EAQs GENERAL
A client with renal failure receives prescriptions for vitamin D and calcium supplements. The client asks the nurse, "Why do I need to take these?" The nurse explains that, with renal failure, which condition exists? A decrease in the inactive forms of vitamin D in the body A decrease in the active metabolite of vitamin D in the body An increase in the conversion of skin cholesterol into vitamin D An increase in the vitamin D-associated intestinal absorption of calcium
B Rationale Renal failure results in a decrease in the active metabolite of vitamin D because inactive vitamin D gets activated in the liver and then in the kidneys. Food sources of vitamin D and sunlight contribute to an inactive form of the hormone in the body. Inactive vitamin D will decrease if foods rich in vitamin D are not consumed or exposure to sunlight is reduced. Conversion of skin cholesterol to vitamin D depends on exposure to sunlight and not renal impairment. In renal failure there is less active vitamin D and therefore less intestinal absorption of calcium.
After a spontaneous pneumothorax, a client's assessment findings include extreme drowsiness, tachycardia, and tachypnea. Which condition would the nurse suspect? Hypercapnia Hypokalemia Increased PO 2 Respiratory alkalosis
A Pneumothorax results in decreased surface area for gas exchange. If unaffected pleural regions cannot compensate, carbon dioxide builds up in the blood (hypercapnia). The client will become drowsy and may lose consciousness. The body attempts to compensate by increasing respiratory and pulse rates and by the kidneys retaining bicarbonate. Hypokalemia causes extreme muscle weakness, abdominal distention, and changes in the electrocardiogram (ECG) pattern. The PO 2 is decreased with a pneumothorax because of the decreased surface area for gas exchange. Respiratory acidosis occurs with an elevated PCO 2.
Which response would the nurse make when postoperatively, a client asks, "Could I have a pillow under my knees? My legs feel stretched."? "I'll get pillows for you. I want you to be as rested as possible." "It's not a good idea, but you do look uncomfortable. I'll get you a pillow." "We don't allow pillows under the legs because you will get too warm." "A pillow under the knees can result in clot formation because it slows blood flow."
D Rationale Flexing the hips and pressure against the popliteal space impedes venous return, increasing the risk for clot formation. Although comfort and rest should be encouraged, placing pillows under the knees is contraindicated due to the risk for venous thrombosis of the calves. Pillows under the knees produce pressure, not warmth.
During the infusion of dialysate during peritoneal dialysis, the client exhibits symptoms of severe respiratory difficulty. Which action would the nurse take? Slow the rate of the client's infusion. Place the client in a low-Fowler position. Auscultate the client's lungs for breath sounds. Drain the fluid from the client's peritoneal cavity.
D Rationale Pressure from the dialysate may cause upward displacement of the diaphragm; the dialysate should be drained from the peritoneal cavity. Additional fluid, even at a decreased rate of infusion, will aggravate the respiratory difficulty. The client should already be in the semi-Fowler position. Auscultation is important, but it does not alleviate the respiratory difficulty
Which information would the nurse include in teaching a client who is advised to wear compression stockings for varicose veins? Put the stockings on at the first sign of discomfort. Don the stockings before getting out of bed in the morning. Ensure that the cuff of the stockings reaches the middle of the knees. Substitute elastic bandages for compression stockings if they are more comfortable.
B Should be put on before dependent position.
An 18-year-old primigravida at 36 weeks' gestation is admitted with a diagnosis of mild preeclampsia. Which is the nurse's most important goal for the client at this time? Easing her anxiety Limiting the bleeding Reducing her blood pressure Decreasing the circulating blood volume
C Rationale Treatment is directed primarily toward reducing the blood pressure and preventing seizures. Although anxiety may be present, easing it is not the priority. Bleeding is not generally a problem with preeclampsia unless abruptio placentae occurs. With preeclampsia there is already a decrease in circulating blood volume, which causes hemoconcentration and decreased organ perfusion.
Which nursing care would the nurse provide an 8-month-old infant with tetralogy of Fallot? Restriction of fluid intake to conserve energy Provision of iron-fortified formula to prevent anemia Administration of coagulants to control bleeding tendencies Prevention of increased respiratory effort to promote oxygenation
D Rationale Preventing respiratory distress minimizes the workload of the heart; this is accomplished with such interventions as positioning, maintaining diet restrictions, administering medications, and promoting conservation of energy. Restriction of fluid intake will promote hemoconcentration (increasing thrombus risk) and dehydration (increasing risk of tet spell); if oral fluids are limited to conserve energy, intravenous fluids may be indicated. Additional iron intake will aggravate the polycythemia that results from hypoxia caused by reduced pulmonary blood flow. Administration of coagulants along with hemoconcentration is conducive to thrombus formation.
Which would the nurse do to prepare a client in her third trimester who is scheduled for an amniocentesis? Instruct her to void immediately before the test. Tell her to assume the high Fowler position before the test. Encourage her to drink three glasses of water before the test. Advise her to take nothing by mouth for several hours before the test.
