NCLEX Passpoint

The nurse is caring for a client who is a recent immigrant from China. Through the hospital interpreter, the client expresses an unwillingness to eat the fried fish that was on the meal tray, describing it as "too hot." What is the nurse's best action?

Ask the interpreter to ask the client about the specific meaning of the description of "hot." In many Asian cultures, foods are categorized on a continuum of cold to hot that is independent of their physical temperature. Consequently, it is important for the nurse to assess the precise meaning of the client's statement before taking further action such as changing the client's diet. It is appropriate to assess the client's food preferences, but this data should come from the client, not the interpreter.

An unlicensed assistive personnel (UAP) reports to the nurse that the client had a large amount of blood on the adult brief in a skilled nursing home. Place the steps the nurse will take to assess and care for the client in order. All options must be used.

Ask the unlicensed assistive personal to recover the adult brief. Examine the adult brief. Assess the client's perineal area for any further drainage. Obtain the client's vital signs. Report the findings to the healthcare provider. Report the event to the family with any change in treatment.

A nurse is reviewing the healthcare provider's orders for a client admitted with systemic lupus erythematosus (SLE). Which medication would the nurse expect to find in this client's plan of care?

hydroxychloroquine Fatigue, photosensitivity and a "butterfly" rash on the face are all signs and symptoms of SLE. Hydroxychloroquine is used in the treatment of SLE to prevent inflammation. Pharmacological treatment of SLE also involves nonsteroidal anti-inflammatory drugs, corticosteroids, and immunosuppressive agents. Morphine is an opioid analgesic, ketoconazole is an antifungal agent, and dimenhydrinate is an antiemetic.

A client with venous insufficiency reports swelling in the feet and ankles. What is the most appropriate intervention for the nurse to recommend?

Elevate the feet several times a day. Elevating the feet will promote venous return and decrease foot and ankle edema. Limiting fluid intake is not recommended unless there are additional medical complications such as heart failure; limiting fluids after 8 pm can help with nocturia but time is irrelevant to edema prevention. Buying walking shoes will not necessarily decrease edema. Over-the-counter knee-high "support hose" are not the same as medical-grade graduated compression stockings, and there are some contraindications to compression that should first be ruled out. Therefore, the nurse should not recommend this intervention unless the elevation of legs fails to solve the edema, at which time the client should consult the health care provider about the use of medically approved compression stockings.

A child has ingested poisonous hydrocarbons. What is the most important nursing intervention?

Keep the child calm and relaxed. Keeping the child calm and relaxed will help prevent vomiting. If vomiting is induced, the esophagus will be damaged from regurgitation of the gastric poison. The risk of chemical pneumonitis exists if vomiting occurs. Activated charcoal poorly absorbs hydrocarbons, and it tends to distend the stomach and cause vomiting. The parents should remain with the child to help keep the child calm. It is not necessary to monitor parent-child interactions for possible child abuse.

What adverse reaction might the nurse observe after administering enteric-coated erythromycin to a client?

N/V Erythromycin is an antibiotic. Common adverse effects include nausea, vomiting, diarrhea, abdominal pain, and anorexia. It should be given with a full glass of water and after meals, or with food, to lessen gastrointestinal symptoms.

The nurse is preparing to perform a cultural assessment of a new client. How should the nurse best perform this assessment?

Perform a systematic assessment using a recognized cultural assessment instrument. Cultural assessment is best facilitated by using an assessment instrument designed for the purpose. It is inaccurate to make assumptions based on previous interactions with other individuals. It is not possible to perform a thorough assessment solely through passive observation. Input from a colleague can be helpful, but it does not replace the need for a valid assessment instrument.

The partner of a client with end-stage amyotrophic lateral sclerosis (ALS) discusses with the nurse that the partner is uncomfortable, does not want to be the health care proxy decision maker, and wishes that one of the children take on this responsibility. What is the nurse's first action to facilitate support of the client's family member after their discussion?

