Pass point pt 4

A child has experienced symptoms of hypoglycemia and has eaten sugar cubes. The nurse expects to follow this rapid-releasing sugar with which food? fruit juices six glasses of water foods that are high in protein complex carbohydrates and protein

complex carbohydrates and protein Explanation: When a child exhibits signs of hypoglycemia, most cases can be treated with a simple concentrated sugar, such as honey or sugar cubes, that can be held in the mouth for a short time. This will elevate the blood glucose level and alleviate the symptoms. The simpler the carbohydrate, the more rapidly it will be absorbed. A complex carbohydrate and protein, such as a slice of bread or a cracker spread with peanut butter, should follow the rapid-releasing sugar or the child may become hypoglycemic again.

The nurse is providing care to a client with Alzheimer's disease (AD). Which nursing intervention takes priority? establish a routine that supports former habits maintain physical surroundings that are cheerful and pleasant maintain an exact routine from day to day control the environment by providing structure, boundaries, and safety

control the environment by providing structure, boundaries, and safety Explanation: By controlling the environment and providing structure and boundaries, the nurse is helping to keep the client safe and secure, which is a priority nursing measure. Establishing a routine that supports former habits, maintaining cheerful, pleasant surroundings and an exact routine foster a supportive environment; however, keeping the client safe and secure takes priority.

The nurse is reinforcing education for a client with uric acid calculi. Which type of diet should the nurse inform the client to avoid? high purine low calcium low oxalate high oxalate

high purine Explanation: To control uric acid calculi, the client should follow a low-purine diet, which excludes high-purine foods such as organ meats. The other diets do not control uric acid calculi.

A client develops acute renal failure (ARF) after receiving an I.V. nephrotoxic antibiotic. Because the client's 24-hour urine output totals 240 ml, the nurse suspects that the client is at risk for: hypokalemia. paresthesia. hyperkalemia. dehydration.

hyperkalemia. Explanation: As urine output decreases, the serum potassium level rises; if it rises sufficiently, hyperkalemia may occur, possibly triggering a cardiac arrhythmia. ARF doesn't cause paresthesia (sensations of numbness and tingling). Dehydration doesn't occur during this oliguric phase of ARF, although typically it does arise during the diuretic phase.

A nurse is participating in developing the plan of care for a client in labor. When reviewing the collected data, which finding would the nurse identify as requiring additional action? urine output of 100 mL every 2 hours after epidural placement increase in temperature from 98° F to 99.6° F (36.2° C to 37.6° C) decrease in respirations to 12 at the acme of contractions increase in blood pressure to 154/96 mm Hg during contractions

increase in blood pressure to 154/96 mm Hg during contractions Explanation: During contractions, blood pressure increases, and blood flow to the intervillous spaces changes, compromising the fetal blood supply. Therefore, the nurse should assess the client's blood pressure frequently to determine if it returns to precontraction level and allows adequate fetal blood flow again. A urine output of 100 mL every 2 hours, respirations of 12, and temperature changes are normal.

Which observation is expected in a child with tetralogy of Fallot? increasing cyanosis with crying or activity Eisenmenger complex higher pressure in the upper extremities than in the lower extremities machinelike murmur

increasing cyanosis with crying or activity Explanation: A child with tetralogy of Fallot will be mildly cyanotic at rest and have increasing cyanosis with crying, activity, or straining, as with a bowel movement. A machinelike murmur is a characteristic of patent ductus arteriosus. Eisenmenger complex is a complication of ventricular resistance exceeding systemic pressure. Higher pressures in the upper extremities are characteristic of coarctation of the aorta.

An older adult client postoperative for a fractured right femur develops acute shortness of breath and progressive hypoxia requiring mechanical ventilation. What is the most likely cause of this hypoxia? fat embolism asthma attack bronchitis atelectasis

monitoring the need for suctioning every hour Explanation: Suctioning should be performed only when necessary, based on the client's condition at the time of assessment. Suctioning is a nursing procedure and doesn't require a health care provider's order.

In caring for a client with insulin-dependent diabetes mellitus, the nurse identifies that the client may require which change to their daily routine during periods of infection? less insulin more insulin no changes oral antidiabetic agents

more insulin Explanation: During periods of infection or illness, insulin-dependent clients may need even more insulin, rather than reducing the levels or not making any changes in their daily insulin routines, to compensate for increased blood glucose levels. Clients usually aren't switched from injectable insulin to oral antidiabetic agents during periods of infection.

A nurse is observing a 2½-year-old child playing with another child of the same age in the playroom on the pediatric unit. What type of play should the nurse expect the children to engage in? cooperative play therapeutic play associative play parallel play

parallel play Explanation: Two-year-old children engage in parallel play, in which they play side by side but rarely interact. Associative play is characteristic of preschoolers; it is characterized by children engaging in a similar activity but with little organization. School-age children engage in cooperative play, which is organized and goal directed. Therapeutic play is a technique that can be used to help understand a child's feelings. It consists of energy release, dramatic play, and creative play.

A client in the fifth month of pregnancy is having a routine clinic visit. When gathering data from the client, the nurse would be alert for which common second trimester condition? mastitis metabolic alkalosis physiologic anemia respiratory acidosis

physiologic anemia Explanation: Hemoglobin level and hematocrit decrease during pregnancy as the increase in plasma volume exceeds the increase in red blood cell production. The result is physiologic anemia. Mastitis is an infection in the breast characterized by a swollen, tender breast and flulike symptoms. This condition is most commonly seen in breast-feeding clients. Alterations in acid-base balance during pregnancy result in a state of respiratory alkalosis, compensated by mild metabolic acidosis.

A nurse is caring for a client who received 1 unit of fresh frozen platelets (FFP) for a platelet count of 20,000 mm3. Which repeat laboratory values will be of greatest concern to the nurse? platelet count 22,000 mm3 blood urea nitrogen 20 mg/dL white blood cell count 4.8 µL red blood cell count 5.2 µL

platelet count 22,000 mm3 Explanation: Platelet transfusions are given when the platelet count falls below 20,000 mm3. One unit is expected to raise the count by 5000 to 10,000 mm3. The count was only raised by 2000 mm3. All other laboratory values are within normal range.

The nurse's goal in crisis intervention is to provide: medication to sedate the client. nondirective techniques such as free association. an insight-oriented analytic approach. problem-solving techniques and structured activities.

problem-solving techniques and structured activities. Explanation: Individuals in a crisis need immediate assistance. They're unable to solve problems and need structure and assistance in accessing resources. Clients in a crisis don't need lengthy explanations or have time to develop insight on their own. They might need medication but, in most cases, support and direction are the most helpful.

A nurse is caring for a confused, older adult client. Which action should the nurse prioritize for this client's care? promoting safety by protecting from injury identifying the underlying cause of confusion monitoring for deteriorating of neurologic status. encouraging participation in activities of daily living (ADLs)

promoting safety by protecting from injury Explanation: The nurse's first responsibility is always to protect the client from injury. Determining the cause of the confusion and protecting the older adult client's neurologic status from deterioration are the primary care provider's responsibilities. Encouraging the client to participate in ADLs is a nursing intervention, but it is not the most important consideration.

