NCSBN QBANK 1-15
The nurse is caring for a 4 year-old child with a greenstick fracture. In explaining this type of fracture to the parents, the best comment by the nurse should include which point? "Compression of porous bones produces a buckle or torus type break." " Bone fragments often remain attached by a periosteal hinge." "A child's bone is more flexible and can be bent 45 degrees before breaking." "Bones of children are more porous than adults' and often have incomplete breaks."
"Bones of children are more porous than adults' and often have incomplete breaks. This allows the pliable bones of growing children to bend, buckle, and break in a "greenstick" manner. A greenstick fracture occurs when a bone is angulated beyond the limits of bending. The compressed side bends and the tension side develops an incomplete fracture.
The mother of a 4 month-old infant asks the nurse about the dangers of sunburn while they are on vacation at the beach. Which of these statements is the best advice about sun protection for this child? "Liberally apply a sunscreen with a minimum sun protective factor of 15 all over the body." "Dress the infant in lightweight long pants, long-sleeved shirts and brimmed hats." "Sunscreen should not be used on children." "You should keep the baby inside unless it's cloudy outside."
"Dress the infant in lightweight long pants, long-sleeved shirts and brimmed hats." Infants under 6 months of age should be kept out of the sun or shielded from it. Even on a cloudy day, the infant can be sunburned while near water. A hat and light protective clothing should be worn. Sunscreen is not generally recommended for infants under the age of 6 months; however, the American Academy of Pediatrics states that it can be applied to small areas of the baby's skin that are exposed to the sun (such as the baby's face or the back of the hands).
A client has just received an extracorporeal shock-wave lithotripsy (ESWL) procedure. What is the priority information the nurse should teach ? "Restrict milk and dairy products for one to two months." "Drink 3,000 to 4,000 mL of fluid each day for one month." "Increase intake of citrus fruits to three servings per day for two months." "Limit fluid intake to 1,000 mL each day for two months."
"Drink 3,000 to 4,000 mL of fluid each day for one month." Drinking three to four quarts (3,000 to 4,000 mL) of fluid each day will aid passage of fragments of the broken up renal calculi and help prevent formation of new calculi.
A new task force has been created at a hospital to address a recent increase in patient falls. The first meeting is scheduled with members from several departments. Which of the following statements by the nurse leader indicate intent to increase meeting effectiveness? (Select all that apply.)
"During our meeting today we will share the information we have on falls." "Let's discuss when next we should meet and what information we will bring." "Please introduce yourselves and your departments." "Let's focus on the number of falls first and then we can talk about staffing." A leader increases meeting effectiveness by not permitting one person not to dominate the discussion, encouraging brainstorming, encouraging others to further develop ideas and helping to engage the team in future discussions. An effective team leader will periodically summarize the information and ensure that all ideas are recorded for all to see (for example, on a whiteboard) and then follow up with minutes of the meeting. Beginning and ending on time is also important to keep everyone focused on the task at hand and to demonstrate respect team members' other commitments.
A client is started on long-term corticosteroid therapy. Which comment by the client indicates a need for more teaching? "For one week every month I will stop taking the medication." "I will keep a weekly weight record." "The medication needs to be taken with food." "I will be sure to eat foods high in potassium."
"For one week every month I will stop taking the medication." To suddenly stop taking a steroid may result in a sudden drop in the blood pressure from a loss in fluid volume associated with adrenal crisis. Clients should be warned not to abruptly stop taking the medication. Corticosteroids can lower the amount of potassium in the body so the client should eat more potassium-rich foods. Weight gain is an expected effect of corticosteroid therapy; clients should regularly keep track of their weight. Normally corticosteroid medications are taken with breakfast.
A client who lives in an assisted living facility tells the nurse, "I am so depressed. Life isn't worth living anymore." What is the best response by the nurse to the client's statement? "Have you thought about hurting yourself?" "Did you tell any of this to your family?" "Maybe you are just having a bad day today." "Try to think of the many positive things in your life."
"Have you thought about hurting yourself?" It is most important to determine whether someone who voices thoughts about death is considering suicide (suicidal ideation). Individuals may provide both behavioral and verbal clues as to the intent of their act. Behavioral clues include giving away prized possessions, getting financial affairs in order, writing suicide notes and demonstrating a sudden lift in mood. Verbal clues may be both direct and indirect. An example of a direct statement includes, "I want to die." An example of an indirect statement includes, "I don't have anything worth living for anymore." This client's statement indicates suicidal ideation and the client's safety is the highest priority. The nurse should ask the client directly about thoughts or plans to harm themselves. The other responses are nontherapeutic and will not help identify if the client is at risk for suicide.
The nurse is providing information to a client about a prescribed medication. Which one of these statements, if made by a client, indicates that teaching about propranolol (Inderal) has been effective?
"I can have a heart attack if I stop this medication suddenly." Propranolol is commonly used to treat hypertension, abnormal heart rhythms, heart disease and certain types of tremor. It is in a class of medications called beta blockers. Suddenly discontinuing a beta blocker can cause angina, hypertension, arrhythmias, or even a heart attack.
The nurse is admitting a client who is newly diagnosed with a frontal lobe brain tumor. Which statement made by a spouse may provide important information about this diagnosis and should be communicated to the health care provider? "It seems our sex life is nonexistent over the past six months." "His breathing rate is usually below 12." "I find the mood swings and the change from being a calm person to being angry all the time hard to deal with." "In the morning and evening he complains that reading is next to impossible because the print is blurry."
"I find the mood swings and the change from being a calm person to being angry all the time hard to deal with." The frontal lobe of the brain controls affect, judgment and emotions. Dysfunction in this area results in findings such as emotional lability, changes in personality, inattentiveness, flat affect and inappropriate behavior.
At a senior citizen's group meeting the nurse talks with a client who has type 1 diabetes. Which statement by the client during the conversation is most predictive of a potential for impaired skin integrity? "I had a penny in my shoe all day last week, and I didn't even realize it until I took my shoes off!" "I give my insulin to myself in my thighs and belly and alternate sites." "Here are my glucose test readings that I wrote on my calendar." "If I bathe more than once a week my skin feels too dry."
"I had a penny in my shoe all day last week, and I didn't even realize it until I took my shoes off!" Peripheral neuropathy can lead to lack of sensation in the lower extremities. Clients who do not feel pressure and/or pain are at high risk for skin impairment.
A client expresses anger when a call light is not answered within five minutes. The client demanded a blanket. How should the nurse respond? "I see this is frustrating for you. I have a few minutes so let's talk." "I am surprised that you are upset. The request could have waited a few more minutes." "Let's talk. Why are you upset about this?" "I apologize for the delay. I was involved in an emergency."
"I see this is frustrating for you. I have a few minutes so let's talk." This is the best response because it gives credence to the client's feelings and then concerns. To say "let's talk" and ask a why question is not a therapeutic approach because it does not acknowledge or validate the client's feelings. To apologize and not notice the client's feelings is inappropriate. To say it could have waited a few minutes is rude and non-accepting of the client's verbalized needs.
A 15 year-old client has been placed in a Milwaukee brace. Which statement made by the client is incorrect and indicates a need for additional teaching?
"I will only have to wear this for six months." The brace must be worn long-term, during periods of growth, usually for one to two years. It is used to correct scoliosis, the lateral curvature of the spine.
A client has been prescribed dexamethasone by mouth daily for transplant rejection prophylaxis. The client asks the nurse for more information about the medication. What information should the nurse include? (Select all that apply)
"Take the medication with food" "Take acetaminophen for minor pain or aches." Adverse effects (ADEs) of long-term corticosteroid therapy include: behavioral/psychological changes, eye changes such as cataracts and glaucoma, and increased susceptibility to infections, hyperglycemia, hypocalcemia, fluid retention, HTN, edema, myopathy, muscle wasting, osteoporosis and peptic ulcers.To reduce the aforementioned ADEs, it is recommended to take the drug with food, avoid using NSAIDs for pain and increase dietary intake of calcium, found in dairy products.To prevent or avoid adrenal atrophy and acute adrenal insufficiency, discontinue corticosteroids gradually. Never discontinue corticosteroids abruptly!