A Rationale The client is instructed to void immediately before the test to help prevent injury to the bladder as the needle is introduced into the amniotic sac. The supine position with a hip roll under the right hip is the preferred position for this procedure. Telling the client to assume the high Fowler position before the test will cause the bladder to fill, making it vulnerable to injury as the needle is inserted into the amniotic sac. Encouraging the client to drink three glasses of water before the test is advised if the amniocentesis is being performed early during pregnancy. There is no reason to withhold food or fluid, because the test does not involve the gastrointestinal tract.
The nurse is admitting a client with severe myxedema coma. Which interventions would the nurse include in the plan of care? Select all that apply. One, some, or all responses may be correct. Administer intravenous (IV) levothyroxine. Avoid use of corticosteroids. Give IV normal saline. Wait for laboratory results before treating. Monitor blood pressure every 4 hours.
A, C Rationale Myxedema coma is a major complication of poorly treated hypothyroidism. Interventions include administering IV levothyroxine. This promotes the return to normal thyroid hormone levels. IV normal saline corrects dehydration. Corticosteroids are administered as part of the treatment. Levothyroxine is initiated before obtaining lab results because awaiting can cause death. The BP should be monitored hourly.
For which condition is a pregnant client who takes levothyroxine at increased risk? Anemia Infection Preeclampsia Thyroid storm
C Rationale Levothyroxine is prescribed for hypothyroidism. Ferrous sulfate should be taken at least 4 hours apart from levothyroxine. When taken together, the ferrous sulfate decreases the absorption of T 4, increasing the client's risk for inadequately treated hypothyroidism. Pregnant women with untreated or inadequately treated hypothyroidism are at risk for preeclampsia. The risks for anemia and infection are not increased. A thyroid storm is associated with hyperthyroidism.
A client with hepatitis B (HBV) develops cirrhosis and is hospitalized. One potential sequela of chronic liver disease is fluid and electrolyte imbalance. The nurse determines that this may be attributed to a decrease in serum albumin level. Which condition results from this imbalance? Hemorrhage with subsequent anemia Diminished resistance to Malnutrition of cells, bacterial insult Reduction of colloidal especially hepatic cells osmotic pressure in the blood
D Albumin is an essential component of the bloodstream that helps maintain both osmotic pressure and fluid and electrolytes. This is not a cause of hemorrhage. Blood components such as platelets, thrombin, and erythrocytes are involved in the prevention of hemorrhage or anemia. Diminished resistance to bacterial insult is not involved directly with immunity and resistance. Blood components, such as T and B lymphocytes, are involved in this process; the liver synthesizes specific proteins intrinsic to the function of antibodies. The serum albumin level is not related to nutrition of cells.
The nurse is teaching a parent of a 2-year-old toddler how to administer eardrops. Which direction would the nurse teach the parent to pull the pinna? Forward Up and back Straight back Down and back
D Rationale In children younger than 3 years of age the eustachian tube is shorter, wider, and more horizontal. Pulling the pinna down and back facilitates passage of fluid by way of gravity to the eardrum. Pulling the pinna forward does not help position the canal for passage of the drops to the eardrum. Pulling the pinna up and back is the technique used for administering eardrops to children older than 3 years of age and adults. Pulling the pinna straight back does not position the canal for passage of the drops to the eardrum.
When providing care for a client during the first few hours after admission to the burn unit with full-thickness burns of the trunk and head, which goal is the nurse's priority during the emergent phase of this injury? Preventing pain Managing leukopenia Preventing infection Managing fluid loss
D Rationale There are massive fluid shifts during the emergent (resuscitation) phase of burns; fluid balance is the priority. A full-thickness burn will not feel pain during the emergent phase. The leukocyte count is not affected in the first few hours. Although infection is a possibility, its prevention is not the priority goal; fluid balance is the priority.
Which substance history of a severe allergic reaction results in avoidance of the cephalosporins such as cefazolin, cefditoren, cefotetan, and ceftriaxone? Select all that apply. One, some, or all responses may be correct. Some correct answers were not selected Milk Aspirin Calcium Penicillin Strawberries
A, B, C, D Rationale Use of cephalosporins like cefazolin should be avoided in the client with a history of severe allergic reaction to penicillin because of the potential of cross-sensitivity. The cephalosporin cefditoren should not be administered to the client with a milk allergy because it contains the milk protein caseinate. Bleeding can be magnified with the use of aspirin and the use of the cephalosporins cefotetan or ceftriaxone. The cephalosporin ceftriaxone and calcium should not be administered together because they cause the formation of precipitates. Strawberry allergies do not prohibit the use of these medications.