Explore with the partner how to hold a family meeting and address this concern with all of the children. After the discussion about the partner's concern, the best strategy is for the nurse to assist the partner in arranging a family meeting to determine who can assume the role of health care proxy decision maker. The change in the situation and the result of the intervention need to then be communicated to the health care team. The nurse serves as an advocate for both the client and the partner and does not try to change the partner's decision nor independently contact and obtain legal assistance.

An adolescent client is admitted for surgical treatment of genital lesions. The client appears withdrawn. What action will the nurse use with the client's care?

Have an assistant when providing care. it is important for the nurse to recognize that some clients are often modest or simply feel more comfortable with a chaperone or assistant present for intimate care needs. The nurse will need to explain and encourage family visitations. The nurse does not assume the client is embarrassed. The nurse must provide teaching in a way that the client can be receptive to understanding and not focus on sexual gratifications.

A competent client in a long-term care facility refuses to take oral diuretic medication. The nurse informs the client 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 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.

A client asks the nurse, "My urologist told me that to prevent urinary tract infections I need to take cranberry capsules twice a day, but why not just drink cranberry juice instead of taking cranberry capsules?" Which information is most important for the nurse to include in a teaching plan for this client?

The client's proper dose is 32 ounces of unsweetened cranberry juice daily. The most important information is that the client needs to drink 32 ounces of unsweetened cranberry juice if the client does not desire to take the cranberry capsules. Other information to discuss if the client can actually drink this volume of unsweetened cranberry juice is to check for a possible allergy to cranberries, and to consider the cost factor of both treatment options.

The laboratory has just notified the nurse that a client on the unit has a phenytoin level of 32 mg/dl. Which symptoms should the nurse anticipate from this client?

ataxia and confusion A level of 32 mg/dl indicates phenytoin toxicity. Symptoms of toxicity include confusion and ataxia. Phenytoin doesn't cause hyponatremia, seizure, or urinary incontinence. Incontinence may occur during or after a seizure.

The nurse is caring for an 8-year-old child who arrived at the emergency department with chemical burns to both legs. What is the priority intervention for this child?

diluting the chemicals Diluting the chemical is the priority. It will help remove the chemical and stop the burning process. The remaining treatments are initiated after dilution.

A client is scheduled for amniocentesis. What priority intervention should the nurse implement?

have the client void Before amniocentesis, the client should empty the bladder which reduces the risk of bladder perforation. This client doesn't need to drink fluids or fast before amniocentesis. A client would be placed in a supine position for an amniocentesis.

A nurse is making a home visit to a client who is receiving chemotherapy as part of the treatment plan for cervical cancer. The client reports nausea as a side effect of treatment. The client asks the nurse, "I do not want to put any other medicines in my body. Do you have any suggestions for a natural remedy to help with my nausea?" Which suggestion would the nurse most likely make?

lavender ginger peppermint

A nurse is assessing a client with bipolar disorder. The client tells the nurse that the family health care provider prescribed lithium. Which symptom would indicate that the client is developing lithium toxicity?

lethargy Nausea, vomiting, diarrhea, thirst, polyuria, lethargy, slurred speech, hypotension, muscle weakness, and fine hand tremors are signs of lithium toxicity.

Which medication would the nurse anticipate as the provider's treatment of choice for scarlet fever?

penicillin The causative agent of scarlet fever is Group A beta-hemolytic streptococci, which is susceptible to penicillin. Erythromycin is used for penicillin-sensitive children. Anti-inflammatory drugs, such as prednisone, are not indicated for these clients. Acyclovir is used in the treatment of herpes infections. Amphotericin B is used to treat fungal infections.

A client with sickle cell disease is discussing his therapeutic regimen. Which statement by the client indicates further teaching is needed?

"I should take one baby aspirin daily to help prevent sickle cell crisis." Aspirin inhibits platelet aggregation and won't help prevent sickle cell crisis. Hydroxyurea is prescribed for some people to help prevent sickle cell crisis. High altitude increases oxygen demand and therefore can also precipitate a crisis. Tobacco, alcohol, and dehydration can precipitate a sickle cell crisis and should be avoided.

