NCLEX SAUNDERS Q&A PT. 4

The nurse provides instructions to a client about the use of an incentive spirometer. The nurse determines that the client needs further teaching about its use if the client makes which statement?

"After maximal inspiration, I will hold my breath for 10 seconds and then exhale." For optimal lung expansion with the incentive spirometer, the client should assume a semi-Fowler's or high-Fowler's position. The mouthpiece should be covered completely and tightly while the client inhales slowly, with a constant flow through the unit. When maximal inspiration is reached, the client should hold the breath for 5 seconds and then exhale slowly through pursed lips.

The parents of a neonate who is not circumcised request information on how to clean the newborn's penis. Which is the correct response for the nurse to make to the parents? 1. "Retract the foreskin and cleanse with every diaper change." 2. "Retract the foreskin and cleanse the glans when bathing the neonate." 3. "Avoid retracting the foreskin to cleanse the glans because this may cause adhesions." 4."Retract the foreskin no farther than it will easily go and replace it over the glans after cleaning."

"Avoid retracting the foreskin to cleanse the glans because this may cause adhesions." In newborn males, the prepuce is continuous with the epidermis of the glans and is nonretractable. Forced retraction may cause adhesions to develop. Separation should be allowed to occur naturally, which will take place between 3 years and 5 years of age. Most foreskins are retractable by 3 years of age and should be pushed back gently for cleaning once a week.

A hospitalized client who is experiencing delusions and has a diagnosis of schizophrenia says to the nurse, "I know that the doctor is talking to the CIA to get rid of me." Which should be the nurse's bestresponse?

"I don't know anything about the CIA. Do you feel afraid that people are trying to hurt you?" When delusional, a person truly believes what he or she thinks to be real is real. The person's thinking often reflects feelings of great fear and aloneness. It is most therapeutic for the nurse to empathize with the client's experience. Disagreeing with delusions may make the client more defensive, and the client may cling to the delusions even more. Encouraging discussion regarding the delusion is inappropriate.

Which statement by the client should cause the nurse to suspect that the thyroid test results drawn on the client this morning may be inaccurate?

"I had a radionuclide test done 3 days ago." Recent radionuclide scans performed before the test can affect thyroid laboratory results. There are no food, fluid, or activity restrictions required for this test.

A client hospitalized with a paranoid disorder refuses to turn off the lights in the room at night and states, "My roommate will steal me blind." Which is an appropriate response by the nurse?

"I hear what you are saying, but I don't share your belief." Paranoid beliefs are coping mechanisms and therefore not easily relinquished. It is important not to support the belief and not ridicule, argue, or criticize it. Asking the client "why" places the client in a defensive position. Encouraging the client to expound on the belief when discussion should be limited is also inappropriate. Threatening the client by denying a privilege is unethical.

Griseofulvin (Gris-PEG) is prescribed for a child with tinea capitis. The nurse reinforces instructions to the family regarding administration of the medication. Which statement by the mother indicates a need for further teaching? 1. "I need to keep my child out of the sun." 2."I need to continue the therapy as long as it is prescribed." 3."I need to administer the medication 2 hours before meals." 4."I need to shake the oral suspension before preparing the dose."

"I need to administer the medication 2 hours before meals." Gris-PEG is given with or after meals to avoid gastrointestinal (GI) irritation and to increase absorption. Oral suspensions should be shaken well. Parents are instructed to continue therapy as prescribed and not to miss a dose. Exposure to the sun is avoided during treatment.

A client who received a kidney transplant is taking azathioprine (Imuran), and the nurse reinforces instructions about the medication. Which statement by the client indicates a need for further teaching?

"I need to discontinue the medication after 14 days of use." Azathioprine is an immunosuppressant medication that is taken for life. Because of the effects of the medication, the client must watch for signs of infection, which are reported immediately to the HCP. The client should also call the HCP if more than one dose is missed. The medication may be taken with meals to minimize nausea.

The nursing instructor is providing a session on cultural beliefs related to health and illness. Following the session, the instructor asks a nursing student to describe the beliefs of an African-American client with regard to illness. Which statement describes the beliefs of an African-American client with regard to illness?

"Illness is a disharmonious state that may be caused by demons and spirits. In the African-American culture, illness is viewed as a disharmonious state that may be caused by demons and spirits. The goal of treatment, from the traditional African perspective, is to remove the harmful spirit from the body of the ill person. Asian Americans believe that illness is caused by an imbalance between yin and yang and by prolonged sitting or lying, or by overexertion.

A client says to the home care nurse, "I can't believe that my wife died yesterday. I keep expecting to see her everywhere I go in this house, ready to plan our activities for the day." Which is the therapeutic nursing response?

"It must be hard to accept that she has passed away." The therapeutic nursing response is the one that recognizes the difficulties of grieving the loss of a loved one and facilitates expression of feelings. The remaining responses are not therapeutic and do not encourage expression of feelings.

A nursing student is asked to discuss juvenile idiopathic arthritis (JIA) at a clinical conference scheduled for the end of the clinical day. Which statement by the nursing student indicates the need for further research of this disorder? "The cause of this disease is unknown." 2."JIA most often occurs by age of 10 years." 3."This disease is twice as likely to occur in boys rather than girls." 4."Clinical manifestations include morning stiffness and painful, stiff, swollen joints."

"This disease is twice as likely to occur in boys rather than girls." JIA is twice as likely to occur in girls as in boys. The cause of JIA is unknown. JIA has two peak ages of onset: between 1 and 3 years of age and between 8 and 10 years of age. This autoimmune inflammatory disease causes painful inflammation of joints.

A client who has just received a diagnosis of asthma says to the nurse, "This condition is just another nail in my coffin." Which response by the nurse is therapeutic?

"You seem very distressed over learning you have asthma." Clients who have learned they have a chronic illness may exhibit denial, anger, or sarcasm because of the fear associated with the chronic illness. It is important for the nurse to convey an accepting attitude to enhance mutual respect and trust. Asking the client if asthma will kill them paraphrases the client's words but is somewhat sarcastic. Telling the client that you will not work with them is punitive in its approach and threatens the client. Informing the client that asthma is a treatable condition lectures the client and does not deal directly with the client's expressed concerns.

The nurse determines that which herbal therapies can be prescribed for its use as an antispasmodic? Select all that apply.

- Chamomile - Peppermint oil Chamomile has a mild sedative effect and acts as an antispasmodic and anti-inflammatory. Peppermint oil acts as an antispasmodic and is used for irritable bowel syndrome. Topical aloe promotes wound healing. Aloe taken orally acts as a laxative. Kava has an anxiolytic, sedative, and analgesic effect. Ginger is effective in relieving nausea.

The nurse determines that which clients are at high risk for metabolic acidosis? Select all that apply.

- Diabetes clients - Kidney failure clients - Malnourishment clients Diabetes mellitus, kidney failure, and malnutrition lead to metabolic acidosis by increasing acids in the body. Asthma, pneumonia, and severe anxiety lead to respiratory, not metabolic, imbalances.

A client in the postpartum unit complains of sudden, sharp chest pain. The client is tachycardic and the respiratory rate is increased, and the health care provider diagnoses a pulmonary embolism. Which interventions apply to the care of this client? Select all that apply.

- administer oxygen - monitor blood pressure - prepare to administer morphine sulfate - prepare to administer an IV line If pulmonary embolism is suspected, oxygen is administered to decrease hypoxia. The client also is kept on bed rest, with the head of the bed slightly elevated, not supine, to reduce dyspnea. Morphine sulfate may be prescribed for the client to reduce pain and apprehension. An IV line also will be required, and vital signs must be monitored. Heparin therapy (not warfarin sodium) is administered.

The registered nurse (RN) tells a licensed practical nurse (LPN) that the health care provider has prescribed a hypotonic intravenous (IV) solution for a client. Which IV solution should the LPN obtain for administration to the client? 1. 0.45% saline 2. 5% dextrose in water 3. 10% dextrose in water 4. 5% dextrose in 0.9% saline

0.45% saline Five percent dextrose in water is an isotonic solution; 10% dextrose in water and 5% dextrose in 0.9% saline are hypertonic solutions; 0.45% saline is hypotonic and is probably the only hypotonic solution used in clinical situations. Distilled water is another example of a hypotonic solution. Hypotonic solutions contain a lower concentration of salt or more water than an isotonic solution.

Which safety measures that should be implemented when working in the newborn nursery? Select all that apply. 1. Adhere to standard precautions. 2. Place bassinets 1 foot apart from one another. 3. It is acceptable for nurses who are ill to work in the nursery. 4. An identification bracelet should be placed on the infant only after the initial bath is completed. 5. The parents should be instructed to not release their infant to anyone wearing improper identification. 6.The mother should be fingerprinted and the infant should be footprinted on the identification card before removing the infant from the delivery room.

1. Adhere to standard precautions. 2. The parents should be instructed to not release their infant to anyone wearing improper identification. 6. The mother should be fingerprinted and the infant should be footprinted on the identification card before removing the infant from the delivery room. Newborn safety, infection prevention, and abduction prevention are major responsibilities for nurses working in the newborn nursery. Standard precaution guidelines need to be followed to prevent transmission of bacteria and other illnesses to newborns. Following safety precautions to prevent newborn abduction includes footprinting the newborn along with fingerprinting of the mother on the identification card. This also includes placing bracelet identification on the mother and infant before removing the newborn from the delivery room. Educating parents to release their newborn only to those wearing proper identification is key in preventing newborn abductions in the inpatient situation. Bassinets are to be 3 feet apart. Nurses who are ill should not be working in the nursery.

A mother of a 5-year-old child tells the nurse that the child scolds the floor or table if the child hurts herself on the object. According to Piaget's theory of cognitive development, which behavior is this known as? 1. Animism 2. Egocentric speech 3. Object permanence 4. Global organization

1. Animism Animism means that all inanimate objects are given living meaning. Object permanence, the realization that something out of sight still exists, occurs in the later stages of the sensorimotor stage of development. Egocentric speech occurs when the child talks just for fun and cannot see another's point of view. Global organization means that if any part of an object or situation changes, the whole thing has changed. Options 2 and 4 occur during the preoperational stage.

A postoperative client has been placed on a clear liquid diet. Which items is the client allowed to consume? Select all that apply. 1. Broth 2. Coffee 3. Gelatin 4. Pudding 5. Ice cream 6. Vegetable juice

1. Broth 2. Coffee 3. Gelatin A clear liquid diet consists of foods that are relatively transparent to light and are clear and liquid at room and body temperature. These foods include water, bouillon, clear broth, carbonated beverages, gelatin, hard candy, lemonade, Popsicles, and regular or decaffeinated coffee or tea. The incorrect food items are allowed on a full liquid diet.

Several laboratory tests are prescribed for a client, and the nurse reviews the results of the tests. Which laboratory results warrant a call to the health care provider (HCP)? Select all that apply. 1. Calcium, 7 mg/dL 2. Magnesium, 1 mg/dL 3. Serum creatinine, 1 mg/dL 4. Blood urea nitrogen, 10 mg/dL 5. White blood cells, 3000 cells/mm3 6. Thyroid-stimulating hormone (thyrotropin), 0.4 microunits/mL

1. Calcium, 7 mg/dL 2. Magnesium, 1 mg/dL 3. White blood cells, 3000 cells/mm3 The normal values include the following: white blood cells, 4500 to 11,000 cells/mm3; thyroid-stimulating hormone, 0.2 to 5.4 microunits/mL; magnesium, 1.6 to 2.6 mg/dL; calcium, 8.6 to 10.0 mg/dL; blood urea nitrogen, 5 to 20 mg/dL; and serum creatinine, 0.6 to 1.3 mg/dL. Therefore, values that are abnormal should be reported to the HCP.

A mother brings her 4-month-old infant to the well-baby clinic for immunizations. Which immunizations should be administered to this infant? 1. Diphtheria, tetanus, acellular pertussis (DTaP), Haemophilus influenzae type b (Hib), inactivated poliovirus vaccine (IPV), pneumococcal vaccine (PCV) 2.Varicella and hepatitis B vaccines 3.Measles, mumps, rubella (MMR), Hib, DTaP 4.DTaP, MMR, IPV

1. Diphtheria, tetanus, acellular pertussis (DTaP), Haemophilus influenzae type b (Hib), inactivated poliovirus vaccine (IPV), pneumococcal vaccine (PCV) DTaP, Hib, IPV, and PCV are administered at 4 months of age. DTaP is administered at 2 months, 4 months, 6 months, between 12 and 18 months, and between 4 and 6 years of age. Hib is administered at 2 months, 4 months, 6 months, and between 12 and 15 months of age. IPV is administered at 2 months, 4 months, 6 months, and between 4 and 6 years of age. The first dose of MMR is administered between 12 and 15 months of age; the second dose is administered at 4 to 6 years of age (if the second dose was not given by 4 to 6 years of age, it should be given at the next visit). The first dose of hepatitis B vaccine is administered between birth and 2 months, the second dose is administered between 1 and 4 months, and the third dose is administered between 6 and 18 months of age. Varicella zoster vaccine is administered between 12 and 18 months of age. PCV is administered at 2, 4, and 6 months of age and between 12 and 15 months of age.

The advantages of using spinal anesthesia for delivery of a fetus include which? Select all that apply. 1. Ease of administration 2. Absence of fetal hypoxia 3. Immediate onset of anesthesia 4. Blockade of sympathetic fibers 5. Increased voluntary expulsive efforts 6. Decreased incidence of bladder atony

1. Ease of administration 2. Absence of fetal hypoxia 3. Immediate onset of anesthesia Keeping the woman in bed for at least 8 hours after receiving spinal anesthesia is thought to decrease the risk of headache. Advantages of spinal anesthesia include onset of anesthesia in 1 to 3 minutes, ease of administration, and absence of fetal hypoxia. A disadvantage is the intense blockade of sympathetic fibers resulting in a high incidence of hypotension; a potential decrease in voluntary expulsive efforts, increasing the incidence of the need of an operative birth; and an increased incidence of bladder and uterine atony.