Which type of incontinence can be improved by teaching the client Kegel exercises? Reflex incontinence Stress incontinence Overflow incontinence Functional incontinence
B Stress incontinence is the involuntary loss of urine during coughing, laughing, or sneezing. In women, this is often seen after having children. Kegel exercises increase the perineal muscle tone, helping control involuntary voiding. Reflex incontinence is preceded by abnormal detrusor contractions from neurological abnormalities. Overflow incontinence is caused by overdistention of the bladder, and exercises will not help. Functional incontinence is associated with environmental or cognitive factors due to which the client is unable to get to the toilet or does not have the necessary cognitive abilities to use the toilet.
If a 5½-month-old infant's immunizations are on schedule, which immunizations does the nurse expect the infant to have had already? a. Measles, mumps, and rubella vaccine b. Booster dose of inactivated polio vaccine c. Two doses of diphtheria, tetanus, and pertussis vaccine d. First booster dose of diphtheria, tetanus, and pertussis vaccine
C The schedule for active immunization is three doses of diphtheria, tetanus, and pertussis (DTaP) at 2-month intervals beginning at 2 months of age. The measles, mumps, and rubella vaccine is not given until 12 to 15 months because maternal antibodies block the formation of the infant's antibodies. An inactivated polio vaccine booster (fourth dose) is due at 4 to 6 years of age. The first booster dose of DTaP is given at 15 to 18 months, or approximately 1 year after the third dose that is given at 6 months of age.
Which action would the nurse take first after noting stridor in a client who just arrived in the postanesthesia care unit (PACU) after receiving a general anesthetic? Have the client cough. Check respiratory rate. Auscultate breath sounds. Notify the health care provider.
D Stridor is caused by obstruction of the larynx or trachea and in the immediate postoperative period after general anesthesia indicates laryngeal swelling and airway obstruction. The health care provider will be immediately notified and the nurse will prepare to assist with reintubation of the client. Coughing will not help clear the airway, because the obstruction is caused by laryngeal edema. The respiratory rate will be obtained, but notification of the health care provider and preparation for intubation is needed first. Breath sounds will be checked after the client is reintubated.
Nursing actions after a client has had general anesthesia are directed at preventing which postoperative respiratory complication? Pleural effusion Empyema Pneumothorax Atelectasis
d Rationale Atelectasis occurs after general anesthesia because of decreased respiratory depth and resulting collapse of alveoli. Pleural effusion is not a typical postoperative problem. Empyema would not be expected after surgery. Pneumothorax is not a common postoperative diagnosis.
Which gauge size would the nurse choose for a peripheral catheter insertion to administer saline to an infant? 14 gauge 18 gauge 20 gauge 24 gauge
Rationale A 24- to 26-gauge size is appropriate for transfusion and administration of saline in an infant. A 14 gauge is the preferred size for trauma and surgical clients requiring rapid fluid resuscitation in an adult client. An 18 gauge is the preferred size for surgery for an adult. A 20-gauge size is adequate for all therapies related to an adult client.
Which rationale explains why insulin is prescribed for clients in acute renal failure? It promotes transfer of potassium into cells to lower serum potassium levels. Insulin is required because the alpha cells of the pancreas cease to function with renal failure. It is necessary to manage the elevated blood glucose levels that accompany renal failure. Insulin reduces the accumulated toxins by lowering the metabolic rate.
A Rationale Insulin promotes the transfer of potassium into cells, which reduces the circulating blood level of potassium. Renal failure does not cause pancreatic alpha cells to cease functioning. Blood glucose levels usually are not elevated in acute renal failure. Insulin will not lower the metabolic rate.
Which intervention would the nurse implement to relieve the symptoms associated with a hypoglycemic reaction? Give 4 oz (120 mL) of fruit juice. Administer 5% dextrose solution intravenously (IV). Withhold a subsequent dose of insulin. Provide a snack of cheese and dry crackers.
A Rationale Liquids containing simple carbohydrates are most readily absorbed and thus increase the blood glucose level quickly. Although a solution of 50% dextrose may be given if the client is comatose, 5% dextrose does not supply sufficient carbohydrates. Withholding a subsequent dose of insulin will not alter the current situation. Complex carbohydrates and protein take longer to increase the blood glucose level, so they should be administered after a simple carbohydrate.
The nurse is caring for a client who underwent a total thyroidectomy. Which assessment finding would lead the nurse to notify the rapid response team? Stridor Hoarseness Bradycardia Hypocalcemia
A Rationale Stridor is an indication of respiratory distress, which would require immediate intervention from the rapid response team. Hoarseness is a normal postoperative finding. Tachycardia, not bradycardia, is a sign of respiratory distress. Hypocalcemia can be corrected with intravenous (IV) calcium gluconate or calcium chloride.
Which action would the nurse take to avoid red man syndrome when preparing to administer a vancomycin infusion? Infuse slowly. Change the intravenous (IV) site. Reduce the dosage. Administer vitamin K.