A client with a vaginal yeast infection asks the nurse if it is a good idea to start taking acidophilus along with the prescribed vaginal cream. What assessment question would the nurse ask prior to answering the client's question?

"How often do you eat yogurt with live cultures?" If the client consumes one cup of yogurt containing live lactobacillus acidophilus daily, there is no need to take additional acidophilus. Although acidophilus is used for gastrointestinal problems, this client is not using it for this reason. Diets high in sugar have been associated with yeast infections and weight fluctuations are a part of a comprehensive assessment, but do not provide background information to answer the client's question.

A client diagnosed with bipolar disorder becomes verbally aggressive during group therapy. The client states, "I hate all of you." Which response by the nurse is best?

"You are frightening people. We will walk down the hall to release some energy." This response indicates that the behavior is unacceptable, and that the client deserves help. The other responses are nontherapeutic and accusatory.

A nurse, working in a rural county's public health department, has been alerted that there is an outbreak of tuberculosis (TB) in the area. Which client is at highest risk for developing TB?

A 43-year-old homeless man with a history of alcoholism Clients who are economically disadvantaged, malnourished, and have reduced immunity, such as those with a history of alcoholism, are at extremely high risk for developing TB. A high school student, daycare worker, and a man traveling on business have a much lower risk of contracting TB.

Which nursing intervention is a priority for an infant during the first 24 hours following surgery for cleft lip repair?

Carefully clean the suture line after feedings to reduce the risk of infection. The suture line must be carefully cleaned with a sterile solution after each feeding to reduce the risk of infection, which could adversely affect the healing and cosmetic results. The infant shouldn't be placed in the prone position, because this puts pressure on the incision and may affect healing. Anticipatory care should be provided to reduce the risk of the infant crying, which puts strain on the incision. Pacifiers and other firm objects should not be placed in the infant's mouth because they can disrupt the suture line.

What is the most important intervention for the nurse to implement while caring for a neonate with an omphalocele?

Carefully position and handle the omphalocele. Careful positioning and handling prevents infection and rupture of the omphalocele. The omphalocele should be kept moist until the neonate is taken to the operating room. The parents can see the defect if they so choose. Palpation of the omphalocele increases the risk of rupture and infection.

A client with a history of successful cesarean birth is admitted to the labor and delivery unit at 34 weeks' gestation of her second pregnancy. The client suddenly vomits and loses consciousness. The fetal heart rate is 100 beats/min. What is the nurse's priority intervention?

Place the client in recovery position, and assess respirations and pulse. The client is unconscious, and the airway must be protected. The recovery position is a left-side-lying position that prevents aspiration and optimizes uterine blood flow. The nurse must determine if the client requires cardiopulmonary resuscitation before taking any other actions. If the client is not breathing or is pulseless, the degree of cervical dilation, other assessment findings, and the need for cesarean are irrelevant.

A nurse is teaching a client about simple wound care. The client insists on using a smartphone to record the procedure. What is the nurse's best response to the client?

"I will need to clarify with my manager if you can record the procedure." The use of technology and use of social media should be reviewed with the client. The institution may have a policy regarding the method of discharge instructions for liability purposes. Posting the video to the Internet may be considered a violation of the nurse's privacy if a voice or physical appearance is visible. Suggesting that any Internet site can provide information is not safe for the client's wound care needs. A reputable, evidence-based site should be used. The nurse should not confirm the idea about taping a procedure until the facility approves the use of the client's technology.

The nurse is caring for a group of clients in an acute medicine setting. What statement by a client would most warrant a referral to spiritual care, with the client's permission?

"It feels like one round of bad news after another for me, like I am being punished." A client's allusion to feeling "punished" suggests that they are feeling some distress about the relationship with a cosmic power. A referral to spiritual care may be helpful. Untreated pain, lack of social support, and anxiety are all problems that the nurse must address, but none is as directly suggestive of spiritual distress.

The nurse is setting goals for end-of-life care with a client who states, "I'm not a religious person, but I consider myself a spiritual person." Based on this conversation, what is the best question to ask about the client's spirituality?