An oncology clinic nurse is reinforcing prevention measures for oropharyngeal infections to a client receiving chemotherapy. Which statement by the client indicates an understanding of the nurse's teaching? "I use an alcohol-based mouthwash every morning." "I replace my toothbrush every month." "I lubricate my lips with petroleum jelly." "I clean my teeth gently several times a day."

"I clean my teeth gently several times a day." Explanation: Frequent, gentle cleaning or rinsing of the mouth decreases bacteria build-up in the oral cavity, thus reducing the risk of oropharyngeal infection. Changing the toothbrush each month reduces oral bacteria for only the first few uses. Petroleum jelly moistens the lips, but it doesn't prevent breakdown of the mucous membranes or reduce the risk of oropharyngeal infection. Alcohol-based products dry the mucous membrane, which increases the likelihood of oropharyngeal infection.

The daughter of a client diagnosed with Alzheimer's disease tells a nurse, "My mother is incompetent. You'll need to contact me or my sister if any decision must be made about my mother's care." Which response by the nurse is best? "Thank you for informing me of your wishes." "I'll tell the health care team that you and your sister will make all of your mother's health care decisions." "I'll need a physician's order that permits you and your sister to make care decisions." "I must respect your mother's rights until she is legally deemed incompetent."

"I must respect your mother's rights until she is legally deemed incompetent." Explanation: Even though the client has a psychiatric diagnosis, the nurse is still legally responsible to respect the client's wishes until she is legally deemed incompetent. Accepting the daughter's wishes and telling the health care team to abide by them violate the client's rights. The client's rights must be upheld regardless of the physician's order.

A client is diagnosed with a fungal infection of the scalp. The nurse knows the client understands the treatment plan when which statement is made? Select all that apply. "The rash is not contagious." "I will need to take all of my medication even if the rash gets better." "I should throw away my combs and hats." "I should apply over the counter steroid cream if the rash begins to itch." "I can stop the medication once the rash is gone."

"I should throw away my combs and hats." "I will need to take all of my medication even if the rash gets better." Explanation: Tinea capitis is a fungal infection of the scalp. Tinea corporis describes fungal infections of the body. Tinea cruris describes fungal infections of the inner thigh and inguinal creases. Tinea pedis is the term for fungal infections of the foot. Over the counter steroid cream is not an appropriate treatment for fungal rashes. Fungal infections can be spread via a fomite transmission, so combs and hats should be discarded. Medications should be taken as ordered even if the rash is gone. Steroid cream will make fungal rashes worse.

A client was admitted with human immunodeficiency virus (HIV). Which statement by the client would indicate the need for further education regarding safer sex practices? "Latex condoms are the best choice for preventing the spread of HIV." "I should use plenty of oil-based lubricant to prevent latex condom tearing." "I must check the expiration date on the package before using the condom." "I should inspect the condom for damage or defects before I use it."

"I should use plenty of oil-based lubricant to prevent latex condom tearing." Explanation: Water-based lubricants should be used; oil- or petroleum-based products can damage latex condoms. Latex condoms or polyurethane (if the client has a latex allergy) condoms have been proven to decrease the spread of HIV. Checking for damaged, defective, or expired condoms ensures the integrity of the condoms and decreases the likelihood of HIV transmission. Remediation:

When reinforcing education with the parents about signs that indicate levothyroxine overdose, which comment by a parent indicates the need for further education? "I shouldn't worry if my baby doesn't sleep very much." "Irritability is a sign of overdose." "If my baby's heartbeat is fast, I should count it." "If my baby loses weight, I should be concerned."

"I shouldn't worry if my baby doesn't sleep very much." Explanation: Parents need to be aware of signs indicating overdose, such as insomnia, rapid pulse, dyspnea, irritability, fever, sweating, and weight loss. The parents are given acceptable parameters for the heart rate and weight loss or gain. If the baby is experiencing a heart rate or weight loss outside of the acceptable parameters, the health care provider should be called.

A client was the driver in an automobile accident in which a 3-year-old was killed; the client is now experiencing dissociative amnesia. After reviewing the treatment plan with the client, the nurse determines that the client demonstrates understanding by which statement? "I won't drive a car again for at least 1 year." "I'll take my lorazepam any time I feel upset about this situation." "I'll visit the child's grave as soon as I'm released from the hospital." "I'll attend my hypnotic therapy sessions prescribed by my psychiatrist."

"I'll attend my hypnotic therapy sessions prescribed by my psychiatrist." Explanation: Hypnosis can be beneficial to this client because it allows repressed feelings and memories to surface. Visiting the child's grave upon release from the hospital may be too traumatic and could encourage continuation of the amnesia. The client needs to learn coping mechanisms other than taking a highly addictive drug such as lorazepam. The client may be ready to drive again, and circumstances may dictate that he drives again before 1 year has passed.

The nurse is triaging phone calls at a local pediatrician's office. Which statement by the parent of a child being treated for pinworms indicates that further teaching is needed? "I'll warn my child to avoid sharing hairbrushes and hats to prevent spreading pinworms to others." "I'll keep my child's nails short." "I'll give my child only one dose of medication." "I'll make my child wash his/her hands well before meals."

"I'll warn my child to avoid sharing hairbrushes and hats to prevent spreading pinworms to others." Explanation: Sharing hairbrushes and hats reduces the spread of lice, not pinworms. Hands should be washed well before food preparation and eating to avoid ingesting eggs that may be under the fingernails from scratching the itchy infested perianal area. Only a single dose of medication, such as mebendazole, is needed to treat pinworms. Keeping the fingernails short reduces the risk of carrying eggs under the nails.

The nurse is caring for a client who just had a cardiac catheterization through femoral approach completed. The client refuses to use the urinal and wants to get up to the bathroom. What is the best nursing response? "If you get out of bed, you may end up with an arrhythmia. Your heart needs to rest." "The doctor has ordered bedrest for you for the next 6 hours. It is important that you follow these orders." "You cannot be up on your feet yet. You may be too weak after the procedure and may fall." "If you bend your leg, you will risk bleeding from the insertion site and it could lead to complications."

"If you bend your leg, you will risk bleeding from the insertion site and it could lead to complications." Explanation: Bedrest is prescribed to allow the arterial puncture to seal and reduce the risk of bleeding. Explaining the rationale to the client is the best way to facilitate the client's cooperation. Getting out of bed after a cardiac catheterization will not cause dysrhythmias. Telling the client that bedrest is ordered does not provide information about how bed rest helps prevent complications and bleeding after cardiac catheterization.

The nurse is developing a teaching plan for a client prescribed levothyroxine. Which instruction concerning its administration should the nurse instruct the client? "Take the drug on an empty stomach." "Take the drug with meals." "Take the drug in the evening." "Take the drug whenever it's convenient."