A Rationale Vancomycin should be infused slowly to avoid the occurrence of the reaction known as "red man syndrome." Changing the IV site reduces the incidence of thrombophlebitis. Reducing the dosage is done in the setting of renal dysfunction. Administration of vitamin K is done to correct an elevated prothrombin time.
Which condition is it most important for the nurse to assess for in a client admitted to the hospital for acute gastritis and ascites secondary to alcohol use and cirrhosis? Nausea Blood in the stool Food intolerances Hourly urinary output
B Erosion of blood vessels may lead to hemorrhage, a life-threatening situation further complicated by decreased prothrombin production, which occurs with cirrhosis. Although increased intra-abdominal pressure because of ascites may precipitate nausea, there is no immediate threat to life. Although food intolerances should be identified, there is no immediate threat to life. Hourly urine output measurements are unnecessary.
Which finding will the nurse expect when caring for a client who is in hypovolemic shock? Slow heart rate Cool skin temperature Bounding radial pulses Increased urine output
B Rationale Shunting of blood to vital organs such as the heart and brain occurs in hypovolemic shock, leading to cool skin because of decreased skin perfusion. Tachycardia, not bradycardia (slow heart rate), occurs as a compensatory mechanism in hypovolemic shock. The pulses in hypovolemic shock are weak and thready because of decreased blood pressure. Urine output will decrease because of decreased kidney perfusion in hypovolemic shock.
Which problem would be the most difficult for the nurse to manage when meeting the needs of an extensively burned client 3 days after admission? Weaning of potent opioids like morphine for severe pain to prevent addiction Changing and debriding wounds to prevent infection Beginning a discussion Turning and positioning related to alteration in body image the client every 30 to 60 minutes to prevent contracture development
B The goals of wound care are to (1) prevent infection by cleansing and debriding the area of necrotic tissue that would promote bacterial growth and (2) promote wound reepithelialization and/or successful skin grafting. Wound care consists of ongoing observation, assessment, cleansing, debridement, and dressing reapplication. The severe pain experienced by the client during debridement of burns places an emotional strain on the nursing relationship, thus making it the most difficult for the nurse to manage. At this phase, addiction is of no concern because all aspects of nursing care cause pain. Maintaining sterility is not a problem if the nurse follows principles of surgical asepsis. According to Maslow, basic needs of survival and safety take precedence over higher-level needs so talking about body image is not appropriate at this time. Passive and active range of motion (ROM) should be performed on all joints by physical therapy (PT) and occupational therapy (OT) personnel.
which intervention would the nurse anticipate for a toddler experiencing moderate gastroenteritis related to iron toxicity? gastric lavage induced emesis bowel irrigation chelation therapy
B emesis empties the stomach more effectively than gastric lavage.
Which intervention would be in the plan of care of a client with kidney dysfunction who is about to undergo renal testing using a contrast medium? Select all that apply. One, some, or all responses may be correct. Assessing the client for a history of cirrhosis Asking the client about known shellfish allergies Assessing for a history of lactic acidosis Evaluating the client's hydration status by checking blood pressure and respiratory rate Discontinuing metformin for 24 hours from the time of t
1, 2, 4 Rationale While interviewing a client who is about to undergo kidney procedure using a contrast medium, the nurse should assess for a history of cirrhosis. Clients with cirrhosis have an increased chance of developing kidney failure after the procedure. The nurse should confirm any known shellfish allergies because contrast dye administered during the study may cause nephrotoxicity. The nurse should also assess the client's hydration status by checking blood pressure and respiratory rate. It is not necessary to check the client for a history of lactic acidosis when ensuring the client's safety for renal testing. If the client had lactic acidosis currently, then this would be a significant factor when ensuring the client's safety for renal testing. Accumulation of metformin can induce lactic acidosis when contrast medium-induced renal failure happens in the 48 hours after the injection. Metformin should be discontinued for 48 hours after the procedure. The therapy is resumed on
The nurse is providing care to a client with ascites secondary to liver failure. Which intervention is appropriate to include in the client's care? Select all that apply. One, some, or all responses may be correct. High-protein diet Low-sodium diet Daily abdominal girth measurements Encourage increased fluid intake by mouth Daily weights
2, 3, 5 Rationale In the client with liver failure and ascites, the liver has lost its ability to synthesize proteins. This leads to hypoalbuminemia and decreased oncotic pressure in the vessels. This decrease in oncotic pressure leads to fluids leaking out of the vessels and into the interstitial spaces and peritoneum, causing edema and ascites. A low-sodium and low- protein diet is recommended. A high-protein diet will worsen the symptoms, and often these clients are on fluid restriction. Taking daily abdominal girth measurements and daily weights is the most reliable indicator of fluid retention.
Which nursing assessment finding is consistent with fluid volume overload from high-flow intravenous (IV) fluid replacement therapy? Select all that apply. One, some, or all responses may be correct. Pulse quality Pulse pressure Bounding pulse Presence of dependent edema Neck vein distention in the upright position
3, 4, 5 Rationale Bounding pulse, presence of dependent edema, and neck vein distention in the upright position are all indicators of fluid overload, which should be reported by the nurse. Pulse quality and pulse pressure are indicators to monitor the client's response to fluid therapy.