"What are the beliefs that guide your daily decisions?" The concept of spirituality encompasses a person's values and beliefs that guide one's life, personal hopes, and attitudes toward life and death. It further focuses on the meaning and purpose of people's lives. Rituals, rites, and practices refer to specific religious beliefs.

A 12-year-old child sustains a moderate burn injury. The parent reports that the child last received a tetanus injection at 5 years of age. Which immunization would the nurse anticipate for this child?

0.5 ml of tetanus toxoid I.M. Tetanus prophylaxis is given to all clients with moderate to severe burn injuries if it has been longer than 5 years since the last immunization, or if there is no history of immunization. The correct dosage is 0.5 ml I.M., one time, if the child was immunized within 10 years. If it has been more than 10 years, or the child hasn't received tetanus immunization, the dosage is 250 units of tetanus immune globulin, one time. There is no I.V. form of tetanus immune globulin available.

Which client would benefit most from information explaining the importance of receiving an annual Papanicolaou (PAP) test?

A client infected with the human papillomavirus (HPV) HPV causes genital warts, which are associated with an increased incidence of cervical cancer. Recurrent candidiasis, pregnancy before age 20, and the use of oral contraceptives have not been shown to increase the risk of cervical cancer.

A nurse is providing care to a recently deceased female client who is a member of the Muslim community. The client's family is at the bedside. When providing end-of-life care, which action would be most appropriate for the nurse to do?

Anticipate that burial will occur within 24 hours of death. Typically, when a Muslim client dies, only relatives may touch or wash the body of a deceased Muslim, and the family should be consulted before performing postmortem care. If postmortem care is to be done by a provider, then the provider should be of the same sex. Religious items or family pictures in a patient's room are thought to prolong death and should be removed. Burial should take place within 24 hours. Cleaning the body to symbolize cleaning the soul reflects a practice associated with Hinduism.

The nurse assesses a school-age child in the emergency department and finds a respiratory rate of 52 breaths/min, accessory muscle use, wheezing, and an oxygen saturation of 87% on room air. What action will the nurse take first?

Apply supplemental oxygen. A client in respiratory distress with a saturation lower than 90% needs to have supplemental oxygen placed immediately, followed by initiation of cardiac monitoring. The other interventions follow these actions.

The nurse is planning care for an infant with bronchiolitis. What is the nurse's priority intervention for this child?

Assess respiratory status frequently. Infants with bronchiolitis will have impaired gas exchange related to bronchiolar obstruction, atelectasis, and hyperinflation. Changes in respiratory status may occur quickly as energy reserves are depleted; therefore, close monitoring is essential. Positioning the infant, monitoring fluid status, and including parents in care plan are necessary, but not the priority.

The nurse is preparing to feed an infant diagnosed with pyloric stenosis prior to surgical repair. What is the nurse's most important intervention?

Burp the infant frequently. These infants usually swallow a lot of air from sucking on their hands and fingers because of their intense hunger. Burping frequently will reduce gastric distention, and increase the likelihood that the infant will retain the feeding. Feedings should be given slowly with the infant lying in a semi-upright position. Parental participation should be encouraged to the extent possible, but this will not increase the likelihood that the feeding will be retained. Record the type, amount, and character of the vomit, as well as its relation to the feeding. The amount of feeding volume lost is usually refed to the infant.

A nurse is preparing to conduct research and is searching the literature for evidence-based research information. Which source would the nurse most likely use to obtain appropriate information with the strongest level of evidence? Select all that apply.

Cochrane Collaboration National Guideline Clearinghouse Johanna Briggs Institute Information obtained from the Cochrane Collaboration and Johanna Briggs Institute are considered level I evidence which involve a systematic review of all relevant randomized controlled trials (RCTs). Information from the National Guideline Clearinghouse provides level I evidence, identifying clinical practice guidelines based on systematic reviews of RCTs. Information from MEDLINE and CINAHL provide reviews of descriptive or qualitative studies or articles of original quantitative studies, which are considered lower levels of evidence.