The nurse is examining a 2 year-old child with a tentative diagnosis of Wilm's tumor. The nurse would be most concerned about which statement by the mother? "Urinary output seems to be less over the past two days." "The child prefers some salty foods more than others." "My child has lost three pounds in the last month." "All the pants have become tight around the waist."
"Urinary output seems to be less over the past two days." Wilm's tumor is a malignant tumor of the kidney that can lead to kidney dysfunction; therefore, a recent decrease in urinary output should be investigated further as it may be a sign of renal dysfunction. Increasing abdominal girth is a common finding in Wilm's tumor, but does not require immediate intervention by the nurse.
A client has had a positive reaction to purified protein derivative (PPD). When the client asks, "What does this mean?" the nurse should respond with which statement? "You have been exposed to the organism Mycobacterium tuberculosis." "This means you have never had or been around someone with tuberculosis." "You are mostly likely have a natural immunity to the bacteria." "You most likely have a resistant form of active tuberculosis.
"You have been exposed to the organism Mycobacterium tuberculosis." The PPD skin test is used to determine the presence of tuberculosis antibodies. In an otherwise healthy person, an induration greater than or equal to 15 mm is considered a positive skin test. This indicates that the client has been exposed to the organism Mycobacterium tuberculosis. Additional tests such as a chest x-ray and sputum culture will be needed to determine if active tuberculosis is present. The sputum cytology test is the only definitive test to confirm a diagnosis of active TB.
A nurse entering the room of a postpartum mother observes the baby lying at the edge of the bed while the mother sits in a nearby chair. The mother states, "This is not my baby, and I do not want it." After repositioning the child safely, the nurse should respond with which comment? "Many women have postpartum blues and need some time to love the baby." "What a beautiful baby! Her eyes are just like yours and so is her smile." "This is a common occurrence after birth, but you will come to accept the baby." "You seem upset. Tell me what the pregnancy and birth were like for you."
"You seem upset. Tell me what the pregnancy and birth were like for you. A nonjudgmental, open ended response facilitates dialogue between the client and the nurse. The other three options ignore the situation and the needs of the mother. Note that the correct answer is the only client-centered option that is directly associated with the given situation.
During a yearly health screening, a 54 year-old female reports having irregular menstrual cycles, mood swings and hot flashes. She requests a more natural approach to manage these symptoms of perimenopause. What education about non-pharmacological interventions will the nurse include in client teaching? (Select all that apply.
"You should drink at least 8-10 glasses of water a day." "Yoga may help you manage stress and relieve symptoms." "Incorporate more vegetables and legumes in your diet." "Use deep breathing exercises when you start having a hot flash." Measures that have been found to be effective in helping manage symptom of hot flashes include exercise, stress reduction and getting enough sleep at night. Reducing the temperature in the room at night and taking a warm bath or shower before bedtime can help clients get a better night's sleep. Slow abdominal breathing (6-8 breaths a minute) at the onset of hot flashes can help. Other measures that can lessen the number of and severity of hot flashes include yoga, as well as avoiding alcohol, spicy foods and caffeine. Eating a more plant-based diet can also help.
Which individual is at greatest risk for the development of hypertension? 40 year-old Caucasian nurse 60 year-old Asian-American shop owner 45 year-old African-American attorney 55 year-old Hispanic teacher
45 year-old African-American attorney The incidence of hypertension is greater among African-Americans than other groups in the United States. The incidence among the Hispanic population is rising.
A nurse is working with one licensed practical nurse (LPN) and a mental health tech (an unlicensed assistive personnel). Which newly admitted client would be appropriate to assign to the mental health tech?
A middle-aged client diagnosed with an obsessive compulsive disorder The mental health tech (a type of unlicensed assistive personnel or UAP) can be assigned to care for a client with a chronic condition after an initial assessment by the nurse. This client has minimal risk of instability of condition and has a situation of expected outcomes.
An external disaster has occurred in the town. The triage nurse from the emergency department is transported to the site and assigned to triage the injured. Which of these clients would the nurse tag as "to be seen last" by the providers at the scene? An older adult person with a open fracture of the left arm An infant with bilateral fractured lower legs with no active bleeding A teenager with small amount of bright red blood dripping out of the nose A middle-aged person with deep abrasions that are over 90% of the body
A middle-aged person with deep abrasions that are over 90% of the body The clients that are least likely to survive are to be tagged as the "last to be seen." Deep abrasions are usually treated as second or third degree burns because the fluid loss is great.
The clients listed below are all using patient-controlled analgesic (PCA) pump for pain control. Which of these clients is least appropriate to use a PCA pump? A young adult with a history of Down syndrome A teenager who reads at a 4th-grade level An older adult client with numerous arthritic nodules on the hands A preschooler with intermittent episodes of alertness
A preschooler with intermittent episodes of alertness A preschooler is the one client most likely to have difficulty with the use or understanding of a PCA pump. The preschooler also has a decreased level of consciousness and would not be able to fully benefit from the use of a PCA pump. School-age children, ages 6 and up, are better candidates for PCA electronic pumps.
The nurse is preparing to administer albuterol inhaled to a 11 year-old with asthma. Which assessment by the nurse indicates there is a need for the health care provider to adjust the medication? Temperature of 101 F (38.3 C) Apical pulse of 112 Lethargy Lower extremity edema
Apical pulse of 112 One of the more common adverse effects of beta adrenergic medications such as albuterol (AccuNeb, ProAir HFA, Proventil HFA, Ventolin HFA), is an increase in heart rate. Normal resting heart rate for children 10 years and older is the same as adults: 60-100 beats per minute.
The nurse receives a client from the post anesthesia care unit following a left femoral-popliteal bypass graft procedure. Which of the following assessments requires immediate notification of the health care provider? Left foot is cool to the touch Absent left pedal pulse using Doppler analysis Inability to palpate the left pedal pulse Acute pain in the left lower leg
Absent left pedal pulse using Doppler analysis Although the inability to palpate the left pedal pulse, a cool extremity, and increased pain in the left lower leg are important findings, they all require additional nursing assessment prior to contacting the health care provider. In clients without palpable pedal pulses, the next step in the assessment is to perform a Doppler analysis. The inability to locate the left pedal pulse using the Doppler analysis requires immediately notifying the health care provider.
The client needs to be moved up in bed. The client is able to partially assist and weighs 135 pounds. Which action by the nursing staff best supports an awareness of ergonomics and safe client handling? (Select all that apply.) Adjust the height of the bed for caregivers Move the bed into the flat position Pull the client up from the head of the bed Use a friction-reducing device Coordinate lifting the client by counting to 3
Adjust the height of the bed for caregivers Move the bed into the flat position Use a friction-reducing device The algorithm for safe client handling and repositioning a client from side-to-side or up in bed states: use 2 to 3 caregivers for a client who can partially assist and who weighs less than 200 pounds, use a friction-reducing device, move the bed so that it's flat and at a comfortable height for the caregivers. The client should not be pulled from the head of the bed. There really is no safe method to manually lift another adult.
A client is admitted with severe injuries resulting from an auto accident. The client's vital signs are BP 120/50, pulse rate 110, and respiratory rate of 28. What should be the initial nursing intervention? Administer oxygen as ordered Initiate continuous blood pressure monitoring Initiate the ordered intravenous therapy Institute continuous cardiac monitoring
Administer oxygen as ordered Early findings of shock are associated with hypoxia and manifested by a rapid heart rate and rapid respirations. Therefore, oxygen is the most critical initial intervention; the other interventions are secondary to oxygen therapy.