"Take the drug on an empty stomach." Explanation: Levothyroxine (a thyroid hormone) The nurse should instruct the client to take levothyroxine on an empty stomach (to promote absorption) in the morning (to help prevent insomnia and to mimic normal hormone release). Remediation:

A client recovering from hip replacement surgery questions the need for admission to a rehabilitation center because there are family members available at home to provide care. Which response by the nurse is best? "The rehabilitation staff can evaluate your progress and help you recover without risking injury." "The healthcare provider advises care at a rehabilitation center until you can care for yourself." "The rehabilitation staff can provide you with better, safer care than untrained family members." "You'll need help with your bath and meals for quite some time, which can be difficult for family members."

"The rehabilitation staff can evaluate your progress and help you recover without risking injury." Explanation: The nurse should respond by emphasizing that the rehabilitation center can evaluate progress and make sure that exercises are performed without risking injury. This response points out that the goal of rehabilitation is safely achieving mobility and not providing total care. Stating that the client will need help with bathing and meals for a long period does not provide adequate information about the role of rehabilitation or the client's future needs. The rehabilitation center will help the client learn to provide self-care. Telling the client that the rehabilitation staff can provide better care than family is judgmental about care the family might provide and does not adequately explain the role of a rehabilitation center. Telling the client that the health care provider wants the client to go does not explain the importance of a rehabilitation center.

The nurse reinforces instructions about breathing exercises for a client with chronic bronchitis. Which information should the nurse include? "Inhale longer than you exhale." "Exhale through an open mouth." "Use diaphragmatic breathing." "Practice rhythmic chest breathing."

"Use diaphragmatic breathing." Explanation: In a client with chronic bronchitis, the diaphragm is flat and weak. Diaphragmatic breathing helps to strengthen the diaphragm and maximizes ventilation. Exhalation should be longer than inhalation to prevent collapse of the bronchioles. A client with chronic bronchitis should exhale through pursed lips to prolong exhalation, keep the bronchioles from collapsing, and prevent air trapping. Diaphragmatic breathing, not chest breathing, increases lung expansion.

A client who sustained an L1 to L2 spinal cord injury in a construction accident asks a nurse if he'll ever be able to walk again. Which response by the nurse is appropriate? "If you keep a positive attitude, you can do anything." "What makes you think you won't be able to walk again?" "What has your physician told you about your ability to walk again?" "Most likely you won't be able to, but we never know for sure."

"What has your physician told you about your ability to walk again?" Explanation: The nurse should respond by asking the client what he's already been told about his ability to walk again. After assessing the client's knowledge, she can better respond to the client's questioning. Option 1 provides the client with false hope, and option 2 may place the client on the defensive. Option 4 is an inappropriate response.

A 49-year-old client with acute respiratory distress watches everything the staff does and demands full explanations of all procedures and medications. The nurse identifies which assessment as evidence that the client has achieved an increased level of psychological comfort? making decreased eye contact asking to see family members joking about the present condition sleeping undisturbed for three hours

"Where would you like to begin?" Explanation: A broad opening statement is used when more information is required and allows the client to take the lead in the conversation. An example of this type of statement would include a statement such as, "where would you like to begin?"

The nurse is assessing the puncture site of a client who has received a purified protein derivative test. Which finding indicates a need for further evaluation? Reddened area 15-mm induration Blister 3-mm induration

15-mm induration Explanation: A 10-mm induration strongly suggests a positive response in this tuberculosis screening test; a 15-mm induration clearly requires further evaluation. The other options aren't positive reactions to the test and require no further evaluation.

A nurse is monitoring the progress of a client with acute respiratory distress syndrome (ARDS). Which data best indicate that the client's condition is improving? The sputum and sensitivity culture shows no growth in bacteria. The client's blood pressure has stabilized. The bronchoscopy results are negative. Arterial blood gas (ABG) values are normal.

Arterial blood gas (ABG) values are normal. Explanation: Normal ABG values would indicate that the client's oxygenation has improved. ARDS is characterized by hypoxia, so the bronchoscopy and sputum culture results have no bearing on the improvement of ARDS. Increased blood pressure isn't relative to the client's respiratory condition.

An elderly client with Alzheimer's disease begins supplemental tube feedings through a gastrostomy tube to provide adequate calorie intake. The nurse observes the client during feeding and is concerned most with which potential development? Hyperglycemia Fluid volume excess Aspiration Constipation

Aspiration Explanation: Of the choices listed, aspiration is the most serious potential complication of tube feedings. Dehydration — not fluid volume excess — is a concern because of decreased free water intake. Hyperglycemia is a complication secondary to carbohydrate load of enteral feeding solutions. Constipation can be a problem, but it usually isn't a serious one. The client would most likely experience diarrhea.

During the first 24 hours after a client is diagnosed with Addisonian crisis, which task should the nurse perform frequently? Weigh the client. Administer oral hydrocortisone. Assess vital signs. Test urine for ketones.

Assess vital signs. Explanation: Because the client in Addisonian crisis is unstable, the nurse should assess his vital signs and fluid and electrolyte balance every 30 minutes until he's stable. Daily weights are sufficient when assessing the client's condition. The client shouldn't have ketones in his urine, so there is no need to assess the urine for their presence. Oral hydrocortisone isn't administered during the first 24 hours in severe adrenal insufficiency.

The nurse prepares to perform postural drainage. Which method would the nurse use to determine the best position for facilitating drainage of the lungs? Auscultation Chest X-ray Inspection Arterial blood gas (ABG) levels

Auscultation Explanation: Breath sounds should be auscultated before doing postural drainage to determine the areas that need draining. After the areas are identified, the nurse can position the client appropriately. Inspection, chest X-rays, and ABG levels are all parameters that give good information about respiratory function, but they aren't necessary to determine lung areas requiring postural drainage.

A nurse is caring for a postoperative thyroidectomy client at risk for hypocalcemia. What intervention should the nurse implement in this client's care? Observe for swelling of the neck, tracheal deviation, and severe pain. Observe for muscle twitching and numbness or tingling of the lips, fingers, and toes. Evaluate the quality of the client's voice postoperatively, noting any drastic changes. Monitor laboratory values daily for an elevated thyroid-stimulating hormone.

Observe for muscle twitching and numbness or tingling of the lips, fingers, and toes. Explanation: Muscle twitching and numbness or tingling of the lips, fingers, and toes are signs of hyperirritability of the nervous system caused by hypocalcemia. The other options describe complications for which the nurse should also be observing; however, tetany and neurologic alterations are primary indications of hypocalcemia.

A home health nurse is evaluating a client's risk of contracting herpes zoster. Which client is most at risk for developing herpes zoster? a 76-year-old client taking immunosuppressant medication a 21-year-old client with a heat rash and psoriasis a 42-year-old client with a previous myocardial infarction a 5-year-old client recently diagnosed with strep throat

a 76-year-old client taking immunosuppressant medication Explanation: Herpes zoster (shingles) is an acute inflammation caused by infection with the herpes virus varicella-zoster (chickenpox virus). It is most common in adults age 65 years and older. Others at risk include clients with decreased immunity (transplants, HIV/AIDS, immunosuppressant medications, etc.), chronic lung or kidney disease, or clients who had chickenpox at a younger age.