The nurse is caring for a client who is admitted to the hospital with ascites and a diagnosis of cirrhosis of the liver. Which does the nurse conclude is the probable cause of ascites? Impaired portal venous return Inadequate secretion of bile salts Excess production of serum albumin Decreased interstitial osmotic pressure
A An enlarged liver impairs venous return leading to an increased portal vein hydrostatic pressure and a fluid shift into the abdominal cavity. Bile plays an important role in digestion of fats, but it is not a major factor in fluid balance. Increased serum albumin causes hypervolemia, not ascites. Ascites is not associated with the interstitial fluid compartment.
Which finding in a client who has just arrived in the cardiac intensive care unit after having coronary artery bypass grafting (CABG) requires the most rapid action by the nurse? The serum potassium level is 3.1 mEq/L (3.1 mmol/L). The client is confused about the date and time of day. The client reports incisional pain at level 8 (0 to 10 scale). Chest tube collection chamber has 150 mL of bloody fluid.
A Rationale Hypokalemia is a common complication after CABG and immediate infusion of potassium to correct hypokalemia is needed to prevent postoperative dysrhythmias. Confusion in the immediate postoperative period is common after cardiopulmonary bypass and will be monitored by the nurse, but does not require any other action at this time. Incisional pain is common after CABG and the nurse will administer prescribed pain medications, but pain is not a life-threatening complication. Chest tube drainage of 100 to 200 mL is not unusual in the first hours after CABG; the nurse will monitor the chest tube drainage hourly, but no other action is needed.
Which food would the nurse teach a client who has a prescription for warfarin to limit? Select all that apply. One, some, or all responses may be correct. Spinach Oranges Broccoli Chicken breast Sweet potatoes
A, C Rationale Because the effectiveness of warfarin is decreased by vitamin K, the nurse will teach the client to limit foods high in vitamin K such as spinach or broccoli. Oranges contain minimal vitamin K. Chicken breast is low in vitamin K. Sweet potatoes are high in vitamin A and potassium, but they are low in vitamin K.
Which intervention would the nurse implement during a peritoneal fluid exchange of a client with end-stage renal disease receiving peritoneal dialysis? Maintain the client in the supine position during the entire procedure. Position the client from side to side if fluid is not draining adequately. Remove the cannula at the end of the procedure and apply a dry, sterile dressing. Notify the primary health care provider if there is a deficit of 100 mL in the drainage return.
B If fluid is not draining adequately, the client should reposition from side to side with the head raised in the low-Fowler position. A supine position does not facilitate drainage by gravity. The primary health care provider, not the nurse, removes the dialysis cannula. A deficit of 100 mL is not enough to require notifying the primary health care provider.
A client anticipates removal of his or her chest tube with angst. Which diagnostic procedure does the nurse discuss when determining when to remove a client's chest tube? The client tolerates disconnection from the chest tube's drainage system for 24 hours. A chest x-ray examination occurs before removal to determine lung reexpansion. A required arterial blood gas occurs to determine sustained oxygenation status. The nurse will sedate the client 30 minutes before the scheduled procedure.
B Rationale Before removal of a chest tube, a chest x-ray examination occurs to ensure and document the lung has reexpanded and has remained expanded. The drainage system should not be disconnected from the actual chest tube while still in the client because this may cause a pneumothorax to recur. An arterial blood gas may be performed before removal but is not necessary. An oxygen saturation reading with a pulse oximeter is usually sufficient to determine oxygenation level. The client may receive pain medication before the procedure but not sedation because this may decrease the oxygen status.
Which action will the nurse take after noticing condensation in the tubing of humidified oxygen? Replace the entire oxygen system. Drain the condensation into a water trap. Empty the condensation into the humidifier. Reassure the client that no action is needed.
B Rationale Draining the condensation into a water trap removes the condensation from the tubing and prevents contamination of the humidifier. The system does not need to be replaced when the water can be safely drained into a water trap or other container. The condensation should not be returned to the humidifier because it can contaminate the water for humidification. Although condensation is expected, action is needed because condensation in the tubing may change the FiO 2 being delivered or be inadvertently drained into the client respiratory system.
When evaluating the condition of a client with burns to the upper body, which finding would alert the nurse of a potential respiratory obstruction? Deep breathing Hoarse quality to the voice Pink-tinged, frothy sputum Rapid abdominal breathing
B Rationale Hoarseness is a sign of potential respiratory insufficiency as a result of inhalation injury, which causes edema in the surrounding tissues, including the vocal cords. Sputum will be sooty, not frothy; pink-tinged, frothy sputum is associated with pulmonary edema. Deep breathing and rapid abdominal breathing indicate metabolic acidosis, not respiratory insufficiency
When a client who has had a thoracotomy develops respiratory acidosis, which action would the nurse take? Administer oral fluids. Encourage deep breathing. Increase the oxygen flow rate. Perform nasotracheal suctioning.