A nulliparous woman asks the nurse when she will feel fetal movements. The nurse responds by telling the woman that the first recognition of fetal movement will occur at approximately which week of gestation?

18 The first recognition of fetal movements, or "feeling life," by the multiparous woman may occur as early as the 14th to 16th week of gestation. The nulliparous woman may not notice these sensations until the 18th week of gestation or later. The first recognition of fetal movement is called "quickening."

The nurse is reinforcing instructions regarding cardiopulmonary resuscitation (CPR) to a group of nursing students. The nurse tells the group that when performing chest compressions on adults, the sternum should be depressed to least which depth? 1. 1 inches 2. 2 inches 3. One third to one half the depth of the chest 4. Deep enough to make a hand impression

2 inches When performing CPR on adults, the sternum is depressed at least 2 inches. The remaining depths of compression could be ineffective or harmful.

A client has been admitted for urinary tract infection and dehydration. The nurse determines that the client has received adequate volume replacement if the blood urea nitrogen (BUN) level drops to which value? 1. 6 mg/dL 2. 15 mg/dL 3. 29 mg/dL 4. 35 mg/dL

2. 15 mg/dL The normal blood urea nitrogen value for the adult is 10 to 20 mg/dL. Thus the value of 15 mg/dL is correct. Values of 29 and 35 mg/dL reflect continued dehydration. Option 1 reflects a lower than normal value, which may occur with fluid overload, among other conditions.

The nursing student is presenting a clinical conference and discusses the causative factors related to beta-thalassemia. Which group is at greatest risk of developing this disorder? 1, A child of Mexican descent 2.A child of Mediterranean descent 3.A child whose intake of iron is extremely poor 4.a child breast-fed by a mother with chronic anemia

2. A child of Mediterranean descent Beta-thalassemia is an autosomal recessive disorder. This disorder is found primarily in individuals of Mediterranean descent. The disease also has been reported in Asian and African populations. Options 1, 3, and 4 are not risk factors for this disorder. Beta thalassemia is a blood disorder that reduces the production of hemoglobin. In people with beta thalassemia, low levels of hemoglobin lead to a lack of oxygen in many parts of the body.

A urinalysis has been prescribed for an infant and the nurse plans to collect the specimen. The nurse implements which appropriate method to collect the specimen? 1. Catheterizes the infant, using a No. 5 French Foley 2. Attaches a urinary collection device to the infant's perineum 3. Obtains the specimen from the diaper, using a syringe, after the infant voids 4. Monitors the urinary patterns and prepares to collect the specimen into a cup when the infant voids

2. Attaches a urinary collection device to the infant's perineum Although many methods have been used to collect urine from an infant, the most reliable method is the urine collection device. This device is a plastic bag that has an opening lined with adhesive so that it may be attached to the perineum. Urine for certain tests, such as specific gravity, may be obtained from a diaper. Urinary catheterization is not to be done unless specifically prescribed because of the risk of infection. It is not reasonable to monitor urinary patterns and attempt to collect the specimen in a cup when the infant voids.

A 1-year-old child with hypospadias is scheduled for surgery to correct this condition. The nurse is asked to assist in preparing a plan of care for this child. During this developmental time period, which factor should the nurse take into account? 1. Sibling rivalry will cause regression to occur. 2. Fears of separation and mutilation are present. 3. Embarrassment of voiding irregularities is common. 4. Concern over size and function of the penis is present.

2. Fears of separation and mutilation are present. At the age of 1 year, a child's fears of separation and mutilation are present because the child is facing the developmental task of trusting others. As the child gets older, fears about virility and reproductive ability may surface. The question does not provide enough data to determine that siblings exist. Options 3 and 4 may be issues if the child were older.

A client has been diagnosed with acute gastroenteritis. Which diet should the nurse anticipate to be prescribed for the client? 1. Low fat 2. Low fiber 3. High fiber 4. High carbohydrate

2. low fiber A low-fiber diet places less strain on the intestines because this type of diet is easier to digest. This diet is prescribed for clients with inflammatory bowel disease, ileostomy, colostomy, partial obstructions of the intestinal tract, acute gastroenteritis, or diarrhea.

The licensed practical nurse (LPN) is assisting a school nurse in conducting a session with female adolescents regarding the menstrual cycle. The LPN tells the adolescents that the normal duration of the menstrual cycle is which?

28 days The normal duration of the menstrual cycle is about 28 days. The first day of the menstrual period is counted as day 1 of the woman's cycle. The remaining options are incorrect.

The nurse is preparing to auscultate a client's abdomen for bowel sounds. The nurse listens for bowel sounds in which abdominal quadrant first? Refer to figure.

3 When auscultating the abdomen, the nurse begins in the right lower quadrant (RLQ), in the ileocecal valve area, because bowel sounds are always present here normally. The nurse then proceeds to the other quadrants 1, 2, and 4.

A clinic nurse prepares to administer an MMR (measles, mumps, rubella) vaccine to a child. The nurse should administer this vaccine by which method? 1. Intramuscularly in the deltoid muscle 2.Subcutaneously in the gluteal muscle 3. Subcutaneously in the outer aspect of the upper arm 4.Intramuscularly in the anterolateral aspect of the thigh

3. Subcutaneously in the outer aspect of the upper arm The MMR vaccine is administered subcutaneously in the outer aspect of the upper arm. The gluteal muscle is most often used for intramuscular injections. The MMR vaccine is not administered by the intramuscular route.

Penicillin V 250 mg orally every 8 hours, is prescribed for a child with a respiratory infection. The child's weight is 45 pounds. The safe pediatric dosage is 25 to 50 mg/kg/day. Which statement accurately describes the prescribed dosage for this child? 1. The dosage is too low. 2. The dosage is too high. 3. The dosage is within the safe dosage range. 4. There is not enough information to determine the safe dosage.

3. The dosage is within the safe dosage range. Convert pounds to kilograms by dividing by 2.2 and then determine the dosage frequency.Pounds to kilograms:45 lb ÷ 2.2 lb/kg = 20.45 kgDosage parameters:25 mg/kg/day × 20.45 kg = 511.25 mg/day50 mg/kg/day × 20.45 kg = 1022.5 mg/dayDosage frequency:250 mg × 3 doses (every 8 hours) = 750 mg/dayThe dosage is within the safe dosage range.

The nurse is preparing to administer 30 mEq of liquid potassium chloride (KCl) to an adult client. The label on the medication bottle reads 40 mEq/15 mL. The nurse prepares how many milliliters of KCl to administer the correct dose of medication? Fill in the blank. Round your answer to the nearest whole number.