A client with acute diarrhea is prescribed loperamide, 2 mg after each unformed stool up to 16 mg/day, until the diarrhea subsides. The client asks the nurse how soon the medication will start to work after the first dose is taken. The nurse responds that the medication will work in how much time? "Within 2 to 4 hours" "Within 20 minutes" "Within 5 minutes" "Within 1 hour"

"Within 1 hour" Explanation: Loperamide (Loperamide is used to treat diarrhea.) starts to act within 1 hour after administration. Onset of action isn't as rapid as 5 or 20 minutes or as slow as 2 to 4 hours.

The nurse educator is preparing a lecture on dementia. The educator will include that which is the most common cause of dementia in an elderly client? Alzheimer's disease Excessive drug use Delirium Depression

Alzheimer's disease Explanation: Alzheimer's disease is the most common cause of dementia in the elderly. About 5% of people older than age 65 have severe cases of Alzheimer's disease, and about 12% of people older than age 65 have mild or moderate cases of the disease. Delirium, or acute confusion, is caused by an underlying disease and isn't itself a cause of dementia. Depression is common in the elderly but tends to manifest itself in apathy, self-deprecation, or inertia — not dementia. Excessive drug use, commonly stemming from the elderly client seeing multiple physicians who are unaware of drugs that other physicians have prescribed, can cause dementia, but this problem isn't as common as Alzheimer's disease.

The LVN/LPN is visiting an adult client with diabetes mellitus who lives at home. Which of the following situations should the nurse be most concerned about? A sharps container is placed on the kitchen table. An insulin bottle is left on the center table in the living room. The client has a stash of hard candy in her purse. The client has bruises around her umbilicus from insulin administration.

An insulin bottle is left on the center table in the living room. Explanation: A sharps container on a kitchen table possesses no risk for the client. An insulin bottle left on a center table can affect the potency of the drug because insulin needs to be refrigerated. This is not safe. The client is allowed to keep hard candy in case of a hypoglycemic episode. Bruises around the belly button results from injections. It can be minimized by rotating sites and not massaging the area vigorously after injection.

During a routine examination of a client's fingernails, the nurse notes a horizontal depression in each nail plate. When documenting this finding, the nurse should use which term? Clubbing Splinter hemorrhage Beau's line Paronychia

Beau's line Explanation: Beau's line is a horizontal depression in the nail plate. Occurring alone or in multiples, this depression results from a temporary disturbance in nail growth. A splinter hemorrhage is a linear red or brown streak in the nail bed. Paronychia refers to an inflammation of the skinfold at the nail margin. Clubbing describes an increased angle between the nail plate and nail base.

Which statement best explains why it is important to monitor behavior in a client who has stopped using phencyclidine (PCP)? Fatigue can cause feelings of being overwhelmed. Bizarre behavior can be a precursor to a psychotic episode. Memory loss and forgetfulness can cause unsafe conditions. Nausea and vomiting can occur during withdrawal.

Bizarre behavior can be a precursor to a psychotic episode. Explanation: Bizarre behavior and speech are associated with PCP withdrawal and can indicate psychosis. Fatigue isn't necessarily a problem when a client stops using PCP. Agitation, mood swings, memory loss, and forgetfulness don't tend to occur when a client has stopped using PCP.

If a central venous catheter becomes disconnected accidentally, what should the nurse do immediately? Call the physician. Apply a dry sterile dressing to the site. Clamp the catheter. Tell the client to take a deep breath and hold it.

Clamp the catheter. Explanation: If a central venous catheter becomes disconnected, the nurse should immediately apply a catheter clamp, if available. If a clamp isn't available, the nurse can place a sterile syringe or catheter plug in the catheter hub. After performing these measures, the nurse should notify the registered nurse immediately. The other options aren't appropriate at this time.

A client undergoes a craniotomy with supratentorial surgery to remove a brain tumor. On the first postoperative day, the nurse notes the absence of a bone flap at the operative site. How should the nurse position the client's head? Flat Turned onto the operative side Elevated no more than 10 degrees Elevated 30 degrees

Elevated 30 degrees Explanation: After supratentorial surgery, the nurse usually elevates the client's head 30 degrees to promote venous outflow through the jugular veins. The nurse keeps the client's head flat after infratentorial, not supratentorial, surgery. However, after supratentorial surgery to remove a chronic subdural hematoma, the neurosurgeon may order the nurse to keep the client's head flat; typically, the client with such a hematoma is older and has a less expandable brain. A client without a bone flap can't be positioned with his head turned onto the operative side because this may injure brain tissue. Elevating the head 10 degrees or less wouldn't promote venous outflow through the jugular veins.

Which measures should the nurse include in the plan of care to help minimize calcium loss from the bones of a hospitalized client? Offer dairy products at frequent intervals Encourage the client to walk in the hallway Reposition the client every 2 hours Provide supplemental feedings between meals

Encourage the client to walk in the hallway Explanation: Calcium absorption diminishes with reduced physical activity. Therefore, encouraging the client to increase physical activity, such as by walking in the hallway, helps minimize calcium loss. Turning or repositioning the client every 2 hours would not increase activity sufficiently to minimize calcium loss. Providing dairy products and supplemental feedings would not lessen calcium loss, even if the dairy products and feedings contained extra calcium.

A client is treated in the emergency department for a Colles' fracture sustained during a fall. What is a Colles' fracture? Fracture of the distal radius Fracture of the olecranon Fracture of the humerus Fracture of the carpal scaphoid

Fracture of the distal radius Explanation: Colles' fracture is a fracture of the distal radius, such as from a fall on an outstretched hand. It's most common in women. Colles' fracture doesn't refer to a fracture of the olecranon, humerus, or carpal scaphoid.

The nurse is teaching a client with osteomalacia how to take prescribed vitamin D supplements. The nurse stresses the importance of taking only the prescribed amount because high doses of vitamin D can be toxic. Early signs and symptoms of vitamin D toxicity include: sensory neuropathy and difficulty maintaining balance. dry skin, hair loss, and inflamed mucous membranes. flushing and orthostatic hypotension. GI upset and metallic taste.

GI upset and metallic taste. Explanation: GI upset and metallic taste are early signs and symptoms of vitamin D toxicity. Such toxicity also may cause headache, weakness, renal insufficiency, renal calculi, hypertension, arrhythmias, muscle pain, and conjunctivitis. Dry skin, hair loss, and inflamed mucous membranes suggest vitamin A toxicity. Flushing and orthostatic hypotension (effects of vasodilation) may result from nicotinic acid and nicotinamide supplements, used to correct niacin deficiency. Sensory neuropathy and difficulty maintaining balance suggest pyridoxine toxicity.

The physician prescribes several drugs for a client with hemorrhagic stroke. Which drug order should the nurse question? Heparin sodium Dexamethasone Methyldopa Phenytoin

Heparin sodium Explanation: Administration of heparin, an anticoagulant, could increase the bleeding associated with hemorrhagic stroke. Therefore, the nurse should question this order to prevent additional hemorrhage in the brain. In a client with hemorrhagic stroke, dexamethasone may be used to decrease cerebral edema and pressure; methyldopa, to reduce blood pressure; and phenytoin, to prevent seizures.