B Rationale Hypoventilation because of pain is the usual cause of respiratory acidosis after chest surgery and the nurse would encourage deep breathing to help eliminate excess carbon dioxide. Oral fluids are helpful in liquefying respiratory secretions, but will not increase respiratory rate or depth to eliminate carbon dioxide. Increasing oxygen flow rate would be used to treat hypoxemia, but will not decrease carbon dioxide levels in the blood. Suctioning would help eliminate excessive secretions if the client was unable to cough effectively, but would not decrease carbon dioxide levels.
Which statement made by the parent of an infant receiving phototherapy for jaundice would cause concern? a. "I keep track of the number of wet diapers." b. "My baby's skin is dry, so I applied a little lotion" c. " I placed my baby under the lights dressed only in a diaper" d. "I closed my baby's eyes before placing the mask over them"
B Rationale Lotions, creams, and ointments should not be applied to the infant's skin during phototherapy because it can absorb heat and cause burns. The infant should be placed under the phototherapy lights dressed only in a diaper. The number of wet or soiled diapers is monitored because it is an indicator of the infant's hydration status. The eyes of the infant should be closed before placing the mask over the eyes to prevent scratching of the cornea.
Which instruction would the nurse include when teaching a female client with a new infant who is prescribed amoxicillin for a urinary tract infection? "Take this medication on an empty stomach." "Report signs of allergic reaction such as skin rash or itching." "Stop taking the medication as soon as you void without burning." "Breast-feeding should stop until you have finished with this medication."
B Rationale Penicillin class medications have a high incidence of allergic reaction, so the client should monitor for allergy and report symptoms of an allergic reaction. Amoxicillin may be taken with food. The entire course of treatment should be completed, not stopped when symptoms are absent. It is safe to breast-feed with amoxicillin.
Which action would the nurse take first when a client who is receiving peritoneal dialysis reports difficulty breathing after instillation of dialysate into the peritoneal space? Weigh the client. Check pulse oximetry. Auscultate lung sounds. Reposition the client.
B Rationale Pulse oximetry will assess for adequate oxygen saturation and would be done first because a low saturation would indicate the need for rapid implementation of actions such as oxygen administration and notification of the health care provider. Weighing the client would help in determining fluid overload but would be done after assuring adequate oxygen saturation. The lung sounds would be auscultated to see if the client has fluid overload or whether the dialysate infusion is decreasing room for lung expansion, but can be done after checking oxygen saturation. If the lung sounds indicate that the dialysate is decreasing the ability of the lungs to expand, the client can be repositioned to allow better lung expansion.
Which suggestion would the nurse make for a client with heart failure? "Take a hot bath before bedtime." "Avoid emotionally stressful situations." "Avoid sleeping in an air-conditioned room." "Exercise daily to a pulse rate of 100 beats/minute."
B Rationale Stressful situations increase the body's oxygen demands. Clients with a low cardiac reserve cannot tolerate extremes of temperature; a hot bath increases the body's oxygen demands. Hot, humid weather is detrimental for those with heart disease; these individuals should use an air conditioner. Clients with heart failure should exercise daily, but may not be able to tolerate high heart rates.
A client develops acute respiratory distress syndrome (ARDS). The nurse assesses the client and notes signs of pulmonary edema and atelectasis. The findings correspond to which phase of ARDS? Fibrotic Exudative Reparative Proliferative
B Rationale The exudative (injury) phase of ARDS is the early phase. Alveoli become fluid-filled with pulmonary shunting and atelectasis. The fibrotic phase of ARDS leads to pulmonary hypertension and fibrosis. The reparative (resolution) phase starts about 2 weeks after injury; it is characterized by recovery. If this phase persists for a prolonged time, extensive fibrosis, death, or chronic disease may result. Proliferative occurs after the exudative (injury) phase, producing more hypoxia.
Which priority nursing intervention for a child with severe burns and extensive eschar formation on the arms would the nurse implement? Removing blisters Checking radial pulses Administer pain medication Performing range-of-motion (ROM) exercises
B Rationale The radial pulses are a reflection of how the child is adapting to the eschar formation. Eschar is rigid and may restrict circulation, leading to loss of perfusion to the limbs. Blisters are a protective adaptation and should not be disturbed. Although administering pain medication and performing ROM exercises are important, adequate arterial perfusion is the priority
Which treatment option will the nurse anticipate the need to teach the client about when caring for a client with symptomatic bradycardia caused by heart block? Overdrive pacing Demand pacemakers Cardiac resynchronization therapy Implantable cardioverter-defibrillators
B Rationale Treatment for symptomatic bradycardia typically includes the placement of a temporary or permanent demand pacemaker to prevent the heart rate from dropping below a preset rate. Overdrive pacing is used to treat atrial tachycardias such as atrial flutter. Cardiac resynchronization therapy is used to improve ventricular function and cardiac output in clients with severe heart failure. Implantable cardioverter-defibrillators are used for clients at risk for sudden cardiac death caused by ventricular tachycardia or ventricular fibrillation.