30 / 40 x 15 = 11.25 = 11 mL

The nurse is checking the remaining volume in a 1000-mL intravenous (IV) bag that is scheduled to infuse over 8 hours on an electronic infusion pump. The nurse has just noted at 11:00 am that the remaining IV fluid is at the 500-mL level. At 12:00 noon at which numerical level (mL) should the IV fluid be? Fill in the blank.

375 mL If the IV is scheduled to run over 8 hours, then the hourly rate is 125 mL/hr. Using 500 mL as the reference point, the next hourly marking should be at 375 mL, which is 125 mL less than 500 mL. DIVIDE 8 HRS OVER 1000 mL = 125 mL/hr 500 mL - 125 mL/hr = 375/hr @ 12:00 pm

A client has been diagnosed as having syndrome of inappropriate antidiuretic hormone (SIADH) secretion following cranial surgery. The nurse interprets that this complication is not resolving if which urine specific gravity measurement is obtained? 1. 1.016 2. 1.018 3. 1.020 4. 1.030

4. 1.030 The normal range for urine specific gravity is from 1.016 to 1.022. Elevations may occur with SIADH because the kidneys are stimulated to reabsorb water, thus causing a higher concentration of the urine.

The nurse is reviewing the procedure for vitamin K injection in a newborn. Which information is included in the procedure? 1. Inject at a 45-degree angle. 2. Use a 22-gauge, 1-inch needle for the injection. 3. Do not massage the injection site after administration. Inject at a 45-degree angle. 2. Use a 22-gauge, 1-inch needle for the injection. 3. Do not massage the injection site after administration. 4. Inject into skin that has been cleansed and allowed to have alcohol dry on the puncture site for 1 minute.

4. Inject into skin that has been cleansed and allowed to have alcohol dry on the puncture site for 1 minute. Vitamin K is given in the middle third of the vastus lateralis muscle using a 25-gauge, ⅝-inch needle. It is injected into skin that has been cleansed or allowed to alcohol dry for 1 minute to remove organisms and prevent infection. It is given at a 90-degree angle. The site is massaged after removing the needle to increase absorption.

Which is the primary goal that should be included in the plan of care for a child who has cerebral palsy? 1. Eliminate the cause of the disease. 2. Improve muscle control and coordination. 3. Prevent the occurrence of emotional disturbances. 4. Maximize the child's assets and minimize the limitations.

4. Maximize the child's assets and minimize the limitations The goal of managing the child with cerebral palsy is early recognition and intervention to maximize the child's abilities. The cause of the disease cannot be eliminated. It is best to minimize emotional disturbances, if possible, but not to prevent them because it is healthy for the child to express emotions. Improvement of muscle control and coordination is a component of the plan, but the primary goal is to maximize the child's assets and minimize the limitations caused by the disease.

The nurse is providing information to the family of a child about a synthetic cast that has been applied to the child for the treatment of a clubfoot. Which information should the nurse provide to the mother? 1. The synthetic cast takes 24 hours to dry. 2. The synthetic cast is heavier than a plaster cast. 3. The synthetic cast is stronger than a plaster cast. 4. The synthetic cast allows for greater mobility than a plaster cast.

4. The synthetic cast allows for greater mobility than a plaster cast. Synthetic casts dry quickly (in less than 30 minutes) and are lighter than plaster casts. Synthetic casts allow for greater mobility than a plaster cast. However, synthetic casts are not as strong as plaster casts and are more expensive.

A client is admitted to the hospital with a diagnosis of malnutrition. The nurse is told that blood will be drawn to determine whether the client has a protein deficiency. Which laboratory data indicates that the client is experiencing a protein deficiency? 1. Calcium, 10 mg/dL 2. Sodium, 138 mEq/L 3. Creatinine, 0.6 mg/dL 4. Transferrin, 90 mg/dL

4. Transferrin, 90 mg/dL Serum transferrin is an iron transport protein that can be measured directly or calculated as an indirect measurement of total iron-binding capacity. It is a more sensitive indicator of protein status than albumin. When the serum transferrin level is less than 100 mg/dL, the level of visceral protein depletion is severe. Options 1, 2, and 3 identify normal laboratory values.

Several children have contracted rubeola (measles) in a local school, and the school nurse conducts a teaching session for the parents of the school-children. Which statement, if made by a parent, indicates a need for further teaching regarding this communicable disease? 1. "Small blue-white spots with a red base may appear in the mouth." 2."The rash usually begins centrally and spreads downward to the limbs." 3."Respiratory symptoms such as a very runny nose, cough, and fever occur before the development of a rash." 4."The communicable period ranges from 10 days before the onset of symptoms to 15 days after the rash appears."

4."The communicable period ranges from 10 days before the onset of symptoms to 15 days after the rash appears." The communicable period for rubeola ranges from 4 days before to 5 days after the rash appears, mainly during the prodromal (catarrhal) stage. Options 1, 2, and 3 are accurate descriptions of rubeola. The small blue-white spots found in this communicable disease are called Koplik spots. Option 3 describes the incubation period for rubella, not rubeola.

A client who has just been told that she is pregnant asks a clinic nurse when the fetus's heart will be developed and beating. The nurse tells the client that the fetal heart is beating at what gestational week?

5 weeks The fetal heart is beating and has developed four chambers by gestational week 5.

what is a radionuclide test?

A procedure that involves injecting a radioactive isotope, typically thallium or cardiolyte, into the patient's vein after which an image of the patient's heart becomes visible with a special camera. The radioactive isotopes are absorbed by the normal heart muscle.

What are the deep tendon reflexes?

Achilles (ankle reflex), patellar (knee reflex), brachioradialis, biceps, triceps Deep tendon reflexes, more properly referred to as muscle stretch reflexes, are an integral part of the neurological examination. A stretch reflex is an involuntary reaction of a muscle to being passively stretched by percussion of the tendon. ... This reflex provides information on upper and lower motor neurons.

The nurse is providing information to unlicensed assistive personnel (UAP) regarding caring for the older adult. The nurse tells the UAPs that which situation portrays ageism? 1. Informing the older adult of their rights 2. Allowing older adults to make decisions 3. Accepting differences among older adults 4. Advising older adults to forgo aggressive treatment

Advising older adults to forgo aggressive treatment Ageism is a form of prejudice in which older adults are stereotyped by characteristics found in only a few members of their group. Fundamental to ageism is the view that older people are different from "me" and will remain different from "me." Therefore, they are portrayed as not experiencing the same desires, needs, and concerns. Options 1, 2, and 3 identify supportive roles of the nurse when dealing with the older adult. Option 4 suggests that the older adult is not worthy of aggressive treatment and demonstrates ageism.

A client who has been receiving total parenteral nutrition by way of a central venous access device complains of chest pain and dyspnea. The nurse quickly assesses the client's vital signs and notes that the pulse rate has increased and that the blood pressure has dropped. The nurse determines that the client is most likely experiencing which?