Which iron-rich foods should the nurse encourage an anemic client requiring iron therapy to eat? Shrimp and tomatoes Lobster and squash Cheese and bananas Lamb and dried peaches

Lamb and dried peaches Explanation: Iron-rich foods include lamb and dried peaches. Shrimp, tomatoes, lobster, squash, cheese, and bananas aren't high in iron content.

The nurse must apply a wet-to-dry dressing over an ulcer on a client's left ankle. How should the nurse proceed? Lightly pack the moistened fine-mesh gauze dressings into all depressions and grooves of the wound. Apply the saturated fine-mesh gauze dressings over the wound. Cover the saturated fine-mesh gauze dressings with an elastic bandage. Apply an occlusive dressing over the saturated fine-mesh gauze dressings.

Lightly pack the moistened fine-mesh gauze dressings into all depressions and grooves of the wound. Explanation: The nurse should lightly pack the moistened fine-mesh gauze dressings into all depressions and grooves of the wound because necrotic tissue usually is more prevalent in those areas. Wound packing facilitates wound healing. The nurse should wring out excess moisture from saturated fine-mesh gauze dressings because saturated dressings won't dry properly. The nurse shouldn't apply an occlusive dressing or elastic bandage because they can prevent air circulation and hinder drying of the fine-mesh gauze.

The nurse sees an unauthorized person reading a client's medical record outside a client's room. Which action should the nurse take? Approach the individual and request the client's medical record. Notify the nursing supervisor and approach the individual. Contact security immediately. Document the incident on an incident report.

Notify the nursing supervisor and approach the individual. Explanation: Approaching the person and requesting the client's medical record isn't sufficient considering the confidential health care information. Notifying the nursing supervisor, then approaching the individual before informing the client provides the most appropriate approach to this breech of client confidentiality. Contacting security might not be warranted unless the nurse learns the reason the unauthorized individual was reading the client's chart. The nurse should also document the incident according to facility policy.

A nurse is caring for a bedridden older adult client. Which nursing intervention should the nurse include in this client's care? Vigorously massage areas of redness. Apply lotion to the bony prominences. Post an every 2 hour turn schedule at the bedside. Slide the client onto either side when turning.

Post an every 2 hour turn schedule at the bedside. Explanation: A turning schedule with a signature sheet helps ensure that the client is turned, thus helping to prevent pressure ulcers. Turning should occur every 1 to 2 hours for clients who are in bed for prolonged periods. The nurse should apply lotion to keep the skin moist but should avoid vigorous massage of bony prominences, which could damage capillaries. When moving the client, the nurse should lift, rather than slide, the client to avoid shearing.

A nurse is caring for a client admitted with a diagnosis of multiple myeloma. Which nursing intervention is most appropriate for this client? Balance rest and activity. Prevent bone injury. Monitor respiratory status. Restrict fluid intake.

Prevent bone injury. Explanation: Multiple myeloma is a cancer that forms in a type of white blood cell called a plasma cell When caring for a client with multiple myeloma, the nurse should focus on relieving pain, preventing bone injury and infection, and maintaining hydration. Monitoring respiratory status and balancing rest and activity are appropriate interventions for any client. To prevent such complications as pyelonephritis and renal calculi, the nurse should keep the client well hydrated, not restrict the client's fluid intake.

A geriatric client has experienced several adverse drug reactions. What does the nurse recognize that this client may benefit from? Frequent visits to the physician Nursing home placement Increased drug doses at longer intervals Reduced drug dosages

Reduced drug dosages Explanation: Older clients commonly have diminished hepatic and renal function that reduces drug metabolism and excretion. Adverse reactions tend to be related to blood level; therefore, the client may benefit from reduced drug dosages. Adverse drug reactions aren't a cause for nursing home placement. Increased drug doses at longer intervals may increase adverse reactions rather than decrease them. Although frequent visits to the physician may benefit the client, the visits themselves won't alter how the drug reacts in the client's body.

A nurse is assisting with an educational session for a group of women on the topic of urinary tract infection (UTI) prevention. Which information should the nurse expect to be included in this session? Limit fluid intake to reduce the need to urinate. Take prescribed medications until the symptoms subside. Report any urinary difficulty to the health care provider. Wear only nylon underwear to reduce the chance of irritation.

Report any urinary difficulty to the health care provider. Explanation: Urgency, burning, frequency, and difficulty urinating are all common symptoms of a UTI. Clients should notify their healthcare provider so that microscopic urinalysis can be done and appropriate treatment can be initiated. Women should be instructed to drink 2 to 3 qt (1.9 to 2.9 L) of fluid per day to dilute the urine and reduce irritation on the bladder mucosa. The full course of antibiotics prescribed for UTIs must be taken, even if symptoms subside. Doing so helps to prevent recurrences. Women should avoid scented toilet tissue and bubble baths and should wear cotton (not nylon) underwear to reduce the chance of bladder irritation.

Which of the following is an appropriate nursing diagnosis for a client with renal calculi? Functional urinary incontinence Risk for infection Ineffective tissue perfusion Decreased cardiac output

Risk for infection Explanation: Infection can occur with renal calculi from urine stasis caused by obstruction. Retention of urine usually occurs, rather than incontinence (option 2). Options 1 and 4 aren't appropriate for a client with renal calculi.

An emergency department nurse is assessing a 28-year-old client who reports back pain, migraine headache, and feelings of generalized fatigue. The client's medical record indicates that she has had multiple emergency department visits with the same reports since her abusive husband left her. Based on these findings, the client most likely has which disorder? Functional neurologic symptom disorder Dissociative disorder Illness anxiety disorder Somatic symptom disorder

Somatic symptom disorder Explanation: Somatic symptom disorder is characterized by a pattern of multiple, recurring somatic responses to stress. Intensified psychosocial stress predisposes the client to recurring physical illness. Functional neurologic symptom disorder involves unexplained symptoms or deficits that suggest a neurologic or other medical condition. Illness anxiety disorder is characterized by a preoccupation with the fear of having a serious illness based on the client's own interpretation. Clients with this disorder don't recognize that their concerns about illness are excessive or unreasonable. Dissociative disorders are characterized by an interruption of consciousness, memory, identity, and perception of the environment.

A client receiving total parental nutrition is prescribed a 24-hour urine test. The nurse delegates the collection of the specimen to the unlicensed assistive personnel (UAP). The nurse is aware that the UAP is collecting the specimen correctly when he or she initiates the collection in which instance? Start with the client's first voiding of the day Start after a client's known voiding that empties the bladder Start after the client eats breakfast Ends with the client's last evening's void as the last sample

Start after a client's known voiding that empties the bladder Explanation: When initiating a 24-hour urine specimen, have the client void, and then start timing. The collection should start on an empty bladder. The exact time the test starts isn't important, but it's commonly started in the morning.

A child with bilateral fractured femurs is scheduled for a double hip spica cast and says to the nurse, "Only 3 more months, and I can go home." Further investigation reveals that the child and family believe hospitalization is required until the cast comes off. What should the nurse explain to the family? The child will go home as soon as she can move. The child will go home 1 week after casting. The child will go home 2 to 4 days after casting. The child may be hospitalized 2 to 4 months.