A 9-year-old is brought to the emergency department with extensive burns sustained in a restaurant fire. What is the nurse's most important intervention?

Conduct a wound assessment. The most important aspect of care for a child with burns is wound management. The goals of wound care are to speed debridement, protect granulation tissue and new grafts, and conserve body heat and fluids. Antibiotics aren't always administered prophylactically. Fluids are administered I.V. to replace fluid volume according to the child's body weight. Enteral feedings, rather than meals, are initiated within the first 24 hours after the burn to support the child's increased nutritional requirements.

A client with long-term body-focused repetitive behaviors including trichotillomania (hair pulling) finds support through an online website. The client begins to attend local meetings and realizes that a nurse from the clinic also attends. When approached outside of these meetings, how should the nurse respond?

Discuss this to define the relationship. Social media and self-help groups can contribute to blurred boundaries between personal and professional relationships. The nurse should take the lead to discuss boundaries with the client. This means that the relationship needs to be defined. Generally letting the client do this fails as the client does not understand the conflict and responds positively to having contact with the nurse outside of the professional setting. Pretending not to know the client can be hurtful, while leaving the group can be detrimental to the nurse.

A client has been prescribed digoxin to increase the heart's ability to contract effectively. The nurse is teaching a client about common side effects of digoxin. Of which side effects should this client be aware?

Dizziness anxiety HA Diarrhea Inotropic agents such as digoxin can trigger common side effects such as dizziness, anxiety, headache, and diarrhea. Changes in mood and alertness that include confusion and depression, rather than hyperactivity, may be observed. Weight loss is not associated with cardiac glycosides. The client should be instructed to notify the health care provider if any of these side effects become severe.

A client is admitted to the emergency department with a closed head injury after being found unconscious. Based on information from the client's neighbor, the staff suspects intimate partner violence. The client has a restraining order against the spouse, but the spouse repeatedly attempts to visit the client. Which action should the nurse take?

Inform hospital security personnel of the restraining order and description of spouse. The nurse should inform hospital security personnel about the restraining order and formulate an action plan with security that protects the client. The nurse does not have the authority to assign security personnel to be at the client's bedside. Measures should be in place to stop the spouse before he enters the unit, and a sign on the client's door could actually alert the spouse to the client's location. Admitting the client under an assumed name would require the client's consent and additional supervisor approval.

A client is admitted to the hospital. During the admission process, the nurse, the physician, and the pharmacist review the client's diagnosis and medications. The next person to see the client is a person from the admitting department. What is a rationale for the involvement of a person from the admitting department in the admission process?

It is a federal law that the institution provide a written summary of the client's health care decision-making rights.

A client has received an infusion of antibiotics and is now experiencing an anaphylactic reaction. What is the most important intervention by the nurse?

Maintain a patent airway. The first priority is to maintain a patent airway. The client will then require an epinephrine injection. If hypotension develops, a saline bolus may be given. The client's vital signs should be monitored, but not as the first action.

Which nursing intervention is a priority for a child with hemophilia, who has fallen, and has an acutely bruised leg?

Pressure on the site and administration of the required clotting factor With any bleeding injury in a client with hemophilia, the first line of treatment is always to replace the clotting factor. Pressure is applied along with cool compresses, and the extremity is immobilized. Aspirin is not used because of its anticoagulant properties and the risk of Reye's syndrome in children. Immobilizing the leg and giving ibuprofen would be done after applying pressure and administering the necessary clotting factor. Heat is not used because it increases bleeding.

The graduate registered nurse (RN) is assigned the care of a client with acute renal failure and hypernatremia. Which action can the graduate RN delegate to the unlicensed assistive personnel (UAP)?

Provide oral care. Providing oral care is within the UAP's scope of practice. Monitoring and assessing clients, as well as administering IV fluids, requires the additional education of the licensed nurse.