Which is the function of the water-seal chamber on a closed chest drainage system for a client with hemothorax? Collects drainage from the pleural space Prevents reflux of air back into the pleural space Promotes drainage of blood from the pleural space Controls level of suction applied to intrapleural space
B Rationale Water acts as a seal, preventing air from reentering the pleural space after is has been expelled during expiration. Blood or other drainage from the pleural space collects in the collection chamber of the chest drainage system. Blood from the hemothorax will drain into the collection chamber mainly under the effect of gravity. The level of suction applied to the intrapleural space is controlled by the fluid level in the suction control chamber.
When a client who experienced a myocardial infarction suddenly develops a heart rate of 120 beats/minute, which action would the nurse take first? Offer reassurance. Check blood pressure. Call for an electrocardiogram (ECG). Activate the hospital rapid response team.
B Rationale With a sudden change in heart rate, the nurse's first action would be to determine whether the client was perfusing adequately by checking blood pressure. Reassurance may be needed if the client's high rate is due to anxiety, but more information about the client is needed before meaningful reassurance is offered. An ECG is needed for a sudden change in heart rate, because the client may be re-infarcting, but the nurse would initially check vital signs. The hospital rapid response team may need to be activated, but more information about the client is needed first.
When a client has a chest tube placed in the second intercostal space, how will the nurse evaluate for the effectiveness of the chest tube? Check for bubbling in the suction control chamber. Measure the amount of drainage in the collection chamber. Inspect the amount of bubbling in the water-seal chamber. Observe for the presence of clots in the tubing.
C Rationale A chest tube is placed in the second intercostal space to treat pneumothorax. The chest tube will remove air from the intrapleural space, causing bubbling in the water-seal chamber. Bubbling in the suction control chamber indicates that suction is turned on. Only a few milliliters of drainage are expected with a chest tube placed in the second intercostal space; a tube would be placed at the base of the lung to drain fluid from the pleural space. Clotting in the tubing would not be expected for a chest tube placed at the second intercostal space because there should be only a few milliliters of bloody drainage
Which response would the nurse give when a client with syncope from a vagal response asks why it is important to avoid bearing down during a bowel movement? "Straining can decrease blood flow to your brain because it is filling hemorrhoids." "Trouble moving your bowels is stressing your heart and may lead to a heart attack." "Bearing down stimulates a nerve response that decreases your heart rate and blood pressure." "Difficulty with a bowel movement means you are dehydrated, which causes low bl
C Rationale Bearing down stimulates a vagal nerve response that results in a decrease in heart rate and blood pressure leading to syncope (loss of consciousness). Blood flow to hemorrhoids is not the cause of syncope. Bearing down decreases the heart rate through a vagal response, not ischemic disease leading to myocardial infarction (heart attack). Straining, not dehydration, is a direct cause of vagal stimulation.
When asssigned the care of a client arriving in the emergency department with possible acute coronary syndrome, which prescribed action would the nurse take first? Obtain a 12 lead electrocardiogram (ECG). Draw blood for troponin and creatine kinase MB. Ask the client about level of intensity of the chest pain. Notify the cardiac catheterization laboratory about the client.
C Rationale Because ECG changes occur within minutes with acute coronary syndrome, an ECG should be obtained and interpreted within 10 minutes of admission for any client with possible acute coronary syndrome. Confirmation of changes indicating myocardial infarction will lead to rapid transfer to the cardiac catheterization laboratory and percutaneous coronary interventions. It is appropriate to obtain troponin and cardiac enzyme levels, but these do not immediately elevate in myocardial infarction and results will not affect immediate care of the client. Intensity of pain is asked of all clients, but is not a good reflection of the size of the ischemic area. Notification of the cardiac catheterization laboratory will be done, but the ECG will need to be done before making decisions about whether to transfer the client for interventions.
Which action would the nurse take first when caring for a client with a possible pulmonary embolus? Auscultate the chest. Obtain the vital signs. Elevate the head of the bed. Notify the rapid response team.
C Rationale Elevating the head of the bed promotes better gas exchange by reducing the pressure of the abdominal organs on the diaphragm and increasing thoracic excursion. The nurse will auscultate the chest, but breath sounds are not initially changed with pulmonary embolus, which affects pulmonary circulation, but not ventilation. Heart rate and rhythm, blood pressure, and respiratory rate are likely to be affected by pulmonary embolism, but the nurse's first action would be to attempt to improve oxygenation by elevating the head of the bed. The rapid response team would be rapidly notified, but the initial action would be to elevate the head of the bed to improve oxygenation.