The child will go home 2 to 4 days after casting. Explanation: The double hip spica cast will dry fairly rapidly with the use of fiberglass casting material. The time spent in the hospital after casting, typically 2 to 4 days, will be for educating the child and her family about home care and for evaluating the child's skin integrity and neurovascular status before discharge. The time frames in the other options given are inaccurate for application of a double hip spica cast.

A client with Alzheimer's disease is being treated for injuries from a recent fall and malnutrition. The nurse determines a need to place the client closer to the nurse's station based on which finding? The client exhibits agnosia. The client consistently forgets to eat. The client has a tendency to wander. The client does not change position often.

The client has a tendency to wander. Explanation: A client with Alzheimer's disease is at risk for injury because of the tendency to wander. Placing the client closer to the nurses' station makes it easier to monitor and ensure safety should the client begin to wander. Placing the client closer to the nurses' station will not help the client remember to eat, change position often, or change the agnosia (difficulty finding a word or naming an object).

A client with chest pain doesn't respond to nitroglycerin. On admission to the emergency department, the health care team obtains an electrocardiogram and administers I.V. morphine. The physician also considers administering alteplase. This thrombolytic agent must be administered how soon after onset of myocardial infarction (MI) symptoms? Within 3 to 6 hours Within 24 hours Within 24 to 48 hours Within 5 to 7 days

Within 3 to 6 hours Explanation: For the best chance of saving the client's myocardium, a thrombolytic agent must be administered within 3 to 6 hours after onset of chest pain or other MI signs or symptoms. Within the first 24 hours after an MI, sudden death is most likely to occur. I.V. heparin therapy begins after administration of a thrombolytic agent and usually continues for 5 to 7 days.

Which client would be most at risk for secondary Parkinson disease caused by pharmacotherapy? a 30-year-old client with schizophrenia taking chlorpromazine a 75-year-old client using naproxen for rheumatoid arthritis a 50-year-old client taking nitroglycerin tablets for angina a 60-year-old client taking prednisone for chronic obstructive pulmonary disease (COPD)

a 30-year-old client with schizophrenia taking chlorpromazine Explanation: Phenothiazines, such as chlorpromazine, deplete dopamine, which may lead to tremor and rigidity (extrapyramidal effects). The other clients aren't at a greater risk for developing Parkinson disease caused by pharmacotherapy.

A client has not voided for 10 hours following an inguinal hernia repair. Which factor may place a surgical client at risk for urine retention? dehydration history of smoking duration of surgery anticholinergic medication before surgery

anticholinergic medication before surgery Explanation: Anticholinergic medications, such as atropine, may cause urine retention, particularly for the client who has had surgery in the pelvic area (inguinal hernia, hysterectomy). Dehydration, smoking, and duration of surgery are not risk factors for urine retention.

A client has been admitted with burns on both legs. Which nursing intervention is most important to help prevent contractures? applying knee splints elevating the foot of the bed performing shoulder range-of-motion (ROM) exercises hyperextending the client's palms

applying knee splints

The health care provider has ordered diagnostic testing for a client suspected of having thalassemia. When reviewing labs from this client, which findings does the nurse determine are consistent with the disorder? Select all that apply. hemoglobin 8.8 g/dL (88g/L) hemoglobin 13.4 g/dL (134g/L) hematocrit 36% (0.36) red blood cells 2.9 red blood cells 5.2

hemoglobin 8.8 g/dL (88g/L) red blood cells 2.9 Explanation: A complete blood cell count can be anticipated in the client suspected of having thalassemia. In thalassemia the number of red blood cells and hemoglobin levels are reduced. A normal hemoglobin level for the client in this age group would be 12.5 to 16.1 g/dL (125 to 161 g/L). The normal range for red blood cell count for a client in this age range would be 4.1 to 5.3. The hematocrit level of 36% (0.36) is within normal limits.

A client needs to void 3 hours after a vaginal birth. The nurse implements safety precautions when getting the client out of bed based on an understanding that the client is at risk for which condition? chest pain breast engorgement orthostatic hypotension separation of episiotomy incision

orthostatic hypotension Explanation: The rapid decrease in intra-abdominal pressure occurring after birth causes splanchnic engorgement. The client is at risk for orthostatic hypotension when standing due to the blood pooling in this area. Breast engorgement is caused by vascular congestion in the breast through lactation. The client shouldn't experience separation of the episiotomy incision or chest pain when standing. None of these conditions are risks related to the need to assist the client out of bed.

A 2-year-old child with status asthmaticus is admitted to the pediatric unit and begins to receive continuous treatment with albuterol, given by nebulizer. The nurse should observe for which adverse reaction? bradycardia tachycardia lethargy tachypnea

tachycardia Explanation: Albuterol is a rapid-acting bronchodilator. Common adverse effects include tachycardia, nervousness, tremors, insomnia, irritability, and headache.

A nurse is monitoring a client receiving doxorubicin. Which symptoms would be of greatest concern to the nurse? nausea blurred vision headache tachycardia

tachycardia Explanation: Tachycardia is the greatest concern. Doxorubicin can cause cardiotoxicity, which is damage to the heart by harmful chemicals. Symptoms include chest pain, tachycardia, and arrhythmias. The early damage occurs immediately after drug administration or within 1 to 2 days and can lead to heart failure. Symptoms of nausea, blurred vision, and a headache are not symptoms of cardiotoxicity and can be addressed at a later time.

The nurse is reinforcing education for a client diagnosed with gout. What statement made by the client demonstrates an understanding by the client? "I'll increase my fluids so that the inflammation will be reduced." "Increasing fluid intake will increase the calcium my body absorbs." "Increasing fluid intake will cause my body to excrete more uric acid." "Increasing fluids will help provide a cushion for my bones."

"Increasing fluid intake will cause my body to excrete more uric acid." Explanation: Fluids promote the excretion of uric acid. Fluids don't decrease inflammation, increase calcium absorption, or provide a cushion for bones.

A client with rheumatoid arthritis reports flatulence and heartburn after taking piroxicam. Which instruction should the nurse reinforce to address the client's concern? "These side effects will subside as you continue to take the medication." "Take an antacid at the same time that you take the medication." "This medication is used for short-term treatment of your arthritis." "Try taking a lower dose of the medication to relieve your symptoms."

"Take an antacid at the same time that you take the medication." Explanation: Piroxicam is a nonsteroidal anti-inflammatory drug (NSAID). It should be taken with food or an antacid to decrease the risk of gastrointestinal (GI) upset. Informing the client that the symptoms will subside is not appropriate because the client may continue to experience these side effects from the medication. Because piroxicam may not produce therapeutic effects for 2 to 4 weeks, the client should take it for more than a short time. The client should not adjust the dosage of piroxicam or any other medication unless directed to do so by a healthcare provider.