The nurse makes initial rounds for the clients. Five medications are scheduled for administration at the same time to five different clients. Which medication should the nurse administer first after initial rounds?

morphine sulfate to a client with a myocardial infarction reporting chest pain Morphine sulfate relieves pain which immediately decreases myocardial oxygen demand and decreases preload and afterload pressure. The digoxin is a maintenance dose and does not elicit an immediate reaction. Though administration of naproxen and ondansetron are next in the order of urgency, they are not the priority.

A nurse suspects an infant may have a tracheoesophageal fistula or esophageal atresia. What is the most important intervention by the nurse?

Report the suspicion to the health care provider. The provider needs to be told so that immediate diagnostic tests can be done to determine a definitive diagnosis with surgical correction. Oxygen should be given only after notifying the provider, except in an emergency; a need for oxygen is based on the infant's oxygen saturation levels or arterial blood gas results. It is not the nurse's responsibility to inform the parents of the suspected finding. By the time tracheoesophageal fistula or esophageal atresia is suspected, the neonate would have already been placed in an isolette or a radiant warmer.

The nurse is ambulating a client. The client experiences chest pain after ambulating 50 feet. What is the nurse's priority intervention?

Sit the client down The priority is to decrease oxygen consumption by sitting this client down. When the client's condition is stabilized, he can be returned to bed. An ECG can be obtained after the client is sitting down, and the ordered sublingual nitroglycerin could be administered.

A child with diabetes insipidus will be receiving injectable vasopressin when discharged from the hospital. What is the most important step when teaching injection techniques?

Teach injection techniques to anyone who will provide care for the child as well as to the child if the child is old enough to understand. The most important step is to teach all those who provide care for the child. The child should be included if age-appropriate. It's unrealistic to arrange for a home health nurse to give injections that are required throughout the child's life.

A nurse admitted a client with ulcerative colitis. A case manager is visiting the client and wants to discuss care. What is the nurse's understanding of the case manager?

The case manager collaborates care among all health care partners with the client in the center. Case management is a collaborative process. Case managers work closely with physicians, nurses, social workers, and a wide range of medical and nonmedical professionals. Case managers work to meet complex patient needs. They make provisions for current and future needs of patients. Case management nurses promote quality care that encourages appropriate use of available resources.

A client with cancer has been responding well to chemotherapy and radiotherapy. The client's most recent scan, however, reveals primary tumor growth and likely metastasis. The client tells the nurse, "What I cannot figure out is why this is happening to my life." What is the nurse's best action?

Validate the client's statement, and ask permission to arrange a referral to spiritual care. The client's statement suggests a desire for meaning that may be best addressed by spiritual interventions more so than psychiatry. Depression would not be unexpected in these circumstances, but the client's specific statement does not suggest this. Encouraging dialogue is helpful, but a referral is necessary.

A client is diagnosed with a highly drug-resistant Klebsiella pneumonia. What priority information will the nurse include in the client's teaching plan?

Washing hands before and after eating and as frequently as possible Clients should wash hands before and after they eat and as frequently as possible while hospitalized to reduce infections. Klebsiella is spread by person to person contact. The house does not need to cleaned with a bleach solution. The course of antibiotics may continue with discharge. There are no special precautions with a mask for the client because the bacteria does not spread through airborne means.

The nurse is caring for assigned clients on the oncology unit. Which client is at greatest risk for dehydration?

a 48-year-old having intracavitary radiation for cancer of the cervix Dehydration can occur from fluid loss secondary to tissue destruction at the site of irradiation at any age. After radical vulvectomy, wound drains are generally removed by postoperative day four or five, and don't create a significant risk of dehydration. Tamoxifen therapy is unrelated to dehydration. Although urine may escape through the vagina as a result of a vesicovaginal fistula, it does not cause the loss of an unusual amount of urine or other fluid.

Which client cannot sign out against medical advice?

a client who drank a bottle of vodka 1 hour ago A client who is intoxicated is not competent to sign out against medical advice. A pregnant teen is considered an adult. A competent adult client can discharge against medical advice for any reason. A legally emancipated minor is considered an adult

What is the most important nursing intervention for a child with lead poisoning who must undergo chelation therapy with intramuscular edetate calcium disodium? The nurse should prepare the child for:

a large number of injections. Intramuscular chelation therapy for symptomatic children commonly involves a large number of injections in a relatively short period of time. It's traumatic to most children. Edetate calcium disodium can also be given I.V. The other components of the treatment plan are important but aren't as likely to cause the same anxiety as multiple injections. Allowing adequate rest to protect painful injection sites is helpful. Physical activity is usually limited. Receiving I.V. fluid is not as traumatizing as multiple injections.

A client at term arrives in the labor and delivery unit experiencing contractions every 4 minutes. After a brief assessment, the client is admitted, and an electronic fetal monitor is applied. Which assessment finding would be most concerning to the nurse?

blood pressure of 146/90 mm Hg A blood pressure of 146/90 mm Hg may indicate gestational hypertension. Over time, gestational hypertension reduces blood flow to the placenta and can cause intrauterine growth restriction, and other problems that reduce the fetus's ability to tolerate the stress of labor. A weight gain of 30 lb (13.6 kg) is within expected parameters for a healthy pregnancy. A woman over age 30 doesn't have a greater risk of complications if her general condition is healthy before pregnancy. Syphilis that has been treated does not pose an additional risk.

The nurse is performing an admission assessment of a new client. When assessing potential cultural influences on the client's care, the nurse should address what domains? Select all that apply.

decision-making processes nutrition communication expressions of pain Culture is a concept that encompasses nearly every dimension of the illness experience, including the way that decisions are made, communication, the way pain is expressed, and the role of nutrition and food preferences. Inflammation, however, is a physiologic concept that is not directly influenced by culture.

What is the nurse's priority action when administering phenytoin to a client intravenously?

mix phenytoin with saline solution only Phenytoin is only compatible with saline solutions. Dextrose will cause an insoluble precipitate to form. Phenytoin should be administered at a rate of less than 50 mg/min. There is no need to withhold additional anticonvulsants.

The nurse is preparing to administer I.V. insulin to a client diagnosed with diabetic ketoacidosis (DKA). What will the nurse monitor while the client is receiving this intervention?

hypokalemia and hypoglycemia The nurse should monitor for decreased potassium and decreased glucose. Hypoglycemia might occur if too much insulin is administered, or insulin is administered too quickly. Intravenous insulin forces potassium into cells, thereby lowering plasma levels of potassium. The client may have hyperkalemia prior to starting the insulin therapy, but hypokalemia will occur with insulin administration. Calcium and sodium levels should not be affected.

A client's laboratory results indicate hypokalemia, hyperglycemia, and increased white blood cell (WBC) count. Which newly prescribed medication should the nurse associate as most likely to contribute to these changes?

prednisone Many of the medications listed can contribute to hypokalemia, including prednisone (a corticosteroid), albuterol (a beta-2 agonist), and furosemide (a loop diuretic). Fluoroquinolone antibiotics such as ciprofloxacin can cause hyperglycemia, as can prednisone and albuterol. However, only prednisone can be linked to hyperglycemia, hypokalemia, and increased white blood cell count. The elevation in WBC with corticosteroid use is primarily due to the anti-inflammatory effects, which result in decreased adhesion of neutrophils to endothelium and an associated increase in the number circulating in the blood; it is not an indication of infection related to immunosuppressive effects of the drug.

A client, diagnosed with active tuberculosis (TB), asks the nurse if they will be admitted to the hospital. The nurse responds that hospitalization would most likely occur to

prevent the spread of the disease. A client with active TB is highly contagious until three consecutive sputum cultures are negative. This client should be put on respiratory isolation in a hospital setting.

At the completion of a shift, the nurse is participating in the nursing handoff during the transition from the day shift to the evening shift. At the time of shift change, there are not enough evening nurses to meet mandated nurse-client ratios. What is the nurse's best action?

Document the situation, and remain on the unit until sufficient staffing levels are achieved. In order to avoid abandoning clients, the nurse is required in most jurisdictions to remain on the unit until safe staffing levels are achieved. Careful documentation is necessary during all stages of such a transition.

A client who developed gestational diabetes mellitus during the pregnancy has just been admitted in the labor and delivery unit. What is the priority nursing action for this client?

Ask the client about her most recent blood glucose levels. Asking about the client's most recent blood glucose levels will indicate how well her diabetes has been controlled. Oral hypoglycemic drugs are never used during pregnancy because they cross the placental barrier, stimulate fetal insulin production, and are potentially teratogenic. Plans to admit the infant to the neonatal intensive care unit are premature. Cesarean is not the preferred birth method for clients with diabetes. Vaginal birth is preferred and presents a lower risk to the mother and fetus.

The nurse is planning to administer morphine 1 mg I.V. to a client who is reporting pain. The available vial is morphine 2 mg/1 ml. What is the most appropriate action by the nurse?

Draw 0.5 ml of medication into a syringe and ask another nurse to witness the waste of 0.5 ml of medication. Controlled substances such as morphine require close monitoring by federal law to control abuse by clients and healthcare workers. If a nurse is administering a partial dose of a controlled substance, the partial dose should be immediately discarded as per facility policy with a second nurse acting as a witness. Both nurses would document the disposal of the medication according to the facility policy and medication system in use. A controlled substance should never be disposed of in a sharps container as the container may be easily removed, allowing for diversion of the substance. Asking for a witness after the fact may raise suspicion of diversion.

The nurse is planning care for an infant with bronchiolitis who requires monitoring for fluid balance. What is the most accurate assessment the nurse can perform to determine the total body water volume of the infant?

daily weight The most accurate clinical assessment for total body water is weight. Weight helps assess all the water in all spaces while other assessments are dependent on renal function or movement of fluid between spaces, making them less accurate. While sodium levels are relevant, they cannot inform about total body water volume; an infant can be in fluid volume deficit and hyponatremic concurrently depending on how much sodium is lost in relation to water. Weighing diapers is a way of measuring output, but depending on the renal function of the infant, there can be very little urine output. The infant may be retaining fluids and actually be experiencing fluid volume excess or have very little urine output because of fluid volume deficit. Similarly, urine specific gravity can be altered by the kidney's ability to concentrate the urine, so it may not accurately reflect the total water volume.

This response indicates that the behavior is unacceptable, and that the client deserves help. The other responses are nontherapeutic and accusatory.

depression substance abuse posttraumatic stress Childhood sexual abuse is closely linked to the development of depression and substance abuse disorders. It is also linked to the development of somatization and posttraumatic stress disorders. Victims of childhood sexual abuse aren't predisposed to developing narcissistic disorders. Enuresis is frequently seen in children who are victims of childhood sexual abuse. This is typically outgrown as the child ages.

A nurse is conducting a spiritual assessment on a client admitted for surgery and developing a plan of care based on this assessment. To help ensure that the nurse is most successful in meeting the client's spiritual needs and promote a comfortable working relationship with the client, which aspect would be most important initially for the nurse?

developing an awareness of one's own beliefs about the connection between spirituality and health To ensure success in meeting the client's spiritual needs, the nurse needs to be comfortable in discussing this aspect of care. Typically, nurses who are more aware of their spirituality, such as through introspective reflection, have a deeper understanding of their own spiritual dimension. Subsequently, they are more confident when discussing spirituality. Although identifying the impact on health by the client's beliefs and practices, incorporating the client's participation and role in a specific religious community, and making appropriate referrals are important in meeting the client's spiritual needs, the nurse first needs to be self-aware of beliefs to provide optimal care

Which nursing intervention would help to decrease the adverse effects of radiation therapy on the gastrointestinal tract?

encouraging fluids and a soft diet Radiation therapy can cause adverse effects such as nausea and vomiting, anorexia, mucosal ulceration, and diarrhea. Antispasmodics are used to help reduce diarrhea. Encouraging fluids and a soft diet will help with anorexia. Antiemetics should be given before the onset of vomiting. Frequent mouthwashes are indicated to prevent mycosis.