A newborn is diagnosed with hypothyroidism. In discussing the condition and treatment with the family, the nurse should emphasize which point? This rare problem is always hereditary They can expect the child will be mentally retarded Physical growth and development will be delayed Administration of thyroid hormone will prevent complications
Administration of thyroid hormone will prevent complications Early identification (ideally before 13 days-old) and continued treatment with levothyroxine (thyroid hormone replacement) corrects hypothyroidism in newborns, preventing problems. If undetected and untreated, hypothyroidism can result in poor growth and weight gain, slow heart rate, low blood pressure, and babies who are unusually quiet; the child will be at risk for permanent brain damage and intellectual disabilities. Approximately one in every 4000 babies is born with hypothyroidism.
The charge nurse is making assignments for the shift. Which of these clients would be appropriate to assign to a licensed practical nurse (LPN)? A confused client whose family complains about the nursing care two days after the client's surgery An older adult client diagnosed with cystitis and has an indwelling urethral catheter A client admitted with the diagnosis of possible transient ischemic attack with unstable neurological signs A trauma victim with multiple lacerations that require complex dressing changes
An older adult client diagnosed with cystitis and has an indwelling urethral catheter The most stable client is the one diagnosed with cystitis. Care for this client has predictable outcomes and there is only a minimal risk for complications. The other clients require more complex care and independent, specialized nursing knowledge, skill or judgment that only an RN can provide.
The most important aspects of home care for a child diagnosed with acute spasmodic croup are humidified air and increased oral fluids. Humidified air helps reduce vocal cord swelling. Taking the child out into the cool night air for 10 to 15 minutes can also reduce night time symptoms. Adequate systemic hydration aids mucociliary clearance by keeping secretions thin and easy to remove with minimal coughing effort. Assess respirations and pluse Look at different ECG lead to confirm rhythm
After checking responsiveness, establishing a patent airway and then assessing breathing and circulation are the next priorities (ABCs). This assessment would provide information to decide whether the emergency response team is needed. Because the client is responsive, the monitor rhythm is not correct, as a client with asystole would be unresponsive. Asystole on a rhythm strip may simply be a loose lead; a quick way to check this is to select another lead. The client's obtunded state indicates that ion is needed, so assessment of a central pulse and blood pressure is indicated to determine whether cardiovascular compromise is responsible for this condition. If no evidence of an immediate cardiac event is present, the blood glucose should be checked. Stress and changes in food or fluid consumption secondary to surgery increase the risk of glucose imbalance in the person with diabetes.
The nurse is developing a teaching plan for parents on safety and risk-reduction in the home. Which of the following should the nurse give priority consideration to during teaching?
Age of children in the home Age and developmental level of the child are the most important considerations in the provision of a framework for anticipatory guidance associated with safety, and should be given priority when teaching safety.
An 8 year-old child is brought to the clinic by a parent who states: "This child was so sick last year with cold and the flu. I want her to have the influenza vaccine this year." The nurse assesses the child and reviews the child's history. What information would the nurse recognize as a contraindication for giving the child this vaccine? Family history of convulsions Recent exposure to an infectious disease Allergy to eggs Persistent, inconsolable crying after receiving other immunizations
Allergy to eggs An allergy to egg proteins is listed by the CDC as a contraindication for administering the influenza vaccine. Influenza vaccines are grown on egg embryos and may contain a small amount of egg protein.
A 67 year-old client is admitted with substernal chest pressure that radiates to the jaw. The admitting diagnosis is acute myocardial infarction (MI). What should be the priority nursing diagnosis for this client during the first 24 hours? Altered tissue perfusion Activity intolerance Anxiety Risk for fluid volume excess
Altered tissue perfusion In the immediate post MI period, altered tissue perfusion is priority, as an area of myocardial tissue has been damaged by a lack of blood flow and oxygenation. Interventions should be directed toward promoting tissue perfusion and oxygenation. The other problems are also relevant, but tissue perfusion is the priority.
Two members of the interdisciplinary team are arguing about the plan of care for a client. Which action could any one of the members of the team use as a de-escalation strategy Interrupt, apologize for interruption, and change the subject Adjourn the meeting and reschedule when everyone has calmed down Tell the violators they must calm down and be reasonable Bring the communication focus back to the client
An adolescent who is 18-weeks pregnant with a report of no fetal heart tones and is coughing up frothy sputum The 18 year-old client has an actual complication of left-sided heart failure and a possible stillborn birth. The other clients present with findings of potential, but not actual, complications.
Following an alert of an internal disaster and the need for beds, the charge nurse is asked to list the clients who can potentially be discharged. Which one of these clients should the charge nurse select? An older adult client with an implantable cardiac defibrillator (ICD) admitted yesterday after receiving multiple shocks A school-aged child admitted earlier today with a diagnosis of suspected bacterial meningitis An adult client, diagnosed with type 1 diabetes at age 10, admitted 36 hours ago with diabetic ketoacidosis An adolescent admitted the previous evening with Tylenol intoxication
An adult client, diagnosed with type 1 diabetes at age 10, admitted 36 hours ago with diabetic ketoacidosis The client with type 1 diabetes is the only one with a chronic condition who has been treated for more than a day and whose condition is the most stable. The other clients' conditions are either unstable and/or more acute. Tylenol intoxication requires at least three to four days of intensive observation for the risk of hepatic failure. Because acute bacterial meningitis can lead to permanent brain damage or death, treatment must be started as soon as possible. It is considered a medical emergency for someone with an ICD who experiences multiple shocks.
A 3 year-old has just returned from surgery for application of a hip spica cast. What nursing action will be the priority? Drying the cast using a hair dryer set to "warm" Apply waterproof plastic tape to the cast around the genital area Use the crossbar to help turn the child from side to side Position the child flat in bed, repositioning from back to stomach every two to four hours
Apply waterproof plastic tape to the cast around the genital area The most important aspects of caring for the cast is to keep it clean and dry. Shortly after returning from surgery, waterproof plastic tape will be applied around the genital area to prevent soiling. The child should be turned every two hours to help facilitate drying, from side to side and front to back, with the head elevated at all times. If a crossbar is used to stabilize the legs, it should not be used to turn the child (it may break off). After the cast has completely dried and it becomes damp, it can be either exposed to air or a hair dryer (set to cool) may be used to help dry the cast.
The nurse, who is participating in a community health fair, assesses the health status of attendees. When would the nurse conduct a mental status examination? The individual reports memory lapses There are obvious signs of depression The individual displays restlessness As part of every health assessment
As part of every health assessment A mental status assessment is a critical part of baseline information and should be a part of every examination.
A woman, who delivered five days ago and who had been diagnosed with pregnancy induced hypertension (PIH), calls a hospital triage nurse hotline to ask for advice. She states, "I have had the worst headache for the past two days. It pounds and by the middle of the afternoon everything I look at looks wavy. Nothing I have taken helps." What should the nurse do next? Advise the client to have someone bring her to the emergency room as soon as possible Ask the client to explain what she has taken and how often, and then evaluate other specific complaints Advise the client that the swings in her hormones may be the problem; suggest that she call her health care provider Ask the client to stay on the line, get the address, and send an ambulance to the home
Ask the client to stay on the line, get the address, and send an ambulance to the home The woman is at risk for seizure activity. The ambulance needs to bring the woman to the hospital for evaluation and treatment. For at-risk clients, PIH may progress to preeclampsia and eclampsia prior to, during, or after delivery; this may occur up to 10 days after delivery.