A 1-year-old infant is pale, but the physical examination is normal. Blood studies reveal the infant's hematocrit is 24%. Which question by the nurse to the parents would be most useful in helping to establish a diagnosis of anemia? "Is the infant on any medications?" "What's the infant's usual daily diet?" "Did the infant receive phototherapy for jaundice?" "What are the pattern and appearance of bowel movements?"

"What's the infant's usual daily diet?" Explanation: Iron deficiency anemia is the most common nutritional deficiency in infants between ages 9 months and 15 months. Anemia in a 1-year-old is mostly nutritional in origin, and its cause will be suggested by a detailed nutritional history. None of the other questions would be helpful in diagnosing anemia.

A nurse is caring for a client who underwent a total hip replacement. Which intervention should the nurse implement in this client's care to prevent dislocation of the new prosthesis? Explain that the client's advance directive appoints the physician as the power of attorney for health care decisions. Use measures other than turning to reduce the possibility of pressure ulcers. Avoid moving the extremity into positions that cause internal rotation. Place several pillows under the knees to maintain hip flexed.

Avoid moving the extremity into positions that cause internal rotation. Explanation: External rotation and abduction of the hip help prevent dislocation of a new hip joint, so positions that cause internal rotation and adduction should be avoided. A postoperative total hip replacement client may be turned onto the unaffected side. Although the hip may be flexed slightly, it should not exceed 90 degrees, and the use of several pillows does not provide a definitive degree of flexion. Maintenance of flexion is not necessary.

A client comes to the emergency department reporting sudden onset of diarrhea, anorexia, malaise, cough, headache, and recurrent chills. Based on the client's history and physical findings, the physician suspects Legionnaires' disease. While awaiting diagnostic test results, the client is admitted to the facility and started on antibiotic therapy. Which medication does the nurse expect for the physician to order as it is considered the drug of choice for treating this disease? Amphotericin B Erythromycin Rifampin Amantadine

Erythromycin Explanation: Erythromycin is the drug of choice for treating Legionnaires' disease. Legionnaires' (LEE-juh-nares) disease is a serious type of pneumonia (lung infection) caused by Legionella (LEE-juh-nell-a) bacteria. Rifampin may be added to the regimen if erythromycin alone is ineffective; however, it isn't administered first. Amantadine, an antiviral agent, and amphotericin B, an antifungal agent, are ineffective against Legionnaires' disease, which is caused by bacterial infection.

A client who is recovering one day after an extensive abdominal surgery is having incisional pain. When should the nurse plan to administer analgesics for this client? Every 3-4 hours Three times a day Four times a day When requested by the client

Every 3-4 hours Explanation: The physiological consequences of postoperative pain can delay or impair postoperative recovery and result in a longer period of hospitalization. The aim of effective postoperative pain management are to improve the comfort and satisfaction of the client, facilitate recovery and functional ability, reduce morbidity, and promote rapid discharge from hospital. Pain should be assessed minimally every 4 hours around the clock as well as after any treatments. It is best for the nurse to use a preventive approach for this client's pain management because it is predictable and major. Adequate postoperative pain assessment can lead to more effective pain control and fewer postoperative complications.

A client comes to the emergency department reporting dull, deep bone pain unrelated to movement. Which statement is correct to determine if the bone pain is caused by a fracture? These are classic symptoms of a fracture. Fracture pain is sharp and related to movement. Fracture pain is sharp and unrelated to movement. Fracture pain is dull and deep and related to movement.

Fracture pain is sharp and related to movement. Explanation: Fracture pain is sharp and related to movement. Pain that's dull and deep and unrelated to movement isn't typical of a fracture.

client is admitted for treatment of the syndrome of inappropriate antidiuretic hormone (SIADH). Which nursing intervention is appropriate? Infusing intravenous (I.V.) fluids rapidly as ordered Restricting fluids Administering glucose-containing I.V. fluids as ordered Encouraging increased oral intake

Restricting fluids Explanation: To reduce water retention in a client with the SIADH, the nurse should restrict fluids. Administering fluids by any route would further increase the client's already heightened fluid load.

A charge nurse in a long-term care facility is planning the nursing assignments for the oncoming shift. Her staff consists of four nursing assistants and a licensed practical nurse (LPN). How should she divide nursing care among the staff to adequately ensure safe, effective care? The charge nurse performs treatments and supervises staff, the LPN administers medications and assists with care, and the nursing assistants provide direct client care. The charge nurse supervises staff, the LPN administers medications, and the nursing assistants provide direct client care. The charge nurse supervises staff and administers medications; the LPN and nursing assistants provide direct client care. The charge nurse supervises staff, the LPN performs treatments and administers medication, and the nursing assistants provide direct client care.

The charge nurse performs treatments and supervises staff, the LPN administers medications and assists with care, and the nursing assistants provide direct client care. Explanation: The charge nurse can best utilize her resources to provide safe and effective care by supervising the staff and providing treatments. The charge nurse should assign the LPN to administer medication and to help with client care as time allows. The nursing assistants should provide direct client care.

Upon admission to a long-term care facility, a client is administered a Mantoux test. The nurse reads the test in 48 hours and observes a 5-mm induration. What does this indicate to the nurse? The client is immune to tuberculosis. The client has active tuberculosis. The client has produced an immune response to the tuberculosis bacteria. The client will develop active tuberculosis.

The client has produced an immune response to the tuberculosis bacteria. Explanation: Skin testing is based on the antigen/antibody response and will show a positive reaction after an individual is exposed to tuberculosis and has formed antibodies to the tuberculosis bacteria. Thus, a positive Mantoux test indicates the production of an immune response. Exposure doesn't confer immunity. A positive test doesn't confirm that a person has or will develop tuberculosis.

The nurse is teaching the client how to use a cane. Which statement is inaccurate? The stride length and the timing of each step should be equal. The nurse should stand behind the client to prevent falls. The client should hold the cane close to his body. The client should hold the cane on the involved side.

The client should hold the cane on the involved side. Explanation: The client should hold the cane on the uninvolved side, 24" to 26" from the base of his little toe. This is done to promote a reciprocal gait pattern. The nurse should instruct the client to hold the cane close to his body to prevent leaning. The stride length and timing of each step should be equal. To prevent falls, the nurse should stand behind the client as he is learning to use the cane.

A client with a pneumothorax receives a chest tube attached to a Pleur-evac. The nurse notices that the fluid of the second chamber of the Pleur-evac is bubbling continuously. Which nursing assumptions would be valid? The tubing needs to be cleared of fluid. The client's affected lung has re-expanded. The tubing from the client to the chamber is blocked. There is a leak somewhere in the tubing system.

There is a leak somewhere in the tubing system. Explanation: Bubbling in the second chamber of a Pleur-evac system signifies that air is moving from the collection chamber to the water seal chamber. It's normal for bubbling to occur during inspiration, but continuous bubbling signifies a leak in the closed system. Absence of bubbling in the second chamber signifies a block in the system. It can also mean that the affected lung has re-expanded. Fluid in the tubing has no effect on the second chamber.