Which action by the nurse is best when a client who experienced a myocardial infarction 2 days ago has a temperature of 100.2°F (37.9°C)? Auscultate the chest for diminished breath sounds. Encourage coughing and deep breathing every hour. Record the temperature reading and continue to monitor it. Suspect an infection and notify the health care provider immediately.
C Rationale Myocardial necrosis causes a rise in body temperature within the first 24 hours after a myocardial infarction. This increase in temperature gradually returns to the usual range for an adult after several days. A temperature of 100.2°F (37.9°C) is an expected response to myocardial necrosis, not a respiratory infection. Auscultating lung sounds and encouraging coughing and deep breathing are not necessary for the temperature elevation. A temperature of 100.2°F (37.9°C) is an expected response and is not an emergency requiring notification of the primary health care provider.
Which response would the nurse give to a menstruating female client who asks how to avoid toxic shock syndrome with tampon use? "Change the tampon every 8 hours." "Force the tampon up as far as it will go." "Wash your hands before inserting the tampon." "Use the strongest absorbency tampon that you need."
C Rationale Washing the hands before inserting the tampon is an intervention to reduce introducing organisms to the vagina and causing toxic shock syndrome. Tampons should be changed every 3 to 6 hours. Tampons should be inserted gently and with care, and not forced into the vagina in order to avoid damaging the tissue. Super absorbent tampons should be avoided.
The nurse is caring for a client 36 hours after the insertion of a chest tube. The tube is attached to a three-chamber, closed- chest drainage system. The nurse identifies that the water in the underwater seal tube is not fluctuating. Which action should the nurse take? Take the client's vital signs. Inform the health care provider. Turn the client to the unaffected side. Check the tube to ensure that it is not kinked.
D Once the drainage tube is patent, the fluctuation in the water column will resume; a lack of fluctuation because of lung reexpansion is unlikely 36 hours after a traumatic open chest injury. Taking the client's vital signs may be done eventually but is not the priority at this time. Informing the health care provider is unnecessary at this time; the chest tube is occluded, and nursing interventions should be attempted first. Turning the client to the unaffected side will compromise aeration of the unaffected lung.
Which description of myelomeningocele is accurate? It is a fusion failure of the vertebral arches without herniation of cord or meninges. There is a defect in the base of the skull through which the brain and meninges have herniated. A membrane-covered sac of meninges, filled with spinal fluid, is protruding through a defect in the spine. A saclike cyst of meninges, containing a portion of spinal cord and fluid, is protruding through a defect in the spine.
D Rationale Myelomeningocele is a neural tube defect in which the meninges and spinal nerves protrude through the opening in the spinal column. Nerve damage may occur at or below the level of the defect. A fusion failure of the vertebral arches without herniation of cord or meninges is spina bifida occulta; there is no break in the skin or protrusion of any structure. A defect in the base of the skull through which the brain and meninges have herniated is an encephalocele; the spinal cord is not involved. A membrane-covered sac of meninges, filled with spinal fluid and protruding through a defect in the spine, is a meningocele; usually there is no nerve damage, although affected individuals may have minor disabilities.
Which response would the nurse provide to the spouse of a pt w CKD admitted to the hospital with severe infection + anemia w reports of feeling depressed + irritable, when asked about the anticipated plan of care? "The staff will provide total care, bc infection causes severe fatigue." "Mood elevators will be prescribed to improve the depression + irritability." "Vitamin B 12 for the anemia, and the stools will be dark." "Protein foods will be restricted so the kidneys can clear waste products
D Rationale One of the kidney's functions is to excrete nitrogenous waste from protein metabolism; restriction of protein intake decreases the workload of the damaged kidneys. The client is encouraged to be as active and independent as possible. Medications are avoided because they may mask symptoms. Iron and folic acid supplements are used for anemia in chronic kidney disease; Vitamin B 12 is used for pernicious anemia and does not make the stools dark; iron makes
Which nursing action is appropriate for a patient during the tonic-clonic stage of a seizure? Go for additional help Establish a patent airway Restrain the client to prevent injury Protect the client's head from injury
D Rationale Protecting the client's head from injury is an appropriate nursing action for a client experiencing a tonic-clonic seizure. The client should not be left unattended. Establishing a patent airway is done after the seizure; the mouth should not be pried open to insert an airway during a seizure because injury may occur. Restraining a client will increase the risk for injury so is an unsafe action during a seizure.
At term a client's hemoglobin level is 10.6 g/dL (106 mmol/L) and her hematocrit is 31%. Which physiological factor accounts for these values? Diuresis Infection Alkalosis Hemodilution
D The increase in circulating blood volume during pregnancy is reflected in lower hemoglobin and hematocrit readings (physiological anemia of pregnancy); this represents hemodilution. Diuresis would contribute to hemoconcentration rather than hemodilution. Neither infection nor alkalosis lead to a lower hemoglobin or hematocrit.