Air embolism The signs and symptoms of air embolism include chest pain, dyspnea, hypoxia, anxiety, tachycardia, and hypotension. The nurse also should hear a loud churning sound over the pericardium on auscultation of the chest. The signs and symptoms of sepsis include fever, chills, and general malaise. The signs and symptoms of a fluid imbalance depend on the type of imbalance that the client is experiencing. Fluid overload causes increased intravascular volume, which increases the blood pressure and the pulse rate as the heart tries to pump the extra fluid volume. Fluid overload also causes neck vein distention and the shifting of fluid into the alveoli, resulting in lung crackles. Complications should be reported to the registered nurse and/or the health care provider immediately.

The nurse is inserting an indwelling urinary catheter into the urethra of a client. As the nurse inflates the balloon, the client complains of discomfort. Which is the appropriate nursing action?

Aspirate the fluid, advance the catheter further, and reinflate the balloon. If the balloon is malpositioned in the urethra, inflating the balloon could produce trauma, and pain will occur. If pain occurs, the fluid should be aspirated and the catheter inserted a little farther to provide sufficient space to inflate the balloon. The catheter's balloon is behind the opening at the insertion tip. Inserting the catheter the extra distance will ensure that the balloon is inflated inside the bladder and not in the urethra. There is no need to remove the catheter and reinsert a new one. Pain when the balloon is inflated is not normal or temporary.

The nurse is planning the client assignments. Which is the least appropriate assignment for the unlicensed assistive personnel (UAP)?

Assisting a child who is profoundly developmentally disabled to eat lunch The nurse must determine the most appropriate assignment based on the skills of the staff member and the needs of the client. In this case, the least appropriate assignment for the nursing assistant would be assisting with feeding a profoundly developmentally disabled child. The child is likely to have difficulty eating and therefore has a higher potential for complications, such as choking and aspiration. The remaining options do not include data indicating that these tasks carry any unforeseen risk.

A client with portosystemic encephalopathy is receiving oral lactulose daily. The nurse should check which to determine medication effectiveness?

Blood ammonia level Lactulose is a hyperosmotic laxative and ammonia detoxicant. It is used to prevent or treat portosystemic encephalopathy, including hepatic precoma and coma. It also is used to treat constipation. The medication retains ammonia in the colon (decreases the blood ammonia concentration), producing an osmotic effect. It promotes increased peristalsis and bowel evacuation, expelling ammonia from the colon.

The nurse is assigned to care for a client in the immediate postpartum period who received epidural anesthesia for delivery, and the nurse monitors the client for complications. Which would most likelyindicate a hematoma? 1. Changes in vital signs 2. Signs of heavy bruising 3. Complaints of a tearing sensation 4. Complaints of lower abdominal discomfort

Changes in vital signs Changes in vital signs indicate hypovolemia in the anesthetized postpartum woman with vulvar hematoma. Options 3 and 4 are inaccurate for a client who is anesthetized. Heavy bruising may be noted, but vital sign changes are most likely to indicate the presence of a hematoma.

The nurse is assisting in collecting subjective and objective data from a client admitted to the hospital with tuberculosis (TB). The nurse should expect to note which finding?

Complaints of night sweats The client with tuberculosis usually experiences a low-grade fever, weight loss, pallor, chills, and night sweats. The client also will complain of anorexia and fatigue. Pulmonary symptoms include a cough that is productive of a scant amount of mucoid sputum. Purulent, blood-stained sputum is present if cavitation occurs. Dyspnea and chest pain occur late in the disease.

The nurse is collecting data from an older adult client. Which indicates a potential complication associated with the skin of this client? 1. Crusting 2. Wrinkling 3. Deepening of expression lines 4. Thinning and loss of elasticity in the skin

Crusting The normal physiological changes that occur in the skin of older adults include thinning of the skin, loss of elasticity, deepening of expression lines, and wrinkling. Crusting noted on the skin indicates a potential complication.

The nurse reviews the medication history of a client admitted to the hospital and notes that the client is taking leflunomide (Arava). During data collection, the nurse asks which question to determine medication effectiveness?

Do you have any joint pain?" Leflunomide is an immunosuppressive agent and has an anti-inflammatory action. The medication provides symptomatic relief of rheumatoid arthritis. Diarrhea can occur as a side effect of the medication. The other options are unrelated to medication effectiveness.

The nurse in the labor room is caring for a client in the first stage of labor. When monitoring the fetal patterns, the nurse notes an early deceleration of the fetal heart rate (FHR) on the monitor strip. Which is the appropriate nursing action?

Document the findings and continue to monitor the fetal patterns. Early deceleration of the FHR is a gradual decrease in and return to baseline FHR in response to compression of the fetal head. It is a normal and benign finding. Because early decelerations are considered benign, interventions are not necessary. The remaining options are unnecessary.

The nurse receives a telephone call from the admissions office and is told that a child with acute bacterial meningitis will be admitted to the pediatric unit. The nurse prepares for the child's arrival and plans to implement which type of precautions?

Droplet A major priority in nursing care for a child suspected of having meningitis is to administer the prescribed antibiotic as soon as it is prescribed. The child also is placed in a private room, with droplet precautions, for at least 24 hours after antibiotics are given. Contact, enteric, and neutropenic precautions are not associated with the mode of transmission of meningitis. Contact precautions are instituted when contact with infectious items or materials is likely. Enteric precautions are instituted when the mode of transmission is through the gastrointestinal tract. Neutropenic precautions are instituted when the client has a low neutrophil count.

The maternity nursing instructor asks a nursing student to identify the hormones that are produced by the ovaries. Which hormone(s) identified by the student indicates an understanding of the hormones produced by this endocrine gland?

Estrogen and progesterone The ovaries are the endocrine glands that produce estrogen and progesterone. Oxytocin is produced by the posterior pituitary gland and stimulates the uterus to produce contractions. LH and FSH are produced by the anterior pituitary gland.

The nurse is performing a vaginal check of a pregnant client in labor. The nurse notes that the umbilical cord is protruding from the vagina. Which action should the nurse immediately perform?

Exert upward pressure against the presenting part with gloved fingers If the umbilical cord is protruding from the vagina, no attempt should be made to replace it because to do so could traumatize it and further reduce blood flow. The nurse should place a gloved hand into the vagina toward the cervix and exert upward pressure against the presenting part to relieve compression of the cord. The nurse also should wrap the cord loosely in a sterile towel saturated with warm, sterile normal saline solution. Oxygen, 8 to 10 L/minute by face mask, is administered to the mother to increase fetal oxygenation, and the client is prepared for immediate delivery. However, the immediate action is to relieve pressure on the cord. The client would already have an external fetal monitor in place

The nurse witnesses an automobile accident and provides care at the scene of the accident to an open wound on a young child. The family is extremely grateful and insists that the nurse accept monetary compensation for the care provided to the child. Because of the family's insistence, the nurse accepts the compensation to avoid offending the family. The child develops an infection and sepsis and is hospitalized. The family files suit against the nurse who provided care to the child at the scene of the accident. The nurse understands that which is accurate regarding immunity from this suit?

Good Samaritan laws will not provide immunity from suit if the nurse accepted compensation for the care provided. A Good Samaritan law is passed by a state legislature to encourage nurses and other health care providers to provide care to a person when an accident, emergency, or injury occurs, without fear of being sued for the care provided. Called "immunity from suit," this protection usually applies only if all the conditions of the law are met; for example, the health care provider receives no compensation for the care provided, and the care given is not willfully or wantonly negligent.

The nurse is reviewing the laboratory results of a client scheduled for surgery. Which laboratory result should indicate to the nurse that the surgery might be postponed?

Hemoglobin, 9.2 g/dL Routine screening tests include a complete blood cell count, serum electrolyte analysis, coagulation studies, and serum creatinine tests. The complete blood count includes the hemoglobin analysis. All these values are within normal range, except the hemoglobin. If a client has a low hemoglobin level, the surgery may be postponed. For men, 13.5 to 17.5 grams per deciliter. For women, 12.0 to 15.5 grams per deciliter.

What is hemophilia?

Hemophilia is a bleeding disorder Hereditary, sex-linked disorder

The nurse is preparing to reinforce instructions to a client with Addison's disease regarding diet therapy. The nurse understands that which diet should be prescribed for this client? 1. Low-sodium, low-protein diet 2. Low-protein, high-carbohydrate diet 3 .Low-carbohydrate, low-protein diet 4. High-sodium, high-carbohydrate diet

High-sodium, high-carbohydrate diet A high-sodium, high-complex carbohydrate, and high-protein diet will be prescribed for the client with Addison's disease. To prevent excess fluid and sodium loss, the client is instructed to maintain an adequate salt intake of up to 8 g of sodium daily and to increase salt intake during hot weather; before strenuous exercise; and in response to fever, vomiting, or diarrhea.

The nurse notes that a client is receiving lamivudine (Epivir). The nurse determines that this medication has been prescribed to treat which condition?

Human immunodeficiency virus (HIV) infection Lamivudine is a nucleoside reverse transcriptase inhibitor and antiviral medication. It slows HIV replication and reduces the progression of HIV infection. It also is used to treat chronic hepatitis B and is used for prophylaxis in health care workers at risk of acquiring HIV after occupational exposure to the virus. This medication is not used to treat pancreatitis, pharyngitis, or seizures.

Which cardiovascular sign should the nurse expect to note in a client with a diagnosis of hypocalcemia?

Hypotension Cardiovascular manifestations that occur with hypocalcemia include decreased heart rate, diminished peripheral pulses, and hypotension. On the ECG, the nurse should note a prolonged ST segment and a prolonged QT interval.

what type of solutions is 5% dextrose in water?

Isotonic Solution

What is an isotonic solution?

Isotonic solutions contain an electrolyte balance similar to plasma in the bloodstream. When an isotonic solution is administered, the fluid volume of the patient is increased without a fluid shift. Common examples of isotonic solutions are 0.9% normal saline and lactated ringers. A solution that has the same salt concentration as cells and blood. Isotonic solutions are commonly used as intravenously infused fluids in hospitalized patients.

A child seen in the clinic is found to have rubeola (measles) and the mother asks the nurse how to care for the child. Which instruction should the nurse provide to the mother?

Keep the child in a room with dim lights. A nursing consideration in rubeola is eye care. The child usually has photophobia, so the nurse should suggest that the parent keep the child out of brightly lit areas. Children with viral infections are not to be given aspirin because of the risk of Reye's syndrome. Warm baths and the sun will aggravate itching. In addition, the child needs to rest.

What is Meniere's disease?

Meniere's disease is a disorder of the inner ear that can lead to dizzy spells (vertigo) and hearing loss. In most cases, Meniere's disease affects only one ear. Meniere's disease can occur at any age, but it usually starts between young and middle-aged adulthood.

The nurse is collecting data from a client with a suspected diagnosis of gastric ulcer. The client tells the nurse that oral antacids are taken frequently throughout the day. The nurse continues to collect data from the client, understanding that the client is at risk for which acid-base disturbance?

Metabolic alkalosis Increases in base components occur as a result of oral or parenteral ingestion of bicarbonates, carbonates, acetates, citrates, and lactates. Excessive use of oral antacids containing sodium or calcium bicarbonate can cause metabolic alkalosis. Eliminate the options dealing with respiratory problems. Eliminate acidosis because of the ingestion of antacids.

The nurse is monitoring an infant for signs of increased intracranial pressure (ICP) and notes that the anterior fontanel bulges (a rounded swelling or protuberance that distorts a flat surface) when the infant is sleeping. Based on this finding, which is the prioritynursing action?

Notify the registered nurse The anterior fontanel is diamond-shaped and located on the top of the head. It should be soft and flat in a normal infant, and it normally closes by 12 to 18 months of age. A larger-than-normal fontanel may be a sign of increased ICP within the skull. Although the anterior fontanel may bulge slightly when the infant cries, bulging at rest may indicate increased ICP. Increasing oral fluids and placing the infant in the side-lying position are inaccurate interventions. Although the nurse should document the finding, the first action is to report the finding to the registered nurse, who will then contact the health care provider

Emergency surgery is scheduled for a client with a bowel obstruction. The licensed practical nurse (LPN) tells the registered nurse (RN) that she is unable to obtain informed consent from the client because the client has received opioid analgesics and is sedated. The LPN understands that which action should be implemented?

Obtaining a telephone consent from the family member and ensuring that the oral consent is witnessed by two persons Every effort must be made to obtain permission from a responsible family member to perform surgery if the client is unable to sign the consent form. Telephone consent must be witnessed by two persons who hear the family member's oral consent. The two witnesses then sign the consent and document the name of the family member, noting that an oral consent was obtained. In emergencies, the client may be unable to sign and family members may not be available. In this type of a situation, the health care provider is legally permitted to perform surgery without consent. Consent is not informed if it is obtained from the client who is confused, unconscious, mentally incompetent, or under the influence of sedatives.

The registered nurse is preparing to insert a nasogastric (NG) tube in a client and asks the licensed practical nurse (LPN) to obtain supplies needed for the procedure. Which supply obtained by the LPN indicates a need for further teachingregarding this procedure?

Oil-soluble lubricant Water-soluble lubricant is used to lubricate 3 inches of the tube at the insertion end. An oil lubricant is not used because if the tube accidentally enters the bronchus, pneumonia can develop. Half-inch tape is used to secure the tube after correct placement is verified. A 50-mL catheter tip syringe is used to aspirate gastric contents to confirm placement. The client will be asked to take a sip of water through a straw to help with the passage of the tube.

The nurse is checking a dark-skinned client for the presence of petechiae. Which body area is best for the nurse to check in this client?