Which factor should the nurse be most concerned about when caring for a client taking an antianxiety medication? diarrhea transient hypertension abrupt withdrawal constipation

abrupt withdrawal Explanation: Abrupt discontinuation of an antianxiety drug can lead to withdrawal symptoms. Antianxiety medications are usually prescribed for short periods. If used over a prolonged period, such drugs may produce psychological or physical dependence. Transient hypertension, constipation, and diarrhea aren't associated with antianxiety drugs.

Which nursing intervention is most effective in maximizing tissue perfusion for a child in vaso-occlusive crisis? administer analgesics monitor fluid restrictions encourage activity as tolerated administer oxygen as prescribed

administer oxygen as prescribed Explanation: Administering oxygen is the most effective way to maximize tissue perfusion. Short term oxygen therapy helps to prevent hypoxia, which leads to metabolic acidosis, causing sickling. Analgesics are used to control pain. Hydration is essential to promote hemodilution and maintain electrolyte balance. Bed rest should be promoted to reduce oxygen utilization.

The health care provider prescribes several drugs for a client with hemorrhagic stroke. Which drug order should the nurse question prior to administration? methyldopa phenytoin dexamethasone heparin sodium

heparin sodium Explanation: Administration of heparin, an anticoagulant, could increase the bleeding associated with hemorrhagic stroke. Therefore, the nurse should question this order to prevent additional hemorrhage in the brain. In a client with hemorrhagic stroke, dexamethasone may be used to decrease cerebral edema and pressure; methyldopa may be used to reduce blood pressure; and phenytoin may be used to prevent seizures.

The nurse is reinforcing education for a client with uric acid calculi. Which type of diet should the nurse inform the client to avoid? high purine high oxalate low calcium low oxalate

high purine Explanation: To control uric acid calculi, the client should follow a low-purine diet, which excludes high-purine foods such as organ meats. The other diets do not control uric acid calculi.

During a follow-up visit to the physician, a client with hyperparathyroidism asks the nurse to explain the physiology of the parathyroid glands. The nurse states that these glands produce parathyroid hormone (PTH). PTH maintains the balance between calcium and: potassium. phosphorus. magnesium. sodium.

phosphorus. Explanation: PTH increases the serum calcium level and decreases the serum phosphate level. PTH doesn't affect sodium, potassium, or magnesium regulation.

The nurse is gathering data from a client with Meniere disease. Which symptom does the nurse relate to the disease process? epistaxis tinnitus facial pain ptosis

tinnitus Explanation: Tinnitus, dizziness, and vertigo occur in Meniere disease. Facial pain may occur with trigeminal neuralgia. Ptosis occurs with a variety of conditions, including myasthenia gravis. Epistaxis may occur with a variety of blood dyscrasias or local lesions.

A client has been diagnosed with lung cancer and is told that a wedge resection is required. The client asks the nurse for an explanation. What would be the nurse's best response? "The lobe of the lung involved will be removed." "A segment of the lung, including a bronchiole and its alveoli, will be removed." "A small, localized area near the surface of the lung will be removed." "One entire lung will be removed."

"A small, localized area near the surface of the lung will be removed." Explanation: A very small area of tissue close to the surface of the lung is removed in a wedge resection. A segment of the lung is removed in a segmental resection, a lobe is removed in a lobectomy, and an entire lung is removed in a pneumonectomy.

A client receiving ferrous sulfate therapy to treat an iron deficiency reports taking an antacid frequently to relieve heartburn. Which instruction should the nurse provide? "Take ferrous sulfate and the antacid at least 2 hours apart." "Take ferrous sulfate and the antacid at least 1 hour apart." "Take ferrous sulfate and the antacid together." "Avoid taking an antacid altogether."

"Take ferrous sulfate and the antacid at least 2 hours apart." Explanation: The nurse should instruct the client to take ferrous sulfate and an antacid at least 2 hours apart because antacids bind with iron in the GI tract, decreasing the rate or extent of iron absorption.

A mother is concerned that she might be spoiling her 2-month-old daughter by picking her up each time she cries. Which suggestion should the nurse offer? "If the baby's diaper is dry when she's crying, leave her alone and she'll fall asleep." "Continue to pick her up when she cries because young infants need cuddling and holding to meet their needs." "Leave your baby alone for 10 minutes. If she hasn't stopped crying by then, pick her up." "Crying at this age indicates hunger. Try feeding her when she cries."

"Continue to pick her up when she cries because young infants need cuddling and holding to meet their needs." Explanation: The nurse should advise the mother to continue to pick the infant up when she cries because a young infant needs to be cuddled and held when crying. Because the infant's cognitive development isn't advanced enough for her to associate crying with getting attention, it would be difficult to spoil her at this age. Even if her diaper is dry, a gentle touch may be necessary until she falls asleep. Crying for 10 minutes wears an infant out; ignoring crying can make the infant mistrust caregivers and the environment. Infants cry for many reasons, not just when hungry.

A clinical nurse specialist (CNS) is orienting a new licensed practical nurse to an oncology unit where blood product transfusions are frequently administered. In discussing ABO compatibility, the CNS presents several hypothetical scenarios. A well-informed new graduate would know the greatest likelihood of an acute hemolytic reaction would occur when giving: O-negative blood to an O-positive client. O-positive blood to an A-positive client. B-positive blood to an AB-positive client. A-positive blood to an A-negative client.

A-positive blood to an A-negative client. Explanation: An acute hemolytic reaction occurs when there is an ABO or Rh incompatibility. For example, giving A blood to a B client would cause a hemolytic reaction. Likewise, giving Rh-positive blood to an Rh-negative client would cause a hemolytic reaction. It's safe to give Rh-negative blood to an Rh-positive client if there is a blood type compatibility. O-negative blood is the universal donor and can be given to all other blood types. AB clients can receive either A or B blood as long as there isn't an Rh incompatibility.

A nurse is caring for a postoperative client. Which nursing intervention should the nurse perform to prevent thrombophlebitis? Encourage the client to cough and breathe deeply. Apply a sequential compression device. Gently massage the lower legs with lotion. Encourage the client to turn frequently.

Apply a sequential compression device. Explanation: A sequential compression device prevents thrombophlebitis in a postoperative client by applying intermittent pressure to the leg muscles, thereby promoting venous return. Coughing and deep-breathing exercises promote lung expansion and remove retained secretions, reducing the risk of atelectasis and pneumonia; however, they do not prevent thrombophlebitis. Leg massage should not be performed; massage may dislodge any preexisting clots. Frequent turning prevents skin breakdown and enhances lung function but does not prevent thrombophlebitis. Other nursing measures to reduce the risk of thrombophlebitis include early ambulation, leg exercises while on bed rest, subcutaneous heparin, and adequate hydration, as well as avoiding pressure on the back of the knees and deep veins of the legs.

When assessing a client with partial thickness burns over 60% of the body, which finding should the nurse report immediately? Hoarseness of the voice Reports of intense thirst Urine output of 70 ml within the first hour Moderate to severe pain

Hoarseness of the voice Explanation: Hoarseness is indicative of injury to the respiratory system and could indicate the need for immediate intubation. Thirst following burns is expected because of the massive fluid shifts and resultant loss leading to dehydration. