramps, anal fissures, and abdominal distention are more common in Crohn's disease.

Which finding in the client's history would be the least likely to have predisposed the client to renal calculi? having had several urinary tract infections in the past 2 years having taken large doses of vitamin C over the past several years drinking less than the recommended amount of milk having been on prolonged bed rest after an accident the previous year

drinking less than the recommended amount of milk A high, rather than low, milk intake predisposes to renal calculi formation, owing to the calcium in milk. Recurrent urinary tract infections are implicated in stone formation as certain bacteria promote stone formation. High daily doses of vitamins C are a risk factor because they can increase the citric acid level. Prolonged immobility is a risk factor for renal calculi because it causes calcium to be released into the bloodstream.

The client with Ménière's disease is instructed to modify his diet. The nurse should explain that the most frequently recommended diet modification for Ménière's disease is: low sodium. high protein. low carbohydrate. low fat.

low sodium. A low-sodium diet is frequently an effective mechanism for reducing the frequency and severity of the disease episodes. About three-quarters of clients with Ménière's disease respond to treatment with a low-salt diet. A diuretic may also be prescribed. Other dietary changes, such as high protein, low carbohydrate, and low fat, do not have an effect on Ménière's disease.

The priority symptom to assess for in the client who is taking risperidone 1 mg, orally twice a day is: insomnia. headache. anxiety. orthostatic hypotension.

orthostatic hypotension. Significant orthostatic hypotension is associated with risperidone therapy. The nurse should monitor the client's blood pressure sitting and standing and teach the client interventions to manage this adverse effect to prevent risk of injury. Although insomnia, headache, and anxiety are possible adverse effects of risperidone therapy, they are of less immediate concern than orthostatic hypotension.

After receiving a change-of-shift report at 0700, the nurse should assess which client first? A 23-year-old with a migraine headache who has severe nausea associated with retching A 45-year-old scheduled for a craniotomy in 30 minutes and who needs preoperative teaching A 59-year-old with Parkinson's disease who will need a swallowing assessment before breakfast a 63-year-old with multiple sclerosis who has an oral temperature of 101.8° F (38.8° C) and flank pain

a 63-year-old with multiple sclerosis who has an oral temperature of 101.8° F (38.8° C) and flank pain Urinary tract infections are a frequent complication in clients with multiple sclerosis because of the effect on bladder function; therefore, that client should been seen first by the nurse. The elevated temperature and flank pain suggest that this client may have pyelonephritis. The client should be notified immediately so that antibiotic therapy can be started quickly. The other clients should be assessed soon, but do not have needs as urgent as this client.

The nurse is examining charts to identify clients at risk for developing multiple myeloma. Which client is most at risk? A 20-year-old Asian woman A 30-year-old white man A 50-year-old Hispanic woman A 60-year-old black man

A 60-year-old black man Multiple myeloma is more common in middle-aged and older clients. The median age at diagnosis is 60 years. It is twice as common in blacks as it is in whites. It occurs most often in black men.

The nurse is observing a spouse administer eyedrops, as shown in the figure. What should the nurse instruct the spouse to do? Move the dropper to the inner canthus. Have the client raise the eyebrows. Administer the drops in the center of the lower lid. Have the client squeeze both eyes after administering the drops.

Administer the drops in the center of the lower lid. The spouse has positioned the dropper and the client correctly to prevent injury to the client's eye. The spouse should administer the drops in the center of the lower lid. Following administration of the eyedrops, the client should blink the eyes to distribute the medication; squeezing or rubbing the eyes might cause the medication to drip out of the eye.

A client who takes ibuprofen for pain tells the nurse, "I have frequent indigestion." Which of the following actions should the nurse take? Tell the client to take the ibuprofen with a small meal. Ask the client to describe the indigestion. Inform the client to take acetaminophen instead of ibuprofen. Tell the client to request a histamine blocker antacid.

Ask the client to describe the indigestion. The nurse should further assess this client. Side effects of ibuprofen include shortness of breath, dark tarry stools, and frequent indigestion. The client should stop taking ibuprofen and be evaluated by the healthcare provider. Telling the client to request an antacid or take the ibuprofen with a meal is not indicated until further information is obtained. Telling the client to take acetaminophen also is not indicated until an assessment is performed.

A client with seizure disorder comes to the physician's office for a routine checkup. Knowing that the client takes phenytoin to control seizures, the nurse assesses for: Excessive gum tissue growth Drowsiness Hypertension Tinnitus

Excessive gum tissue growth Phenytoin can lead to excessive gum tissue growth, known as gingival hyperplasia. However, brushing the teeth two or three times daily helps retard such growth. Some clients may require excision of excessive gum tissue every 6 to 12 months. Phenytoin may cause central nervous system stimulation, leading to insomnia, nervousness, and twitching; it doesn't cause drowsiness. Other adverse reactions to phenytoin include hypotension, not hypertension; and visual disturbances, not tinnitus.

Which laboratory finding is present in nephrotic syndrome? decreased total serum protein hypercalcemia hyperglycemia decreased hematocrit

decreased total serum protein A decreased total serum protein occurs as extensive amounts of protein are excreted from the body through the urine. Clients may develop hypocalcemia. Hyperglycemia is not a finding related to nephrotic syndrome. A decreased hematocrit is not a finding related to nephrotic syndrome.

A client with breast cancer received chemotherapy approximately 10 days ago. Her complete blood count today is as follows. Which teaching is appropriate based on these laboratory results? White blood cells 5000/cmm Neurophils 75% Hemoglobin 13 g/dL Hematocrit 40% Platelets 45,000/cmm Avoid people with colds or infection Conserve energy by taking frequent rest periods Use electric razor to shave legs Teach client which foods are high in iron

Use electric razor to shave legs These laboratory values are all within normal limits except the platelet count, so the client is at risk for bleeding. The electric razor will minimize the risk of injury when shaving.

The nurse is assessing a client with peripheral arterial disease who had a femoral-popliteal bypass. Which finding indicates improved arterial blood supply to the lower extremity? decrease in muscle pain when walking dependent rubor absence of pulse using a Doppler ultrasound reduction in pitting edema

decrease in muscle pain when walking With increased blood supply to the leg there should be less or absent claudication (cramping pain in leg with walking). Pulses should be palpable with improved blood supply. Edema is associated with venous disease. Pallor with elevation and dependent rubor are symptoms of peripheral arterial disease.

The health care provider prescribes raloxifene hydrochloride for a 60-year-old woman. The drug is effective if the client does not have: hot flashes. osteoporosis. hyperglycemia. migraine headaches.

osteoporosis. Raloxifene hydrochloride, an estrogen receptor modulator, increases bone mineral density without stimulating the endometrium. The drug is useful in preventing osteoporosis in postmenopausal women. This drug is contraindicated for women who smoke cigarettes or who have a history of venous thrombosis. Raloxifene does not prevent hot flashes or hyperglycemia. One of its adverse effects is increased headaches.

Which sign is an early indicator of hypoxia in the unconscious client? restlessness decreased respirations cyanosis hypotension

restlessness Restlessness is an early indicator of hypoxia. The nurse should suspect hypoxia in the unconscious client who becomes restless. The most accurate method for determining the presence of hypoxia is to evaluate the pulse oximeter value or arterial blood gas values. Cyanosis and decreased respirations are late indicators of hypoxia. Hypertension, not hypotension, is a sign of hypoxia.

A man of Chinese descent is admitted to the hospital with multiple injuries after a motor vehicle accident. His pain is not under control. The client states, "If I could be with my people, I could receive acupuncture for this pain." The nurse should understand that acupuncture in the Asian culture is based on the theory that it: purges evil spirits. promotes tranquility. restores the balance of energy. blocks nerve pathways to the brain.

restores the balance of energy. Acupuncture, like acumassage and acupressure, is performed in certain Asian cultures to restore the energy balance within the body. Pressure, massage, and fine needles are applied to energy pathways to help restore the body's balance. Acupuncture is not based on a belief in purging evil spirits. Although pain relief through acupuncture can promote tranquility, acupuncture is performed to restore energy balance. In the Western world, many researchers think that the gate-control theory of pain may explain the success of acupuncture, acumassage, and acupressure.

Which statement by the parent of a toddler diagnosed with nephrotic syndrome indicates that the parent has understood the nurse's teaching about this disease? "My child really likes chips and bologna. I guess we will have to find something else." "We will have to encourage lots of liquids. Did you say about 4 liters every day?" "We worry about the surgery. Do you think we should do direct donation of blood?" "We understand the need for antibiotics. I just wish the antibiotics could be given by mouth."

"My child really likes chips and bologna. I guess we will have to find something else." Children with nephrotic syndrome usually require sodium restriction. Because potato chips and bologna are high in sodium, the mother's statement about finding something else reflects understanding of this need. Although fluid intake is not restricted in children with nephrotic syndrome, 4 L is an excessive amount for a toddler. The typical fluid requirement for a toddler is 115 mL/kg. Surgical intervention and antibiotic therapy are not parts of the treatment plan for nephrotic syndrome.

A multiparous client 48 hours postpartum who is breast-feeding tells the nurse, "I am having a lot of cramping. This did not happen when I nursed my first baby." Which would be the nurse's best response? "I will notify your health care provider. It is possible there are some placental fragments remaining." "I need to check your lochial flow. You may have a clot that is being dislodged." "You must have gotten a heavy dose of oxytocin. It should wear off soon." "The cramping is normal and is caused by your baby's sucking, which stimulates the release of oxytocin."

"The cramping is normal and is caused by your baby's sucking, which stimulates the release of oxytocin." The cramping is caused by the baby's sucking and subsequent stimulation for the release of oxytocin. This cramping is normal. With each subsequent pregnancy, the uterus becomes "stretched" and the release of oxytocin causes the uterus to contract, resulting in the feeling of cramping that can become more severe with each birth. Continued moderate to large amounts of lochia rubra are indicative of retained placental fragments. Cramping indicates that the uterus is contracting and most likely firm. A boggy uterus, continued moderate to heavy lochia, mild vasoconstriction, and restlessness and anxiety suggest delayed postpartum hemorrhage due to subinvolution of the placental site, retained placental tissue, or infection. Most clients receive a standard dose of oxytocin after birth. Oxytocin has a duration of action of 60 minutes. Therefore, the effects of the drug would have worn off by 24 hours postpartum.

An employee health nurse is assisting a stressed working mother with value clarification. Which of the following best defines value clarification? A process by which people come to understand their own values and value systems. A belief about the worth of something, about what matters, that acts as a standard to guide one's behavior. An organization of values in which each is ranked along a continuum of importance, often leading to a personal code of conduct A systematic inquiry into principles of right and wrong conduct, of virtue and vice, and of good and evil, as they relate to conduct.

A process by which people come to understand their own values and value systems. Value clarification is a process by which people come to understand their own values and value systems. A value is a belief about the worth of something, about what matters, that acts as a standard to guide one's behavior. A value system is an organization of values in which each is ranked along a continuum of importance, often leading to a personal code of conduct. Ethics is a systematic inquiry into principles of right and wrong conduct, of virtue and vice, and of good and evil, as they relate to conduct.

The nurse is performing an assessment of a client admitted to the behavioral health unit with schizophrenia. Which of the following behaviors by the client would the nurse document as positive symptoms? Select all that apply. Client is sitting in the corner without expression or movement. Client states, "I am the King of England!" Client is copying the movements of the client sitting next to them. Client states, "Do you see all of the rats crawling on the floor? Kill them!" Client is unable to speak.

Client states, "I am the King of England!" Client is copying the movements of the client sitting next to them. Client states, "Do you see all of the rats crawling on the floor? Kill them!" The positive symptoms of schizophrenia include delusions or false beliefs that are not based in reality, echopraxia is an imitation of the movements and gestures of another person whom the client is watching. Hallucinations are common positive symptoms or perceptual experiences that have no basis in reality. Negative symptoms are alogia and catatonia.

A client comes into the emergency department with severe back pain radiating to the left lower groin region. Morphine sulfate 10 mg IV is administered as ordered. One hour later the client states that the pain is still at 8 of 10. Which actions would the nurse take? Explain that a high dose of the pain medication has been administered and that it takes longer than 1 hour to exert its therapeutic effect. Tell the client that the order is for every 3-4 hours and explain that an additional dose cannot be given for 2 more hours. Contact the physician and explain that the pain is still at 8 of 10 one hour after the morphine has been administered and request a higher dosage. Check to ensure the correct dosage was given and ask the client if he/she has routinely taken painkillers or street drugs.

Contact the physician and explain that the pain is still at 8 of 10 one hour after the morphine has been administered and request a higher dosage. Renal colic can be one of the most severe pain experiences. The ordered dosage of analgesic has not provided relief, so additional intervention is appropriate. Because of the severity of the pain, it is not appropriate for the client to wait until the next dose is due. Although the client is receiving a therapeutic dose, it is not effective. The interval between doses of the analgesic is too great. There may be a tolerance to the analgesic if the client has routinely taken painkillers; however, relief is still needed now.

Immediately after birth, a nurse assesses the neonate's respiratory effort as slow. The neonate is actively moving but grimaces in response to stimulation. His fingers and toes are bluish, and his heart rate is 130 bpm. Which step should the nurse take next? Tell the provider that the neonate appears abnormal Assign an Apgar score of 8 Wrap the infant in a warm blanket Provide oxygen and stimulate the baby to cry

Provide oxygen and stimulate the baby to cry The nurse should stimulate the baby to cry, provide oxygen, and call the provider to evaluate reflex irritability. It would be inappropriate to tell the provider that the neonate appears abnormal. The neonate's Apgar score is 7. Of a maximum possible Apgar score of 10, the nurse deducts one point for acrocyanosis, one point for slow respiratory effort, and one point for the grimace. Although keeping the infant warm is important, the infant clearly needs more aggressive interventions such as oxygen and stimulation

A 16-year-old girl visits the clinic for the first time. She tells the nurse that she has been exposed to herpes. Initially, with primary genital or Type 2 herpes simplex, the nurse should expect the girl to have: dysuria and urine retention. perineal ulcers and erosions. bilateral inguinal lymphadenopathy. burning or tingling on vulva, perineum, or vagina.

burning or tingling on vulva, perineum, or vagina. Genital burning and tingling is the most common initial finding with primary genital or Type 2 herpes simplex. This symptom will advance to vesicular lesions rupturing into ulcerations, which then dry into a crusty erosion. Fever, headache, malaise, myalgia, regional lymphadenopathy, and dysuria, and urine retention are later findings in Type 2 herpes.

The nurse is instructing the client with chronic renal failure to maintain adequate nutritional intake. Which diet would be most appropriate? high-carbohydrate, high-protein high-calcium, high-potassium, high-protein low-protein, low-sodium, low-potassium low-protein, high-potassium

low-protein, low-sodium, low-potassium Dietary management for clients with chronic renal failure is usually designed to restrict protein, sodium, and potassium intake. Protein intake is reduced because the kidney can no longer excrete the byproducts of protein metabolism. The degree of dietary restriction depends on the degree of renal impairment. The client should also receive a high-carbohydrate diet along with appropriate vitamin and mineral supplements. Calcium requirements remain 1,000 to 2,000 mg/day.

At 28 weeks' gestation, a client is admitted in preterm labor. An I.V. infusion of magnesium sulfate is started. Which client outcome reflects the nurse's awareness of an adverse effect of magnesium sulfate? "The client remains free from tachycardia." "The client remains free from polyuria." "The client remains free from hypertension." "The client remains free from hyporeflexia."

"The client remains free from hyporeflexia." Terbutaline and other beta-adrenergic agonists may cause tachycardia, hypotension, bronchial dilation, increased plasma volume, increased cardiac output, arrhythmias, myocardial ischemia, reduced urine output, restlessness, headache, nausea, and vomiting. These drugs are not associated with polyuria, hypertension, or hyporeflexia.

Every morning, a client with type 1 diabetes receives 15 units of Humulin 70/30. What does this type of insulin contain? 70 units of neutral protamine Hagedorn (NPH) insulin and 30 units of regular insulin 70 units of regular insulin and 30 units of NPH insulin 70% NPH insulin and 30% regular insulin 70% regular insulin and 30% NPH insulin

70% NPH insulin and 30% regular insulin

When palpating the bladder of an adult client, a nurse should identify which finding as normal? A nonpalpable bladder A soft, smooth bladder A hard, rough bladder A palpable bladder located 3″ to 5″ (7.5 to 12.7 cm) above the symphysis pubis

A nonpalpable bladder An adult's bladder may not be palpable. An adult's bladder that is palpable is usually firm, smooth, and located 1″ to 2″ (2.5 to 5 cm) above the symphysis pubis.

A client receives midazolam, 2 mg IV, as sedation before bronchoscopy. Five minutes after he receives the drug, his respiratory rate drops to 4 breaths/min. What is the nurse's most appropriate action? Administer naloxone Administer protamine sulfate (Heparin antagonist) Administer phentolamine Administer flumazenil

Administer flumazenil Flumazenil reverses the effects of benzodiazepines such as midazolam. Naloxone is used to reverse opioids, such as morphine. Protamine sulfate reverses the effects of heparin. Phentolamine is injected into the tissues to reverse the damaging effects of a dopamine infiltration.

A client receiving radiation to the head and neck area as treatment for laryngeal cancer develops ulcerations and bleeding of the oral mucosa. Which should the nurse consider as the primary goal for this client? Relief of anxiety Pain relief Increase in self esteem Adequate nutrition

Adequate nutrition The need for food/water are highest on Maslow's hierarchy, followed by the need for comfort (pain), anxiety, and self-esteem

The nurse is instructing a college student with Addison's disease how to adjust the dose of glucocorticoids. The nurse should explain that the client may need an increased dosage of glucocorticoids in which situation? completing the spring semester of school gaining 4 lb (1.8 kg) becoming engaged having wisdom teeth extracted

Adrenal crisis can occur with physical stress, such as surgery, dental work, infection, flu, trauma, and pregnancy. In these situations, glucocorticoid and mineralocorticoid dosages are increased. Weight loss, not gain, occurs with adrenal insufficiency. Psychological stress has less effect on corticosteroid need than physical stress.

Which laboratory value will require intervention in a client who is receiving lithium? Sodium 130 mEq/L Creatinine 1.8 mg/dL Potassium 4.0 mEq Lithium level 1.2 mEq/L

Sodium 130 mEq/L Low sodium levels may predispose clients to toxicity with lithium. The nurse should notify the healthcare provider. The creatinine level is mildly elevated but not the priority for this particular client. The potassium and lithium levels are within normal limits.

A client is admitted to the hospital with aspiration pneumonia secondary to progression of Parkinson's disease. Which assessment finding should the nurse anticipate? Coughing when drinking liquids Muscle flaccidity of the lower extremities Pleasant and smiling demeanor Tremors in the fingers that increase with purposeful movement

Coughing when drinking liquids In Parkinson's disease, dysarthria, or impaired speech, results from a disturbance in muscle control. Muscle rigidity, not flaccidity, causes resistance to passive muscle stretching. The client may exhibit a mask-like appearance rather than a pleasant and smiling demeanor. Tremors should decrease, not increase, with purposeful movement and sleep. When the disease is advanced, swallowing is impaired and coughing would indicated aspiration.

A client with lung cancer develops pleural effusion. During chest auscultation, which breath sound should the nurse expect to hear? Crackles Rhonchi Decreased breath sounds Wheezes

Decreased breath sounds In pleural effusion, fluid accumulates in the pleural space, impairing transmission of normal breath sounds. Because of the acoustic mismatch, breath sounds are diminished. Crackles commonly accompany atelectasis, interstitial fibrosis, and left-sided heart failure. Rhonchi suggest secretions in the large airways. Wheezes result from narrowed airways, such as in asthma, chronic obstructive pulmonary disease, and bronchitis.

A nurse is caring for a client of the Buddhist faith who is dying. The client's family is at the bedside. Which intervention would the nurse implement to support the client's death with dignity? Place the client's bed so that it faces the east. Ensure that the room is calm, dimly lit, and quiet. Allow the family to tie sacred threads on the client's wrists. Position the client's arms so that they are straight.

Ensure that the room is calm, dimly lit, and quiet. In the Buddhist religion, death is associated with rebirth. To ensure dignity, the environment surrounding the dying client should be serene. Placing the bed to face east, tying sacred threads on the client's wrists, and straightening the arms are actions appropriate for a dying person who follows Hinduism.

The nurse prepares the client for a lumbar puncture (LP) (see client chart below) to rule out a subarachnoid hemorrhage. Which assessment finding would require intervention before the procedure? 2/10/2017 1900 56-year-old, right-handed female presents with severe onset of headache and projectile vomiting that started 45 minutes prior to admission. Physical examination findings include nuchal rigidity. Severe vomiting Suspected increased intracranial pressure (ICP) Client requires mechanical ventilation Blood in the cerebrospinal fluid (CSF)

Suspected increased intracranial pressure (ICP) Sudden removal of CSF result in a lowered pressure in the lumbar area than in the brain which can cause brain herniation, especially in the presence of increased ICP. Therefore a LP is contraindicated when increased ICP is suspected. Vomiting may be caused by reasons other than increased ICP; therefore, LP isn't strictly contraindicated. A LP may be performed on clients requiring mechanical ventilation. Blood in the CSF is diagnostic for subarachnoid hemorrhage.

The nurse has been asked to develop a medication education program for clients with chronic mental illness in the rehabilitation program. When developing the course outline, which topic is most important to include? a categorization of many psychotropic drugs interventions for common side effects of psychotropic drugs the role of medication in the treatment of acute illness effects of combining common street drugs with psychotropic medication

interventions for common side effects of psychotropic drugs The psychotropic drugs used to treat chronic mental illnesses have side effects that can lead to noncompliance. Therefore, teaching the clients measures to deal with the common side effects would be most important. Teaching should be focused on the need for compliance and the specific interests of the target audience. Teaching should concentrate on the medications commonly used to treat chronic mental illness, not on many psychotropic drugs or those used in acute illness. Such topics as the role of medication in the treatment of chronic mental illness and the effects of using common street drugs with psychotropic medication should be discussed after the issue of compliance is addressed.

Which of the following arterial blood gas (ABG) results would the nurse anticipate for a client with a 3-day history of vomiting? pH: 7.55, PaCO2: 60 mm Hg, HCO3-: 28 pH: 7.45, PaCO2: 32 mm Hg, HCO3-: 21 pH: 7.28, PaCO2: 25 mm Hg, HCO3: 15 pH: 7.34, PaCO2: 60 mm Hg, HCO3: 34

pH: 7.55, PaCO2: 60 mm Hg, HCO3-: 28 The client's ABG would likely demonstrate metabolic alkalosis. Metabolic alkalosis is a clinical disturbance characterized by a high pH (decreased H+ concentration) and a high plasma bicarbonate concentration. It can be produced by a gain of bicarbonate or a loss of H+. A common cause of metabolic alkalosis is vomiting or gastric suction with loss of hydrogen and chloride ions. The disorder also occurs in pyloric stenosis where only gastric fluid is lost. The other results do not represent metabolic alkalosis.

After the nurse instructs the parents of a 5-month-old infant about the purpose of the Denver Developmental Screening Test (DDST), which statement by the parents about what the test measures would indicate that the teaching was effective? "This test measures a child's IQ." "This test measures a child's emotional development." "This test measures a child's social and physical abilities." "This test measures a child's potential for future development."

"This test measures a child's social and physical abilities." The Denver Developmental Screening Test (DDST) measures a child's social, language, and fine and gross motor skills by testing abilities that usually occur at a given age. The DDST is not designed to measure intelligence or emotional development nor does it necessarily predict future development.

While meeting with the nurse, a client's wife states, "I do not know what else to do to make him stop drinking." The nurse should refer the wife to which organization? Alateen Al-Anon an employee assistance program Alcoholics Anonymous

Al-Anon Al-Anon is a self-help group for spouses and significant others that provides education and support and helps participants learn to lead their own life without feeling responsible for the individual with an alcohol problem. Alateen provides support for teenaged children of a person with an alcohol problem. Employee assistance programs help employees recover from alcohol or drug dependence while retaining their positions or jobs. Alcoholics Anonymous provides support for the individual with alcohol problems to attain and maintain sobriety.

A 4-year-old child is seen in the pediatrician's office. The child is due for immunizations, and the provider discusses with the caregiver the need for the immunizations. The nurse returns to the room to administer the immunizations, and the caregiver refuses to sign the paperwork for the administration of the immunizations. What is the most appropriate action by the nurse? The nurse listens to the caregiver's concerns and discusses the risks of nonimmunization. The nurse documents the interaction and escorts the caregiver and child out of the office. The nurse states the child must have vaccinations for preschool and injects the child without permission. The nurse asks the provider to return to discuss the risks of nonimmunization.

The nurse listens to the caregiver's concerns and discusses the risks of nonimmunization. The nurse can document the interaction but does not need to escort the caregiver and child out of the office. The nurse should not plead his or her opinion and forcefully inject the child without permission. The nurse is responsible for communication refusal, but asking the provider to return is not necessary as the caregiver has the right to refuse immunizations for his or her child.

When inspecting a client's skin, a nurse finds a circumscribed elevated area filled with serous fluid. What term should the nurse use to document this finding? Macule Papule Vesicle Pustule

Vesicle A vesicle is a circumscribed skin elevation filled with serous fluid. A flat, nonpalpable, colored spot is a macule. A solid, elevated, circumscribed lesion is a papule. An elevated, pus-filled, circumscribed lesion is a pustule.

A nurse is evaluating a child with acute poststreptococcal glomerulonephritis (APSGN) for signs of improvement. Which finding typically is the earliest sign of improvement? Decreased hematuria Increased appetite Increased energy level Decreased diarrhea

Decreased hematuria Decreased hematuria, a sign of improving kidney function, typically is the first sign that a child with APSGN is improving. Increased appetite, an increased energy level, and decreased diarrhea aren't specific to APSGN.

The nurse has answered the telephone at the nurses' station, and the individual on the line states that there is bomb in the healthcare facility. What is the nurse's best response? Keep the individual on the line in order to gather more information about the details of the threat. Hang up the telephone immediately, and instruct a colleague to call 911 promptly. Inform the authorities, and begin evacuating clients and closing doors. Hang up the telephone, and use the overhead paging system to call all staff to the nurses' station.

Keep the individual on the line in order to gather more information about the details of the threat. If a bomb threat is received, the nurse should keep the caller on the line and talking as long as possible in order to gather information about the location of the bomb and a description of the bomb and the caller. The threat must be reported promptly, but the nurse should not hang up in order to do this.

Positive end-expiratory pressure (PEEP) therapy has which effect on the heart? Bradycardia Tachycardia Increased blood pressure Reduced cardiac output

Reduced cardiac output PEEP reduces cardiac output by increasing intrathoracic pressure and reducing the amount of blood delivered to the left side of the heart. It doesn't affect heart rate, but a decrease in cardiac output may reduce blood pressure, commonly causing compensatory tachycardia, not bradycardia. However, the resulting tachycardia isn't a direct effect of PEEP therapy itself.

The nurse is assessing an adolescent who has been diagnosed with aplastic anemia. Which of the following should be the priority assessment for the nurse? Signs and symptoms of infection Signs and symptoms of nutritional deficit Inability to perform self-care activities Paresthesias and gait disturbances

Signs and symptoms of infection Aplastic anemia results in a lowering of all blood cell counts, causing the adolescent to be neutropenic. Neutropenia often leads to infection, which can be life-threatening.

An unemployed client without health insurance has not filled his prescription. Which assessment finding indicates that this client is not taking her levothyroxine as prescribed? Diarrhea Rapid heart rate Warm, dry, flushed skin Temperature of 94° F (34.4° C)

Temperature of 94° F (34.4° C) Levothyroxine is prescribed for hypothyroidism, which causes a hypodynamic state. Failure to maintain levothyroxine therapy can lead to a low body temperature as well as slowing all metabolic processes. The other assessments indicate a hypermetabolic state, which could be symptomatic of an increase in thyroid hormones

A client receiving a loop diuretic should be encouraged to eat which foods? Select all that apply. angel food cake banana dried fruit orange juice peppers

orange juice dried fruit banana Hypokalemia is a side effect of loop diuretics. Bananas, dried fruit, and oranges are examples of food high in potassium. Angel food cake and peppers are low in potassium.

Which goal would be appropriate for a client with viral hepatitis? The client will: demonstrate a decrease in fluid retention related to ascites. verbalize the importance of reporting bleeding gums or bloody stools. limit use of alcohol to two to three drinks per week. restrict activity to within the home to prevent disease transmission.

verbalize the importance of reporting bleeding gums or bloody stools The client should be able to verbalize the importance of reporting any bleeding tendencies that could be the result of a prolonged prothrombin time. Ascites is not typically a clinical manifestation of hepatitis; it is associated with cirrhosis. Alcohol use should be eliminated for at least 1 year after the diagnosis of hepatitis to allow the liver time to fully recover. There is no need for a client to be restricted to the home because hepatitis is not spread through casual contact between individuals.

Which assessment would be the most important for the nurse to include in the plan of care for an infant experiencing severe diarrhea? weighing the infant each day monitoring the total 8-hour formula intake checking the anterior fontanel every shift monitoring abdominal skin turgor every shift

weighing the infant each day Because an infant experiencing severe diarrhea is at high risk for a fluid volume deficiency, the nurse needs to evaluate the infant's fluid balance status by weighing the infant at least every day. Body weight is the best indicator of hydration status because a higher proportion of an infant's body weight is water, compared with an adult. Initially, the infant with severe diarrhea is not allowed liquids but is given fluids intravenously. Therefore, monitoring the oral intake of formula is inappropriate. Although checking the anterior fontanel for depression or bulging provides information about hydration status, this method is not considered the best indicator of the infant's fluid balance. Monitoring skin turgor can provide information about fluid volume status. The abdomen is commonly used to assess skin turgor in an infant because it is a large surface area and can be accessed quickly. However, weight is the best indicator of fluid balance.

While reviewing the admission assessment of a client scheduled for colorectal surgery, the nurse discovers that the client stopped taking medications to treat emphysema 3 months ago. What would be a priority in planning collaborative care with the respiratory therapist? Reinforce teaching of coughing and deep breathing. Instruct on how to best induce a sputum specimen. Timely administration of breathing treatments. Instruct on reporting abnormal color and consistency of sputum produced.

Timely administration of breathing treatments. The nurse should collaborate with the respiratory therapist to make sure breathing treatments are administered and the client's respiratory status is watched closely before and after surgery, because of the increased risk of infection and post operative pneumonia. An induced sputum specimen is not necessary at this time. The nurse alone can teach the client coughing and deep breathing exercises and monitor the color and consistency of sputum specimens.

A client has a coxackie B (viral) or trypanosomal (parasite) infection. The nurse should further assess the client for: myocarditis. myocardial infarction. renal failure. liver failure.

myocarditis Intracellular microorganisms, such as viruses and parasites, invade the myocardium to survive. These microorganisms damage the vital organelles and cause cell death in the myocardium. The myocardium becomes weak, leading to heart failure; then T lymphocytes invade the myocardium in response to the viral infection. The T lymphocytes respond to the viral infection by secreting cytokines to kill the virus, but they also kill the virus-infected myocardium. Myocardial infarction, renal failure, and liver failure are not direct consequences of a viral or parasitic infection.

A nurse assesses arterial blood gas results for a client in acute respiratory failure (ARF). Which of the following results are consistent with this disorder? pH 7.28, PaO2 50 mm Hg pH 7.46, PaO2 80 mm Hg pH 7.36, PaCO2 32 mm Hg pH 7.35, PaCO2 48 mm Hg

pH 7.28, PaO2 50 mm Hg ARF is defined as a decrease in the arterial oxygen tension (PaO2) to less than 50 mm Hg (hypoxemia) and an increase in arterial carbon dioxide tension (PaCO2) to greater than 50 mm Hg (hypercapnia), with an arterial pH of less than 7.35.

The nurse is caring for a child with osteomyelitis who will be receiving high-dose intravenous antibiotic therapy for 3 to 4 weeks. What should the nurse plan to monitor? blood glucose level thrombin times urine glucose level urine specific gravity

urine specific gravity Long-term, high-dose antibiotic therapy can adversely affect renal, hepatic, and hematopoietic function. Urine specific gravity would provide valuable information about the kidneys' ability to concentrate or dilute urine, thereby suggesting renal impairment. Blood glucose levels reveal how well the client's body is using glucose. Thrombin times reveal information about the clotting mechanism. Urine glucose levels reveal information about the body's use and excretion of glucose.

The nurse is caring for a client with severe diarrhea. The nurse recognizes that the client is at risk for developing which of the following acid-base imbalances? Metabolic acidosis Respiratory acidosis Metabolic alkalosis Respiratory alkalosis

Metabolic acidosis The client is at risk for developing metabolic acidosis. Metabolic acidosis is caused by diarrhea, lower intestinal fistulas, ureterostomies, and use of diuretics; early renal insufficiency; excessive administration of chloride; and the administration of parenteral nutrition without bicarbonate or bicarbonate-producing solutes (e.g., lactate).

While receiving phototherapy, a neonate begins to have frequent, loose, watery, green stools and is very irritable. The nurse interprets this as which situation? This is a normal adverse effect of phototherapy. The neonate is developing lactose intolerance and needs a soy-based formula. The bilirubin is rising to dangerous levels. The neonate may have a malabsorption problem.

This is a normal adverse effect of phototherapy. Phototherapy increases gastric motility, causing the neonate to have many green, watery stools. The increased gastric motility also causes the neonate to be irritable. There is no evidence that the neonate has a lactose intolerance or malabsorption problem, nor is there evidence that the neonate's bilirubin levels are rising to dangerous levels.

The nurse is reviewing laboratory values of a client receiving clozapine. Which laboratory value should the nurse report to the health care provider (HCP)? WBC of 3,500/µL (3.5 X 109/L) hemoglobin of 8.2 g/dL (82 g/L) sodium level of 136 mEq/L (136 mmol/L) hyaline casts in the urinalysis

WBC of 3,500/µL (3.5 X 109/L) A low WBC may indicate the development of agranulocytosis, a serious life threatening side-effect of clozapine, and should be reported immediately. While a hemoglobin of 8.2 mg/dL is low, it is not life threatening. The sodium level of 136 mEq/L (136 mmol/L) is normal. Hyaline cast are usually caused by dehydration and indicate the need for more fluids.

A nurse is caring for a client with watery diarrhea and dehydration. Given the client's recent history of heavy antibiotic use, what interventions should the nurse consider? Wearing gown and gloves when working in the room Encourage oral fluids between meals Regular administration of PRN anti-diarrhea medication Encourage bulk-forming foods for meals

Wearing gown and gloves when working in the room The client presents with the risk factors and symptoms of Clostridium difficile diarrhea which requires contact isolation. Changing diet or giving anti-diarrhea medications will not improve the situation, specific antibiotics are effective in most cases. It is important to encourage fluids but IV would be preferred since oral fluids are expelled in the stool.

In response to the nurse's question about how she is feeling, a postpartum client states that she is fine. She then begins talking to the baby, checking the diaper, and asking infant care questions. The nurse determines the client is in which postpartal phase of psychological adaptation? taking in taking on taking hold letting go

taking hold The client is in the taking hold phase with a demonstrated focus on the neonate and learning about and fulfilling infant care and needs. The taking in phase is the first period after birth where there is emphasis on reviewing and reliving the labor and birth process, concern with self, and needing to be mothered. Eating and sleep are high priorities during this phase. Taking on is not a phase of postpartum psychological adaptation. Letting go is the process beginning about 6 weeks postpartum when the mother may be preparing to go back to work. During this time, she can have other individuals assume care of the infant and begin the separation process.

The nurse at a health fair is evaluating a client's completed questionnaire about stress-related life events. The client scored 168 points on the Holmes and Rahe stress scale. Which of the following statements by the nurse provides appropriate interpretation of the impact of stressors on the client's health? "You have a low risk of becoming ill in the near future." "These life stressors place you at moderate risk for illness." "The positive stressors will offset the impact of the negative ones." "Watch your health carefully for the next several months."

"These life stressors place you at moderate risk for illness." Holmes and Rahe's theory of stress response suggests that all life events, whether positive or negative, cause stress. The Holmes and Rahe stress scale ranks life events according to how much stress they cause. Scores are interpreted based on points accumulated. Clients who accumulate points totaling up to 150 are considered to have a low risk of developing illness in the near future. Those with points between 150 and 299 are considered to be in the moderate- to high-risk category. Clients with scores 300 and higher are at the greatest risk of stress-related illness.

While auscultating the apical heart rate, the nurse notes an irregular heart rhythm at a rate of 120 beats/min. Which is the nurse's next action? Auscultate the apical pulse with the client on the left side Assess for a pulse deficit Administer atropine Ask the client to hold his or her breath and bear down

Assess for a pulse deficit The correct landmark for obtaining the apical pulse is the left fifth intercostal space in the midclavicular line. The nurse measures the apical-radial pulse for a deficit; apical rate minus radial rate. A deficit is present during atrial fibrillation, and premature ventricular contractions because some heart beats do not perfuse to distal areas. The client should not perform the Valsalva maneuver without electrocardiographic monitoring and the healthcare provider at the bedside; assessment of the underlying disorder should be made first to direct the proper intervention. Prior to calling healthcare providers, the nurse should report vital signs and presence of pulse deficit.

A client undergoes a nephrectomy. In the immediate postoperative period, which nursing intervention has the highest priority? Monitor blood pressure. Encourage the use of the incentive spirometer. Assess urine output hourly. Check the flank dressing for urine drainage.

Assess urine output hourly. After a nephrectomy, a specific aspect of immediate postoperative management includes monitoring urine output at least hourly. Monitoring blood pressure and encouraging the use of incentive spirometry are other important considerations, but because of the surgical disruption of the urinary system, urine output is a priority. Measurement of urine output should also include an estimation of the amount of urine drainage on the flank dressing.

A nurse is monitoring a client for adverse reactions to dantrolene. Which adverse reaction is most common? Excessive tearing Urine retention Muscle weakness Slurred speech

Muscle weakness The most common adverse reaction to dantrolene is muscle weakness. The drug also may depress liver function or cause idiosyncratic hepatitis. Muscle weakness is rarely severe enough to cause slurring of speech, drooling, or enuresis. Although excessive tearing and urine retention are adverse reactions associated with dantrolene use, they aren't as common as muscle weakness.

A 75-year-old client who has been taking furosemide regularly for 4 months tells the nurse about having trouble hearing. What should the nurse do? Tell the client that at age 75 years it is inevitable that there will be hearing loss. Report the hearing loss to the health care provider (HCP). Schedule the client for audiometric testing and a hearing aid. Tell the client that the hearing loss is only temporary; when the body adjusts to the furosemide, hearing will improve.

Report the hearing loss to the health care provider (HCP). Furosemide may cause ototoxicity. The nurse should tell the client to promptly report the hearing loss, dizziness, or tinnitus to help prevent permanent ear damage. Hearing loss is not inevitable, and it is inappropriate to make assumptions about the cause of symptoms without a thorough evaluation. The client's system will not "adjust," and hearing loss will not resolve.

There has been a car accident involving four vehicles on a remote highway. The nearest emergency department is 15 minutes away. Which victim should be transported by helicopter rather than an ambulance to the nearest hospital? a 10-year-old with a simple fracture of the femur, who is crying and cannot find his parents a middle-aged female with cold, clammy skin; heart rate of 120 bpm; and is unconscious middle-aged male with severe asthma, heart rate of 120 bpm, and is having difficulty breathing an older adult with severe headache, but conscious

a middle-aged female with cold, clammy skin; heart rate of 120 bpm; and is unconscious The middle-aged female is likely in shock; she is classified as a triage level I, requiring immediate care. The child with moderate trauma is classified as triage level III, urgent, and can be treated within 30 min. The man with asthma and the man with the severe headache are classified as emergent, triage level II, and can be transported by ambulance and reach the hospital within 15 min.

The major goal of therapy in crisis intervention is to: withdraw from the stress. resolve the immediate problem. decrease anxiety. provide documentation of events.

resolve the immediate problem. During a period of crisis, the major goal is to resolve the immediate problem, with hopes of getting the individual to the level of functioning that existed before the crisis or to a higher level of functioning. Withdrawing from stress doesn't address the immediate problem and isn't therapeutic. The client's anxiety will decrease after the immediate problem is resolved. Providing support and safety are necessary interventions while working toward accomplishing the goal. Documentation is necessary for maintaining accurate records of treatment; it isn't a major goal.

A client is diagnosed with herpes simplex. Which statement about herpes simplex infection is true? During early pregnancy, herpes simplex infection may cause spontaneous abortion or premature birth. Genital herpes simplex lesions are painless, fluid-filled vesicles that ulcerate and heal in 3 to 7 days. Herpetic keratoconjunctivitis usually is bilateral and causes systemic symptoms. A client with genital herpes lesions may have sexual contact but must use a condom.

During early pregnancy, herpes simplex infection may cause spontaneous abortion or premature birth. Herpes simplex may be passed to the fetus transplacentally and, during early pregnancy, may cause spontaneous abortion or premature birth. Genital herpes simplex lesions typically are painful, fluid-filled vesicles that ulcerate and heal within 1 to 2 weeks. Herpetic keratoconjunctivitis usually is unilateral and causes localized symptoms, such as conjunctivitis. A client with genital herpes lesions should avoid all sexual contact to prevent spreading the disease.

A neonate, admitted to the neonatal intensive care nursery for probable meconium aspiration syndrome (MAS), weighs 10 lb, 4 oz (4,650 g), and is at 42 weeks' gestation. The neonate has a heart rate of 110 bpm and a respiratory rate of 40 breaths/min with periods of apnea. The nurse should further assess the neonate for which condition? alkalosis hypoglycemia hyporesonance excessive coughing

hypoglycemia MAS affects small-for-gestational age, term, and postterm neonates who have experienced long labor. Meconium in the lungs allows inhalation but not exhalation. These neonates often require resuscitative efforts at birth to establish adequate respirations. Hypoglycemia is common due to low glucose reserves at birth. Acidosis, not alkalosis, is associated with MAS. Hyporesonance is not associated with MAS. However, coarse bronchial sounds may be auscultated from air trapped in the alveoli. Excessive coughing is not associated with MAS. Rather the neonate exhibits signs of respiratory distress.

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 that within the next week: the client will develop preeclampsia. the fetus will develop mature lungs. the client will not develop preterm labor. the fetus will not develop gestational diabetes.

the client will not develop preterm labor. The absence of fetal fibronectin in a vaginal swab between 22 and 37 weeks' gestation indicates there is less than 1% risk of developing preterm labor in the next week. Fetal fibronectin is an extra cellular protein normally found in fetal membranes and deciduas and has no correlation with preeclampsia, fetal lung maturation, or gestational diabetes.

During each prenatal checkup, a nurse obtains a client's weight and blood pressure and measures fundal height. What is another essential part of each prenatal checkup? Evaluating the client for edema Measuring the client's hemoglobin (Hb) level Obtaining pelvic measurements Determining the client's Rh factor

Evaluating the client for edema During each prenatal checkup, the nurse should evaluate the client for edema, a possible sign of gestational hypertension. If edema exists, the nurse should assess for high blood pressure and proteinuria — other signs of gestational hypertension. Hb is measured during the first prenatal visit and again at 24 to 28 weeks' gestation and at 36 weeks' gestation. The pelvis is measured and the Rh factor is determined during the first prenatal visit.

The body of a critically ill client may use which of the following mechanisms to maintain normal pH? The lungs eliminate carbonic acid by blowing off more CO2. The kidneys retain more HCO3 to raise the pH. The lungs retain more CO2 to lower the pH. The lungs increase tidal volume.

The lungs eliminate carbonic acid by blowing off more CO2. To maintain normal pH in critically ill clients, the lungs eliminate carbonic acid by blowing off more CO2. To maintain normal pH in critically ill clients, the lungs conserve CO2 by slowing respiratory volume. This is the way the body would compensate during an acid-base imbalance in cases of metabolic alkalosis. This is the way the body would compensate during an acid-base imbalance in cases of metabolic acidosis.

A client is at risk for excess fluid volume. Which nursing intervention ensures the most accurate monitoring of the client's fluid status? Measuring and recording fluid intake and output Weighing the client daily at the same time each day Assessing the client's vital signs every 4 hours Checking the client's lungs for crackles during every shift

Weighing the client daily at the same time each day Increased fluid volume leads to rapid weight gain — 2.2 lb (1 kg) for each liter of fluid retained. Weighing the client daily at the same time and in similar clothing provides more objective data than measuring fluid intake and output, which may be inaccurate because of omitted measurements such as insensible losses. Changes in vital signs are less reliable than daily weight because these changes usually are subtle during early stages of fluid retention. Weight gain is an earlier sign of excess fluid volume than crackles, which represent pulmonary edema. The nurse should plan to detect fluid accumulation before pulmonary edema occurs.

After being in labor for 12 hours, a primigravid client is now 10 cm dilated, and the presenting part is at 0 station. The nurse should inform the client and family members that what is occurring? First stage of labor is beginning. Client is now in transition phase. Birth will occur in the next few minutes. Second stage of labor is now beginning.

Second stage of labor is now beginning. A client whose cervix is 10 cm dilated has completed the first stage of labor, which lasts from the beginning of cervical dilation to complete dilation (10 cm), and is starting the second stage of labor. Usually the second stage of labor (pushing) for a primigravid client lasts about 1 to 2 hours. The first stage of labor lasts from the beginning of cervical dilation to complete dilation. The transition phase of the first stage of labor occurs when the client is 8 to 10 cm dilated. If the client is a primigravida and the presenting part is at 0 station, birth is not imminent. A primigravid client needs to push for 1 hour or more before birth. A +3 station is evidence of crowning and imminent birth.

Which action is most helpful to promote circulation for the client with peripheral arterial disease? resting with the legs elevated above the level of the heart walking slowly but steadily for 30 minutes twice a day limiting activity to walking around the house wearing antiembolism stockings at all times when out of bed

walking slowly but steadily for 30 minutes twice a day Slow, steady walking is a recommended activity for the client with peripheral arterial disease because it stimulates the development of collateral circulation needed to ensure adequate tissue oxygenation. The client with peripheral arterial disease should not minimize activity. Activity is necessary to foster the development of collateral circulation. Elevating the legs above the heart is an appropriate strategy for reducing venous congestion. Wearing antiembolism stockings promotes the return of venous circulation, which is important for clients with venous insufficiency. However, their use in clients with peripheral arterial disease may cause the disease to worsen.

A 10-year-old boy is 24 hours post appendectomy. He is awake, alert, and oriented. He tells the nurse that he is experiencing pain. He has a prescription for morphine 1 to 2 mg PRN for pain. What is the priority nursing action in managing the child's pain? Change the child's position in bed. Obtain vital signs with a pain score. Administer 1 mg morphine as prescribed. Perform a head-to-toe assessment.

Obtain vital signs with a pain score. The child is in pain and needs intervention, but before the nurse can determine how to proceed, it is essential to know the client's pain score to determine the appropriate morphine dose. In addition, the nurse cannot evaluate the effectiveness of the pain medication if there is no pain score prior to administering the medication. Changing the child's position and administering pain medication may be helpful to relieve the child's pain, but the nurse must first know the severity of the pain before determining the appropriate intervention. The nurse must perform a head to toe assessment, but it is not the priority in managing the child's pain.