Oral mucosa In a dark-skinned client, petechiae are best observed in the conjunctivae and oral mucosa. Cyanosis is best noted on the palms of the hands and soles of the feet. Jaundice would best be noted in the sclera of the eye.

A pregnant client asks the nurse about the hormone that stimulates postpartum contractions. The nurse tells the client that the primary hormone that stimulates postpartum contractions is which?

Oxytocin Oxytocin stimulates contractions during birth and stimulates postpartum contractions to compress uterine vessels and control bleeding. Prolactin stimulates the secretion of milk, called lactogenesis. Progesterone stimulates the secretions of the endometrial glands and causes the endometrial vessels to become dilated and tortuous in preparation for possible embryo implantation. Testosterone is produced by the adrenal glands in the female and induces the growth of pubic and axillary hair at puberty.

The nurse is reinforcing home care instructions to the mother of an infant who has just been found to have hemophilia. The nurse should instruct the mother to do which?

Pad crib rails and table corners. Establishment of an age-appropriate safe environment is of paramount importance for hemophiliac clients. Providing a safe environment for an infant includes padding table corners and crib rails, providing extra "joint" padding on clothes, observing a mobile infant at all times, and keeping items that can be pulled down onto the infant out of reach. Use of a soft toothbrush is an appropriate measure for a child with hemophilia, but is not typically necessary for an infant. Rectal temperature measurements and the use of aspirin are contraindicated in hemophiliac individuals because of the risk of bleeding.

The nurse is monitoring a client who is attached to a cardiac monitor and notes the presence of U waves. The nurse checks the client and then reviews the results of the client's recent electrolyte results. The nurse expects to note which electrolyte value?

Potassium 3.0 mEq/L The normal sodium level is 135 to 145 mEq/L. The normal potassium level is 3.5 to 5.0 mEq/L. A serum potassium level below 3.5 mEq/L is indicative of hypokalemia. In hypokalemia, the electrocardiogram (ECG) changes that occur include inverted T waves, ST segment depression, heart block, and prominent U waves.

The nurse preparing a client for surgery reviews the client's medication record. The client is to receive nothing by mouth (NPO) after midnight. Which medication noted on the client's record should the nurse question?

Prednisone Prednisone is a corticosteroid that can cause adrenal atrophy, which reduces the body's ability to withstand stress. Before and during surgery, dosages may be temporarily increased. Cyclobenzaprine is a skeletal muscle relaxant. Alendronate is a bone-resorption inhibitor. Allopurinol is an antigout medication.

The maternity nurse is describing the ovarian cycle to a group of nursing students and asks a nursing student to identify the phases of the cycle. Which phase stated by the nursing student indicates a need for further teaching in this area?

Proliferative phase The ovarian cycle consists of three phases: preovulatory, ovulatory, and luteal. The proliferative phase is a phase of the endometrial cycle.

The nurse is reinforcing instructions to a client about the types of fluids that assist in prevention and treatment of urinary tract infections (UTIs). The nurse instructs the client to consume which fluids? Select all that apply. 1. Milk 2. Soda 3. Prune juice 4. Apple juice 5. Cranberry juice

Prune juice Apple juice Cranberry juice The client at risk for UTIs should be instructed to consume adequate amounts (2000 to 2500 mL/day) of fluids. Certain fluids can be used to minimize the risk for development of UTI, such as prune juice, apple juice, cranberry juice, and water. Dairy products and carbonated beverages should be avoided because they are alkylating agents.

A child suspected of having sickle cell disease (SCD) is seen in a clinic, and laboratory studies are performed. Which laboratory value is likely to be increased in sickle cell disease? 1. Platelet count 2.Hematocrit level 3.Hemoglobin level 4.Reticulocyte count

Reticulocyte count A diagnosis is established on the basis of a complete blood count, examination for sickled red blood cells (RBCs) in the peripheral smear, and hemoglobin electrophoresis. Laboratory studies will show decreased hemoglobin and hematocrit levels and a decreased platelet count, an increased reticulocyte count, and the presence of nucleated red blood cells. Increased reticulocyte counts occur in children with SCD because the life span of their sickled RBCs is shortened.

What is a hypertonic solution?

Solute concentration is greater than that inside the cell; cell loses water A solution that contains more dissolved particles (such as salt and other electrolytes) than is found in normal cells and blood. For example, hypertonic solutions are used for soaking wounds.

The nurse provides dietary instructions to a client with Ménière's disease. The nurse tells the client that which food or fluid item is acceptable to consume?

Sugar-free Jell-O The underlying pathological changes of Ménière's disease include overproduction and defective absorption of endolymph. This increases the volume and pressure within the membranous labyrinth until distention results in rupture and mixing of the endolymph and perilymph fluids. Dietary therapy frequently is quite helpful in controlling the symptoms associated with Ménière's disease. The nurse encourages the client to follow a low-salt diet and to avoid caffeine, sugar, monosodium glutamate, and alcohol.

The nurse assigned to care for an older adult client places an extra blanket in the client's room. The nurse understands that the older adult is less able to regulate hot and cold body changes because of alterations in the activity of which gland? 1. Pineal gland 2. Sweat glands 3. Parotid glands 4. Thymus gland

Sweat Glands Functions of the skin include protection, sensory reception, homeostasis, and temperature regulation. The skin helps regulate the body temperature in two ways, by dilation and constriction of blood vessels and by the activity of the sweat glands. As aging progresses, alterations in sweat gland activity make the glands less effective in temperature regulation, so the aging person is less able to regulate hot and cold body changes. The parotid glands are responsible for the drainage of saliva, which plays an important role in digestion. The pineal gland is a major site of melatonin biosynthesis. The thymus gland plays an immunological role throughout life.

The nurse is assisting in caring for a pregnant client who is receiving intravenous magnesium sulfate for the management of preeclampsia and notes that the client's deep tendon reflexes are absent. On the basis of this data, the nurse reports the finding and makes which determination?

The client is experiencing magnesium toxicity. Magnesium toxicity can occur as a result of magnesium sulfate therapy. Signs of magnesium sulfate toxicity relate to the central nervous system depressant effects of the medication and include respiratory depression; loss of deep tendon reflexes; sudden decrease in fetal heart rate or maternal heart rate, or both; and sudden drop in blood pressure. Hyperreflexia indicates increased cerebral edema. An absence of reflexes indicates magnesium toxicity. The therapeutic serum level of magnesium for a client receiving magnesium sulfate ranges from 4 to 7.5 mEq/L (5 to 8 mg/dL).

A client beginning week 30 of gestation comes to the clinic for a routine visit. Which observation by the nurse indicates a need for further teaching?

The client is wearing knee-high hose. Varicose veins often develop in the lower extremities during pregnancy. Any constricting clothing, such as knee-high hose, impedes venous return from the lower legs and thus places the client at higher risk for developing varicosities. Clients should be encouraged to wear support hose (pantyhose). Flat, nonslip shoes with proper support are important to help the pregnant woman maintain proper posture and balance and minimize fall risks.

The nurse reinforces instructions to the parents of an infant with hip dysplasia regarding care of the Pavlik harness. Which instruction provided by the nurse is accurate? 1. The harness must be worn 8 hours a day. 2. The infant should never be moved when out of the harness. 3. The harness must be removed for diaper changes and for feeding. 4. The harness needs to be removed to check the skin and for bathing.

The harness needs to be removed to check the skin and for bathing. The harness should be worn 23 hours a day and should be removed only to check the skin and for bathing. The hips and buttocks should be supported carefully when the infant is out of the harness. The harness does not need to be removed for diaper changes or feedings. Test-Taking Strategy:Select option 4 over option 1 because the time frame in option 1 is rather short. Also note the closed-ended words must in options 1 and 3 and never in option 2.

What is a transvaginal ultrasound?

Transvaginal ultrasonography, in which a lubricated probe is inserted into the vagina, allows evaluation of the pelvic anatomy. A transvaginal ultrasound exam is well tolerated by most clients because it alleviates the need for a full bladder. The client is placed in a lithotomy position or with her pelvis elevated by towels, cushions, or a folded blanket. The procedure is not physically painful, although the woman may feel pressure as the probe is moved. "Transvaginal" means "through the vagina." This is an internal examination.

The nurse is assigned to care for a child with a spica cast. Which action should be avoided when caring for the child? 1. Observing for nonverbal signs of pain 2.Using pillows to elevate the head and shoulders 3.Checking neurovascular status of the extremities 4.Placing the child on a stretcher and bringing the child to the playroom

Using pillows to elevate the head and shoulders Pillows should not be used to elevate the head or shoulders of a child in a body cast because the pillows will thrust the child's chest against the cast and cause discomfort and respiratory difficulty. Neurovascular checks are a critical component of care to ensure that the cast is not causing circulatory compromise. The nurse should observe for nonverbal signs of pain and ask the older child if pain is experienced. A ride on a stretcher to the playroom or around the hospital provides changes of position and scenery.

A pregnant client in the third trimester of pregnancy with a diagnosis of mild preeclampsia is being monitored at home for progression of the disease process. The home care nurse reinforces teaching the client about the signs that need to be reported to the health care provider (HCP) and tells the client to call the HCP if which occurs?

Weight increases by more than 1 pound in a week. The nurse should instruct the client to report any increase in blood pressure, protein in the urine, weight gain greater than 1 pound per week, or edema. The client also is taught how to count fetal movements and is instructed that decreased fetal activity (three or fewer movements per hour) may indicate fetal compromise and should be reported

The nurse is preparing to administer digoxin (Lanoxin) to an infant with heart failure (HF). Before administering the medication, the nurse double-checks the dose, counts the apical heart rate for 1 full minute, and obtains a rate of 88 beats per minute. Based on this finding, which is the appropriate nursing action?

Withhold the medication Digoxin is effective within a narrow therapeutic range (0.5 to 2 ng/mL). Safety in dosing is achieved by double-checking the dose and counting the apical heart rate for 1 full minute. If the heart rate is less than 100 beats per minute in an infant, the nurse should withhold the dose and notify the registered nurse and health care provider. The remaining options are incorrect actions.

What is cerebral palsy?

a condition caused by injury to the parts of the brain that control our ability to use our muscles and bodies; falls under "Orthopedic Impairment" which adversely affects a child's educational performance,

What is a reticulocyte?

an immature RBC

The nurse is asked to assist the primary health care provider in performing Leopold's maneuvers on a client. Which nursing intervention should be implemented before this procedure is performed? 1. Locate fetal heart tones. 2. Warm the sonogram gel. 3. Have the client empty her bladder. 4. Have the client drink 8 ounces of water.

have the client empty her bladder An empty bladder contributes to a woman's comfort during the examination. Drinking water to fill the bladder and warming sonogram gel may be performed before a sonogram (ultrasound). Often, Leopold's maneuvers are performed to aid the examiner in locating the fetal heart tones.

What is Addison's disease?

hormone deficiency caused by damage to the outer layer of the adrenal gland they need diet high in salt, carbs, and protein low in potassium Also called: hypocortisolism

10% dextrose in water and 5% dextrose in 0.9% saline are which type of solutions?

hypertonic solutions

0.45% saline is what type of solution?

hypotonic solution

The nurse is assisting in administering beractant (Survanta) to a premature infant who has respiratory distress syndrome. The nurse understands that the medication should be administered by which route? 1. Intradermal 2.Intratracheal 3.Subcutaneous 4.Intramuscular

intratracheal Respiratory distress is common in premature neonates and may be due to lung immaturity as a result of surfactant deficiency. The mainstay of treatment is the administration of exogenous surfactant, which is administered by the intratracheal route. Options 1, 3, and 4 are not routes of administration for this medication.

what is portosystemic encephalopathy?

is a neuropsychiatric syndrome that can develop in patients with liver disease. It most often results from high gut protein or acute metabolic stress (eg, gastrointestinal bleeding, infection, electrolyte abnormality) in a patient with portosystemic shunting. Symptoms are mainly neuropsychiatric (eg, confusion, asterixis, coma). Diagnosis is based on clinical findings. Treatment is usually correction of the acute cause, oral lactulose, and nonabsorbable antibiotics such as rifaximin.

The clinic nurse reads the results of a tuberculin skin test performed on a 5-year-old child. The results indicate an area of induration measuring 8 mm. Which correct interpretation should the nurse make about these results?

negative Induration measuring 15 mm or greater is considered a positive result in a child 4 years or older who has no associated risk factors. Because this child's results show an area of induration measuring 8 mm, the finding is negative. The remaining options are incorrect interpretations.

The nurse caring for a client with a neurological disorder is assisting in planning care to maintain nutritional status. The nurse is concerned about the client's swallowing ability. The nurse avoids including which food item in this client's diet? 1. Spinach 2. Scrambled eggs 3. Cheese casserole 4. Mashed potatoes

spinach Moist pastas, casseroles, egg dishes, and potatoes are usually well tolerated by the client who has difficulty swallowing. Raw vegetables, chunky vegetables such as diced beets, and stringy vegetables such as spinach, corn, and peas are foods commonly excluded from the diet of a client who has difficulty swallowing.

what is a hypotonic solution?

when the solute concentration is lower outside the cell, the cell will swell

The nurse is caring for a client who has bipolar disorder with aggressive social behavior. Which activity would be most appropriate initially for this client? 1. Chess 2.Writing 3.Ping-Pong 4.Basketball

writing Solitary activities that require a short attention span with mild physical exertion are the most appropriate activities initially for a client who is aggressive. Writing (journaling), walks with staff, and finger painting are activities that minimize stimuli and provide a constructive release for tension. Competitive games (options 1, 3, and 4) should be avoided because they can stimulate aggression and increase psychomotor activity.