A nurse is caring for a client diagnosed with chronic obstructive pulmonary disease (COPD) and who becomes dyspneic. The nurse should take which action? Administer oxygen at six liters per minute via nasal cannula Place the client in a low Fowler's position Instruct the client to breathe into a paper bag Assist the client with pursed-lip breathing
Assist the client with pursed-lip breathing Pursed-lip breathing should be encouraged during periods of dyspnea in COPD to control rate and depth of respiration, to prevent alveolar collapse and to improve respiratory muscle coordination. Clients with COPD are usually on lower doses of oxygen, titrated to maintain an oxygen saturation of 88-91%. Semi-Fowler's position is usually most comfortable for someone with COPD, because this position allows the client's diaphragm to expand
At the beginning of the shift, the nurse is reviewing the status of each of the assigned clients in the labor and delivery unit. Which of these clients should the nurse check first? An adolescent who is 18-weeks pregnant with a report of no fetal heart tones and is coughing up frothy sputum A middle-aged woman with a history of two prior vaginal term births and who is 2 cm dilated A young woman who is a grand multipara, cervical dilation to 4 cm and is 50% effaced A young woman, first-time para, cervical dilation to 1 cm and contractions 15 minutes apart
At the beginning of the shift, the nurse is reviewing the status of each of the assigned clients in the labor and delivery unit. Which of these clients should the nurse check first? An adolescent who is 18-weeks pregnant with a report of no fetal heart tones and is coughing up frothy sputum A middle-aged woman with a history of two prior vaginal term births and who is 2 cm dilated A young woman who is a grand multipara, cervical dilation to 4 cm and is 50% effaced A young woman, first-time para, cervical dilation to 1 cm and contractions 15 minutes apart
A client who is two days postop, has these vital signs: blood pressure of 120/70, heart rate of 110 BPM, respiratory rate of 26, and a temperature of 100.4 F (38 C). The client suddenly becomes profoundly short of breath (SOB) and the skin color becomes grayish in color. Which assessment should the a nurse do first based on the client's change in condition? Palpate the pulses for bounding and irregularity Check for orthostatic hypotension Assess the pupils for unequal responses to light Auscultate for diminished breath sounds
Auscultate for diminished breath sounds The findings suggest pulmonary embolus as a result of a piece of a clot in the legs that has broken off. Thus, the breath sound will most likely be diminished or absent in the lung where the embolus lodged.
The nurse manager informs the nursing staff that the clinical nurse specialist will be conducting a research study on staff attitudes toward client care, and all staff are invited to participate in the study if they wish. This affirms which ethical principle? Justice Beneficence Autonomy Anonymity
Autonomy Individuals must be free to make independent decisions about participation in research without coercion from others. Anonymity means the person's identity is not revealed. Beneficence is the state or quality of being kind, charitable, beneficial or a charitable act.
A nurse is teaching a client to select foods rich in potassium to prevent digitalis toxicity. Which choice indicates the client understands this dietary requirement and recognizes which foods are highest in potassium? Naval orange Three apricots Small banana Baked potato
Baked potato A baked potato contains 610 milligrams of potassium. Apricots, oranges and bananas do have higher potassium content, but because of their size they are not the highest in potassium. A baked potato is the highest in potassium of the given options.
There's a new medication order that reads: "administer 1 gtt ciprofloxacin solution OD Q 4 h" What action should the nurse take? Squeeze one drop of the medication in the left eye every 4 hours Apply one drop in the right ear every 4 hours Call the prescriber to clarify and rewrite the order Ask other nurses for their interpretation of the order
Call the prescriber to clarify and rewrite the order Abbreviations, symbols and dose designations can be misinterpreted and lead to medication errors. "OD" can mean "right eye" (oculus dexter) or "once daily"; it should never be used when communicating medical information. The abbreviation "Q" should be written out as "every." Although "gtt" is not on the official "Do Not Use List", it's best to use "drop" instead. Asking other nurses to interpret an order is a potentially dangerous "workaround." The nurse should call the health care provider who prescribed the medication and clarify the order.
A client has a chest tube inserted immediately after surgery for a left lower lobectomy. During the repositioning of the client during the first postop check, the nurse notices 75 mL of a dark, red fluid flowing into the collection chamber of the chest drain system. What is the appropriate nursing action? Continue to monitor the rate of drainage Call the surgeon immediately Check to see if the client has a type and cross match Turn the client back to the original position
Continue to monitor the rate of drainage It is not unusual for blood to collect in the chest and be released into the chest drain when the client changes position this soon after surgery. The dark color of the blood indicates it is not active bleeding inside of the chest. Sanguinous drainage should be expected within the initial 24 hours postop, progressing to serosanguinous and then to a serous type. If the drainage exceeds 100 mL/hr, the nurse should call the surgeon.
A child is treated with succimer for lead poisoning. Which of these assessments should the nurse perform first? Check serum potassium level Check blood calcium level Test deep tendon reflexes Check complete blood count (CBC) with differential
Check complete blood count (CBC) with differential Succimer (Chemet) is used in the management of lead or other heavy metal poisoning. Although it has generally well tolerated and has a relatively low toxicity, it may cause neutropenia. Therapy should be withheld or discontinued if the absolute neutrophil count (ANC) is below 1200/µ.
The client with a T-2 spinal cord injury reports having a "pounding" headache. Further assessment by the nurse reveals excessive sweating, rash, pilomotor erection, facial flushing, congested nasal passages and a heart rate of 50. What action should the nurse take next? Assist client with relaxation techniques Measure the client's respirations, blood pressure, temperature and pupillary responses Check the client for bladder distention and the urinary catheter for kinks Place the client into the bed and administer the ordered PRN analgesic
Check the client for bladder distention and the urinary catheter for kinks These are findings of autonomic dysreflexia, also called hyperreflexia. This response occurs in clients with a spinal cord injury above the T-6 level. It is typically initiated by any noxious stimulus below the level of injury such as a full bladder, an enema or bowel movement, fecal impaction, uterine contractions, changing of the catheter and vaginal or rectal examinations. The stimulus creates an exaggerated response of the sympathetic nervous system and can be a life-threatening event. The BP is typically extremely high. The priority action of the nurse is to identify and relieve the cause of the stimulus.
The nurse needs to accurately assess gastric placement of a nasogastric tube prior to the administration of an enteral feeding. What is the priority action the nurse should take before starting the infusion?
Check the pH of the aspirate Once the initial placement of the tube has been confirmed by x-ray, the nurse will check the pH of the aspirate before administering medications or enteral feeding solutions. Current practice recommendations include assessing the feeding tube placement by testing the pH of aspirates, measuring the external portion of the tube, and observing for changes in the volume and appearance of feeding tube aspirates. If tube placement is in doubt, an x-ray should be obtained. The other methods are older approaches that are no longer recommended.
The client with cancer is being treated with a biological response modifier. Which of the following side effects does the nurse anticipate with biologic therapy? Constipation Hematuria Photophobia and sun sensitivity Chills and fever
Chills and fever Biological response modifier cancer therapy agents (for example, interferons and interleukins) are drugs that stimulate the body's own defense mechanisms to fight cancer cells. Flu-like findings such as chills, fever and nausea, are common side effects of this type of therapy. The other assessment findings are not what you would expect when the body is fighting pathogens.
A nurse is teaching adolescents about sexually transmitted diseases. What should the nurse emphasize is the most common infection? Herpes Chlamydia GonorrheaHuman immunodeficiency virus (HIV)
Chlamydia Chlamydia is the most frequently reported bacterial sexually transmitted disease in the United States. Prevention is similar to safe sex practices taught to prevent any sexually transmitted disease, such as abstinence, and the use of a condom and spermicide for protection during intercourse. This infection has subtle findings so the infected persons are less likely to pursue medical attention.
The nurse is caring for a client who is experiencing a hypertensive crisis. The priority assessment in the first hour of care after admission to the critical care unit should focus on which factor? Heart rate Lung sounds Cognitive function Pedal pulses
Cognitive function The organ most susceptible to damage in hypertensive crisis is the brain, due to rupture of the cerebral blood vessels. Neurologic findings must be closely monitored.
A client with a diagnosis of methicillin-resistant Staphylococcus aureus (MRSA) has died. Which type of precautions is appropriate to use when performing postmortem care? Contact precautions Droplet precautions Compromised host precautions Airborne precautions
Contact precautions The resistant bacteria remain alive for up to three days after the client dies. Therefore, contact precautions must still be used. The body should also be labeled as MRSA-contaminated so that the funeral home staff can protect themselves as well. Gown and gloves are required.
The nurse is caring for a child diagnosed with Kawasaki disease (mucocutaneous lymph node syndrome or infantile polyarteritis). The nursing care plan should be based on the knowledge that this child is at risk for developing what complication? Occlusions at the vessel bifurcations Pulmonary embolism Chronic vessel plaque formation Coronary artery aneurysm
Coronary artery aneurysm Kawasaki disease affects the mucus membranes, lymph nodes, walls of the blood vessels and the heart. It can cause inflammation of the arteries, especially the coronary arteries of the heart, which can lead to aneurysms and possible heart attack in the child.
The nurse is caring for a postoperative client who develops evisceration of the abdominal incision. Which intervention should the nurse implement first? Place the client on NPO status Instruct the patient care technician (PCT) to obtain a set of vital signs Cover the wound with a sterile, saline-soaked dressing Call the appropriate health care provider immediately
Cover the wound with a sterile, saline-soaked dressing Evisceration is defined as the separation of wound edges to the extent that intestines protrude through the wound. When evisceration occurs, the wound should first be covered with sterile, saline-soaked dressings. This prevents tissue damage and drying of the area until a surgical repair can be done. The other interventions are also appropriate because this is a medical emergency, but should be completed after the wound is dressed.
The clinic nurse is assisting with medical billing. The nurse uses the DRG (Diagnosis Related Group) manual for which purpose? Determine reimbursement for a medical diagnosis Identify findings related to a medical diagnosis Classify nursing diagnoses from the client's health history Implement nursing care based on case management protocol
Determine reimbursement for a medical diagnosis DRGs are the basis of prospective payment plans for reimbursement for Medicare clients. Other insurance companies often use it as a standard for determining payment.
The nurse is providing discharge teaching to a client who has had a total hip prosthesis implanted. During teaching, the nurse should include which content in the instructions for home care? Do not cross your legs at the ankles or knees Ambulate using crutches only Sleep only on your back and not on your side Avoid climbing stairs for three months
Do not cross your legs at the ankles or knees These clients should avoid the bringing of the knees together. Clients are to use a pillow between their legs when lying down and can lie on the back or side. Crossing the legs or bringing the knees together results in a strain on the hip joint. This increases the risk of a malfunction of the prosthesis where the ball may pop out. A walker or crutches may be used as assistive devices. These and other precautions are minimally followed for six weeks postoperative and sometimes longer as indicated.
The nurse is instructing a 65 year-old female client diagnosed with osteoporosis. What is the most important instruction about exercise? Exercise to reduce weight over a few months Use exercise to strengthen muscles and protect bones Avoid exercise activities that increase the risk of fracture Do weight-bearing or resistance activities
Do weight-bearing or resistance activities Weight-bearing or resistance exercises are beneficial in the treatment of osteoporosis. Although loss of bone cannot be substantially reversed, further loss can be greatly reduced if the client includes these exercises. In addition, other approaches are estrogen replacement and calcium supplements in a treatment protocol.
A nurse is teaching a class on human immunodeficiency virus (HIV) prevention. Which activity should be cautioned against since it is shown to increase the risk of HIV? Donation of blood to the state agencies Physical touch of a person with autoimmune deficiency syndrome (AIDS) Use of public bathrooms in any city Engaging in unprotected sexual encounters
Engaging in unprotected sexual encounters Because HIV is spread through exposure to bodily fluids, unprotected intercourse and shared drug paraphernalia remain the highest risks for this infection. The other actions are not at risk behaviors for HIV.
A client taking isoniazid for tuberculosis (TB) asks the nurse about the side effects of this medication. The client should be instructed to report which of these findings?
Extremity tingling and numbness Peripheral neuropathy is a common side effect of isoniazid and other antitubercular medications and should be reported to the health care provider. Daily doses of pyridoxine (vitamin B6) may lessen or even reverse peripheral neuropathy due to isoniazid use.
A nurse is providing care to a primigravida whose membranes spontaneously ruptured (ROM) four hours ago. At the time of rupture, maternal vital signs were within normal limits, she was dilated to 2 centimeters, and the baseline fetal heart rate (FHR) was 150 beats per minute (BPM). The nurse is now reassessing the client. Which of these assessment findings may be an early indication that the client is developing a complication of the labor process?
Fetal heart rate is 188 beats/minute Prolonged ruptured membranes may lead to maternal infection (as suggested by the slightly elevated temperature). But the primary concern is the fetal heart rate of 188; fetal heart rate is typically somewhere between 120 and 160 BPM. Fetal tachycardia may be an early sign of hypoxia. The nurse should contact the health care provider, assist the client to change positions, and administer oxygen and intravenous fluids.
The respiratory technician arrives to draw blood for arterial blood gas (ABG) analysis. What should the nurse understand about the procedure? Supplemental oxygen should be turned off 30 minutes prior to collecting the sample Firm pressure is applied over the puncture site for at least five minutes after the sample is drawn The blood sample must be kept at room temperature and delivered to the lab as soon as possible The femoral artery is the preferred sample site
Firm pressure is applied over the puncture site for at least five minutes after the sample is drawn The radial artery is preferred; the second choice is the brachial artery and then the femoral artery. If a client is receiving oxygen, it should not be turned off unless ordered. After drawing the sample, it's very important to press a gauze pad firmly over the puncture site until bleeding stops or at least five minutes. Do not ask the client to hold the pad because if insufficient pressure is used, a large painful hematoma may form. The sample of arterial blood must be kept cold, preferably on ice to minimize chemical reactions in the blood.
The nurse is preparing to administer a feeding through a percutaneous endoscopic gastrostomy (PEG) tube. What nursing action is needed before starting the infusion? (Select all that apply.) Palpate the abdomen Verify the length and placement of the tube Milk or massage the tube Keep the feeding product refrigerated until ready to use Elevate the head of the bed 30-45 degrees Flush the tube with 30 mL of warm water
Flush the tube with 30 mL of warm water Elevate the head of the bed 30-45 degrees Prior to starting every feeding, the nurse should verify the length and placement of the tube, flush the tube with 30 mL of warm (not hot and not cold) water, and elevate the head of the client's bed at least 30 degrees. The nurse should also verify the presence of bowel sounds before starting the infusion. There's no need to milk the tube unless it's obstructed. Feeding products should be brought to room temperature before the infusion to prevent gastrointestinal discomfort.
A client has received two units of whole blood today after an episode of gastrointestinal bleeding. Which laboratory report should the nurse be sure to monitor closely? White blood cells Hemoglobin and hematocrit Platelets Bleeding time
Hemoglobin and hematocrit The post-transfusion hematocrit provides immediate information about red cell replacement and if there is any continued blood loss; the follow-up hematocrit should be checked around 4 to 6 hours after the infusion is completed.
A pregnant client, at 34-weeks gestation, is diagnosed with a pulmonary embolism (PE). Which of these medications does the nurse anticipate the health care provider will initially order? Low dose aspirin therapy Warfarin (Coumadin) therapy every other day to maintain a PT at 1.5 to 2 times the control value Heparin infusion to maintain the aPTT at 1.5 to 2 times the control value Subcutaneous heparin 5000 units twice a day
Heparin infusion to maintain the aPTT at 1.5 to 2 times the control value Clients diagnosed with PE, whether pregnant or not, are initially treated with intravenous unfractionated heparin (UFH). The client's activated partial thromboplastic time (aPTT) should be monitored and kept in the therapeutic range of between 1.5 to 2 times the baseline value. Alternatively, low molecular weight heparins, such as enoxaparin (Lovenox), can be used to treat PE in women who are pregnant. Warfarin should never be given during pregnancy due to its teratogenic effects. Although aspirin has anticoagulant properties, low dose aspirin therapy (81 mg), with or without heparin, is more often used prophylactically to prevent the development of deep vein thrombosis.
The client is diagnosed with cystic fibrosis (CF). The nurse would expect the client to be treated with oral pancreatic enzymes and which type of diet? High fat, high-calorie Gluten-free, low fiber Dairy-free Sodium-restricted
High fat, high-calorie CF affects the cells that produce mucus, sweat and digestive juices. Someone with CF needs a high-energy diet that includes high-fat and high-calorie foods, extra fiber to prevent intestinal blockage and extra salt (especially during hot weather.) People with CF are at risk for osteoporosis and need calcium and dairy products. Someone with celiac disease or with a gluten intolerance, not CF, needs a gluten-free diet.
There is an order to administer intravenous gentamicin three times a day. What diagnostic finding indicates the client may be more likely to experience a toxic side effect of this medication?
High serum creatinine Gentamicin is excreted unmodified by the kidneys. If there is any reduced renal function, toxicity can result. An elevated serum creatinine indicates reduced renal function and this puts the client at greater risk for toxicity. Reduced renal function will delay the excretion of many medications.
A nurse is teaching home care to the parents of a child diagnosed with acute spasmodic croup. What type of care would be most important to emphasize? Sedation as needed to prevent exhaustion Antihistamines to decrease allergic responses Antibiotic therapy for 10 to 14 days Humidified air with an increase in oral fluids
Humidified air with an increase in oral fluids The most important aspects of home care for a child diagnosed with acute spasmodic croup are humidified air and increased oral fluids. Humidified air helps reduce vocal cord swelling. Taking the child out into the cool night air for 10 to 15 minutes can also reduce night time symptoms. Adequate systemic hydration aids mucociliary clearance by keeping secretions thin and easy to remove with minimal coughing effort.
A group of nurses on a unit are discussing stoma care for clients who have had a stoma made for fecal diversion. Which stomal diversion poses the highest risk for skin breakdown? Ileal conduit Transverse colostomy Sigmoid colostomy Ileostomy
Ileostomy Ileostomy output, which is from the small intestine, is of continuous, liquid nature. This high pH, alkaline output contains gastric and enzymatic agents that when present on skin can denude skin in a few hours. Because of the caustic nature of this stoma output, adequate peristomal skin protection must be delivered to prevent skin breakdown. With a transverse colostomy the stool is of a somewhat mushy and soft nature. With a sigmoid colostomy the output is formed with an intermittent output. An ileal conduit is a urinary diversion with the ureters being brought out to the abdominal wall.
Parents of a 4 year-old boy have just been informed that their son has a congenital neurologic demyelinating disorder that is terminal. The nurse anticipates their reaction to be in which phase of the crisis process? Impact phase Crisis phase Pre-crisis phase Resolution phase
Impact phase There is no data to determine their response phase except the time frame of recent bad news. The impact of crisis is indicative of high levels of stress, sense of helplessness, confusion, disorganization, and the inability to apply problem-solving behavior.
Which statement describes the advantage of using a decision grid to make decisions? It is the only truly objective way to make a decision in a group It is the fastest way for group decision making It is both a visual and a quantitative method of decision making It allows the data to be graphed for easy interpretation
It is both a visual and a quantitative method of decision making A decision grid allows the group to visually examine alternatives and evaluate them quantitatively with weighting.
The nurse assesses a full-term, 30 hour-old newborn and reviews its lab results. The nurse knows that the first-time mother is Rh negative and is breastfeeding exclusively. Which of these findings is a priority to report to the health care provider? Positive Coombs Test Serum bilirubin of 11 mg/dl (188mmol/L) Jaundice is observed Hematrocrit 52%
Jaundice is a common condition in newborns. But for a full-term infant who is 30 hours-old, a total serum bilirubin level of 11 mg/dL (188 µmol/L) is high, which is why this is the priority finding to report to the health care provider. The concern about hyperbilirubinemia is increased because the mother is Rh negative (meaning there's a possible Rh incompatibility) and she is breastfeeding exclusively. The hematocrit is within normal limits for a newborn. The Coombs test results do not indicate if it's direct or indirect.
A nurse is providing a parenting class to individuals living in a community of older homes that were built prior to 1978. During a discussion about formula preparation, which statement is the most important by the nurse to tell the parents how to prevent lead poisoning? Boil the tap water for 10 minutes prior to preparing the formula Buy bottled water labeled "lead free" to mix with the formula Let tap water run for two minutes before adding to formula concentrate Use ready-to-feed commercial infant formula
Let tap water run for two minutes before adding to formula concentrate The use of lead-contaminated water to prepare infant formula is a major source of lead poisoning in infants who live in older houses. Drinking water may become contaminated by lead from old lead pipes or the lead solder used in sealing the water pipes in homes prior to 1978. Letting tap water run for several minutes will diminish the risk for lead contamination. These same houses have the risk of lead contamination from paint chips because prior to that time, paint and gasoline contained lead.
A young adult seeks treatment in an outpatient mental health center. The client tells the nurse: "I am a government official being followed by spies." On further questioning, the client reveals: "My warnings must be heeded to prevent nuclear war." Which of the following actions should the nurse take? Confront the client's delusion Contact the government agency Ask for more information about the spies Listen quietly without comment
Listen quietly without comment The client's comments demonstrate grandiose ideas. The most therapeutic response is to listen but to also avoid being pulled into the client's delusional system. At some point validation of the present situation will need to be done. Confrontation at this time would be an inappropriate action and is not therapeutic.
A community health nurse has been caring for a 16 year-old who is 22-weeks pregnant with a history of morbid obesity, asthma and hypertension. Which of these lab reports need to be communicated to the health care provider as soon as possible? Hematocrit 33% (0.33) and platelets 200,000 μL Blood urea nitrogen 28 mg/dL (10 mmol/L) and glucose 225 mg/dL (12.5 mmol/L) Hemoglobin 11 g/dL (6.8 mmol/L) and calcium 6.7 mg/dL (1.67 mmol/L) Magnesium 0.8 mEq/L (0.33 mmol/L) and creatinine 3 mg/dL (265.26 μmol/L)
Magnesium 0.8 mEq/L (0.33 mmol/L) and creatinine 3 mg/dL (265.26 μmol/L) The magnesium is low and the creatinine is high, indicating acute renal failure - this is the highest priority. With the history of hypertension, the findings may indicate preeclampsia. The rest of client's lab values are all abnormal except for the platelets. The client needs to be referred for immediate follow-up with a health care provider.
The parents of a 5 month-old report that the infant has "vomited nine times in the past six hours." Based on this information, the nurse should observe for which fluid and electrolyte imbalance? Hemodilution effects Hemoconcentration effects Metabolic acidosis Metabolic alkalosis
Metabolic alkalosis Vomiting results in a loss of acid from the stomach. Prolonged vomiting results in excess loss of acid and leads to metabolic alkalosis. Findings include irritability, increased activity, hyperactive reflexes, muscle twitching and elevated pulse. Hemoconcentration due to fluid loss may occur, but is not the best answer because it does not answer the question about an imbalance.
The nurse is caring for a client in a violent relationship. The nurse should understand that immediately after an acute battering incident, the batterer may respond to the partner's injuries by taking which action? Seek medical help for the victim's injuries Be very remorseful and assist the victim to receive medical care Minimize the episode with an underestimation of the victim's injuries Contact a close friend and ask for help with the incident
Minimize the episode with an underestimation of the victim's injuries Many batterers lack an understanding of the effects of their behavior on the person who was battered. Batterers use excessive minimization and denial of the situation and their behaviors or intent.
A client has returned from a cardiac catheterization that was two hours ago. Which finding would indicate that the client has a potential complication from the procedure? No pulse in the affected extremity Increased blood pressure Increased heart rate Decreased urine output
No pulse in the affected extremity Loss of the pulse in the extremity would indicate a potential severe spasm of the artery or clot formation to the extent of an occlusion below the site of insertion. It is not uncommon that initially the pulse may be intermittently weaker from the baseline. However, a total loss of the pulse is a nursing emergency. The health care provider needs immediate notification.
The nurse is assessing a 4 year-old child who is in skeletal traction 24 hours after surgical repair of a fractured femur. The child is crying and reports having severe pain. The right foot is pale and there is no palpable pulse. What action should the nurse take first? Notify the health care provider Administer the ordered PRN medication Reassess the extremity in 15 minutes Readjust the traction for comfort
Notify the health care provider Pain and absence of a pulse within 48-72 hours after a severe injury to an extremity suggests acute compartment syndrome. This condition occurs when there's a build up of pressure within the muscles; this pressure decreases blood flow and can cause muscle and nerve damage. Acute compartment syndrome is a medical emergency. Surgery is needed immediately; delaying surgery can lead to permanent damage to the extremity.
The nurse is reviewing the laboratory results for several clients. Which of the laboratory result indicates a client with partly compensated metabolic acidosis? PaCO2 30 mm Hg Hemoglobin 15 g/dL (150 g//L) Sodium 130 mEq/L (130 mmol/L) Chloride 100 mEq/L (100 mmol/L)
PaCO2 30 mm Hg Metabolic acidosis can be caused by many conditions, including renal failure, shock, severe diarrhea, dehydration, diabetic acidosis, and salicylate poisoning. With metabolic acidosis, you should expect a low pH (less than 7.35) and a low HCO3 (less than 22 mEq/L.) Compensation means the body is trying to get the pH back in balance; therefore, a pure metabolic acidosis should elicit a compensatory decrease in PaCO3 (normal is 35-45 mm Hg.) The hemoglobin is within normal limits (WNL) for both males and females. The chloride and sodium results are also WNL
A nurse is talking by telephone with a parent of a 4 year-old child who has chickenpox. Which approach demonstrates appropriate teaching by the nurse?
Papules, vesicles and crusts will be present at one time All three stages of the chickenpox lesions will be present on the child's body at the same time. Children should not be medicated with aspirin due the possibility of developing Reye's syndrome. A person with chickenpox is contagious one to two days before their blisters appear and remain contagious until all the blisters have crusted over. Antiviral medications are not usually prescribed to otherwise healthy children. Over-the-counter hydrocortisone creams can help relieve itchy skin.
The registered nurse (RN) is planning the care of an 80-year-old client with skin abrasions from a fall in the home. What aspect of this client's care is the primary responsibility of the nurse?
Perform a head-to-toe assessment The RN is responsible to conduct a thorough assessment and evaluation of all body systems for this client. The nurse would document information collected during the focused assessment, such as changes in skin color and breaks in the skin's integrity. Applying lotion would not be a primary responsibility.
The client is admitted to an ambulatory surgery center and undergoes a right inguinal orchiectomy. Which option is the priority before the client can be discharged to home? Able to tolerate a regular diet Post-operative pain is managed Psychological counseling is scheduled Able to ambulate in the hallway with assistance
Post-operative pain is managed An orchiectomy is the surgical removal of one or both testicles. It is usually performed to treat cancer (testicular, prostate or cancer of the male breast), but it may also be performed to prevent cancer (with an undescended testicle.) Due to the location of the incision, pain management is the priority. Most men will be able to eat regularly when they get home; they should at least tolerate liquids before discharge. It's important that the client is able to get up and walk with assistance, but this is not the priority. Psychological counseling may be needed as part of long-term aftercare, but this is not an immediate priority.
The nurse is evaluating a developmentally challenged 2 year-old child. During the evaluation, what goal should the nurse stress when talking to the child's mother? Help the family decide on long-term care Prepare for independent toileting Teach the child self-care skills Promote the child's optimal development
Promote the child's optimal development The primary goal of nursing care for a developmentally challenged child is to promote the child's optimal development.
A newborn who is delivered at home and without a birth attendant is admitted to the hospital for observation. The initial temperature is 95 F (35 C) axillary. The nurse should recognize that cold stress may lead to what complication? Hyperglycemia Reduced partial pressure of oxygen in arterial blood (PaO2) Metabolic alkalosis Lowered basal metabolic rate
Reduced partial pressure of oxygen in arterial blood (PaO2) Hypothermia and cold stress cause a variety of physiologic stresses including increased oxygen consumption, metabolic acidosis, hypoglycemia, tachypnea and decreased cardiac output. The baby delivered in such circumstances needs careful monitoring. In this situation, the newborn must be warmed immediately to increase its temperature to at least 97 F (36 C). Normal core body temperature for newborns is 97.7 F to 99.3 F (36.5 C to 37.3 C).
The nurse is caring for a client in a home setting. Which action is most likely to ensure the safety of the nurse during a home visit? Carry a cell phone, pager and/or hand-held alarm Remain alert and leave if cues suggest the home is not safe Observe for evidence of weapons in the home Review documentation for previous entries about violence
Remain alert and leave if cues suggest the home is not safe Nurses need to assess and manage safety risks and have ongoing clinical supervision and support when making home visits. Proper safety should begin with a thorough assessment of the client's home to identify potential risks, such as pets (the most commonly assessed hazard), drug use and weapons. The nurse should also and develop a plan to mitigate (or eliminate) the risks and understand that there's always the option to end a visit early if the environment does not seem safe. Carrying a phone, using a buddy system, learning about the client prior to the visit can help mitigate risks.
The nurse, who is located in a large urban area, uses telecommunications to provide health care and education to clients in remote locations. What is the best reason for using telehealth? Empowers clients to take a greater interest in their illness Removes time and distance barriers from the delivery of care Reduces health care costs Standardizes electronic data sharing of health information
Removes time and distance barriers from the delivery of care Telehealth is the use of technology to deliver health care, health information, or health education at a distance. People in rural areas or homebound clients can communicate with providers via telephone, email or video consultation, thereby removing the barriers of time and distance for access to care. Although increased access to information and collaboration between the client and provider can be empowering, this is not the primary reason for using telecommunications/telehealth.
A newly admitted 78 year-old client is diagnosed with severe dehydration. When planning care for this client, the nurse should assign which task to an unlicensed assistive personnel (UAP)? Converse with the client to determine if the mucous membranes are impaired Check skin turgor every four hours along with the need to change the adult diaper Monitor client's ability for movement in the bed from side to side Report hourly outputs of less than 30 mL/hr within 15 minutes of the check
Report hourly outputs of less than 30 mL/hr within 15 minutes of the check When assigning a UAP, the nurse must communicate clearly about each delegated task with specific instructions on what must be reported and when. Because the RN is responsible for all care-related decisions, only routine tasks should be assigned to UAPs because such tasks do not require judgments and decisions.
A mother asks about expected motor skill development for her 3 year-old child. Which activity is considered a typical motor skill for the 3 year-old?
Riding a tricycle Three year-old children are developing gross motor skills that require large muscle movement. While there will always be some variation between children, movement milestones typically include pedaling a tricycle, standing on one foot for a few seconds, walking backwards and jumping with both feet. The other activities listed require more coordination and are movement milestones for older children.
A nurse is planning care for a 2 year-old hospitalized child. Which issue will produce the most stress at this age? Fear of pain Separation anxiety Loss of control Bodily injury
Separation anxiety While a toddler will experience all of the stresses, separation from parents is the major stressor. Separation anxiety peaks in the toddler years.
A nurse is reviewing laboratory results on a client diagnosed with acute renal failure. Which lab result should be reported immediately
Serum potassium 6 mEq/L (6 mmol/L) Although all of these findings are abnormal, the elevated potassium level is a life-threatening finding and must be reported immediately. Serious consequences of hyperkalemia include heart block, asystole and life-threatening ventricular dysrhythmias. Anemia (hemoglobin less than 13 g/dL [130 g/L] in men or less than 12 mg/dL [120 g/L] in women) is common with kidney disease. Blood urea nitrogen (BUN) will be increased in acute renal failure (7 to 30 mg/dL [2.5 to 10.7 mmol/L] is a considered normal).
A nurse is working in an OB-GYN clinic. A 40 year-old woman in the first trimester of an unplanned pregnancy provides a health history to the nurse. Which information should receive priority attention?
She has been taking an ACE inhibitor for her blood pressure for the past two years. A report by the client that she has been taking medications in the first trimester of pregnancy should be followed up immediately. ACE inhibitors, commonly used to control high blood pressure, are pregnancy category X, as they can cause teratogenic effects on the developing fetus, increasing the risk of birth defects. Women who are taking medications and who are planning a pregnancy should be switched to medications that are not harmful to the developing fetus before they begin trying to get pregnant.
A nurse is teaching a group of adults about modifiable cardiac risk factors. Which of the following should the nurse focus on first? Weight reduction Stress management Smoking cessation Physical exercise
Smoking cessation Smoking cessation is the priority for clients at risk for cardiac disease. Smoking's effects result in reduction of cell oxygenation and constriction of the blood vessels. All of the other factors should be addressed at some point in time.
A nurse is speaking at a community meeting about personal responsibility for health when a participant asks about chiropractic treatment for illnesses. What should be the focus of the nurse's response? Exercise of joints Spinal column manipulation Electrical energy fields Mind-body balance
Spinal column manipulation The theory underlying chiropractic treatment is that interference with transmission of mental impulses between the brain and body organs produces diseases. Such interference is caused by misalignment of the vertebrae. Manipulation reduces the misalignment (subluxation).
The nurse is caring for a client diagnosed with anemia and confusion. Which task could the nurse assign to the unlicensed assistive person (UAP)? Test stool for occult blood and urine for pH and report the results Suggest foods that are high in iron and prepare a list of the client's likes and dislikes Report mental status changes and level of mental clarity Assess and document skin turgor and skin color changes
Test stool for occult blood and urine for pH and report the results UAP can perform routine tasks that have known or expected outcomes because these tasks typically do not require nursing judgment or decision-making. Any nursing intervention that requires independent, specialize nursing knowledge, skill or judgment cannot be assigned to UAP.
Nursing students are reviewing the various types of oxygen delivery systems. Which oxygen delivery system is the most accurate? A nasal cannula A partial nonrebreather mask The simple face mask The Venturi mask
The Venturi mask The most accurate way to deliver oxygen to the client is through a Venturi system such as the Venti Mask. The Venti Mask is a high flow device that entrains room air into a reservoir device on the mask and mixes the room air with 100% oxygen. The size of the opening to the reservoir determines the concentration of oxygen. The client's respiratory rate and respiratory pattern do not affect the concentration of oxygen delivered. The maximum amount of oxygen that can be delivered by this system is 55%
The health care team consists of one licensed practical nurse (LPN), one unlicensed assistive person (UAP) and one LPN student. The charge nurse (an RN) has made the following assignments. Which assignment should be questioned by the nurse manager? Measuring vital signs and assisting with activities of daily living (ADLs) for the client admitted with myocardial infarction 4 days ago - UAP A child diagnosed with second-degree burns over 20% of the body, has IV packed red cells running and an order for IV albumin - charge nurse The admission at the change of shifts of a client diagnosed with atrial fibrillation and acute heart failure - LPN A client who was diagnosed with a major stroke 6 days ago - LPN student
The admission at the change of shifts of a client diagnosed with atrial fibrillation and acute heart failure - LPN LPNs can provide care for clients whose conditions are stable and there's a low likelihood of an emergency. Since it's a new admission, the client diagnosed with atrial fibrillation and heart failure should not be assigned to a student; the charge nurse (RN) should care for this client. A nurse can assign tasks or activities to UAP, as long as the care of the client is not too complex or variable and the client's condition is stable.
A nurse uses the New Ballard Scale to assess gestational age of a newborn. The assessment score total is very high. What is a reasonable interpretation of this result?
The baby is post-term Birth weight and gestational age are important indicators of the newborn's health and are used to identify any (potential) problems. The New Ballard Scale can help differentiate, for example, between a small for gestational age baby and one that is premature. The New Ballard Scale scoring system adds up the individual scores for 6 external physical assessments and 6 neuromuscular assessments; the total score may range from -10 to 50. Premature babies have lower scores; higher scores correlate with post-maturity. Fetal distress during labor can result in lower scores.
The nurse in a behavioral health inpatient unit is observing a female client who has been diagnosed with obsessive-compulsive disorder (OCD). Which behavior should the nurse expect to see with this diagnosis? The client prefers to interact with female staff members. The client exhibits repetitive, involuntary movements. The client verbalizes suspicions about thefts on the unit. The client is seen washing her hands every 15 minutes.
The client is seen washing her hands every 15 minutes. Washing her hands every 15 minutes indicates compulsive behaviors seen with OCD. OCD is characterized by repetitive, unwanted, intrusive thoughts (obsessions) and irrational, excessive urges to perform certain actions (compulsions). Affected individuals are often unable to stop the compulsive behaviors. The other behaviors are not typically seen with OCD. Verbalized suspicions reflect a paranoid thought process seen with delusional disorders, such as schizophrenia or schizoaffective disorder. Repetitive, involuntary movements are side effects seen with certain antipsychotic medications.
During a situation of pain management, which statement is a priority to consider for the ethical guidance of a nurse? The client's self-report is the most important consideration Cultural sensitivity is fundamental to pain management Clients have the right to have their pain relieved Nurses should not prejudge a client's pain using their own values
The client's self-report is the most important consideration Pain is a complex phenomenon that is perceived differently by each individual. Pain is whatever the client says it is. The other statements are correct but not the most important consideration.
An 18 month-old child is on peritoneal dialysis in preparation for a renal transplant in the near future. When a nurse obtains the child's health history, the mother indicates that the child has not had the first measles, mumps, rubella (MMR) immunization. What should the nurse understand about the child's situation and administration of the immunization? Live vaccines are withheld in children with renal chronic illness An inactivated form of the vaccine can be given at any time The risk of the vaccine side effects precludes the administration of the vaccine The measles, mumps and rubella (MMR) vaccine should be given now, before the transplant
The measles, mumps and rubella (MMR) vaccine should be given now, before the transplant MMR is a live virus vaccine, and should be given at this time. Post-transplant, immunosuppressive drugs will be given and the administration of the live vaccine at that time would be contraindicated because of the compromised immune system.
A nurse who cares for clients undergoing treatment for cancer might expect clients diagnosed with cancer to make the following statements.
The phases of loss or the grief process according to Dr. Kubler-Ross are: denial, anger, negotiation, depression and acceptance.
A client is transported to the emergency department after a motor vehicle accident. When assessing the client 30 minutes after admission, the nurse notes several physical changes. Which finding would require the nurse's immediate attention? Increased restlessness Tachypnea Tachycardia Tracheal deviation
Tracheal deviation Tracheal deviation is a sign that a mediastinal shift has occurred, most likely due to a tension pneumothorax. Air escaping from the injured lung into the pleural cavity causes pressure to build, collapsing the lung and shifting the mediastinum to the opposite side. This obstructs venous return to the heart, leading to circulatory instability and may result in cardiac arrest. This is a medical emergency, requiring emergency placement of a chest tube to remove air from the pleural cavity relieving the pressure.
A client, admitted to the unit because of severe depression and suicidal threats, is placed on suicidal precautions. The nurse should be aware that the danger of the client committing suicide is greatest at what period of time?
When the client's mood improves with an increase in energy level Suicide potential is often increased when there is an improvement in mood and energy level. At this time ambivalence is often decreased and a decision is made to commit suicide. The clients have the energy to carry through with the plan for suicide.
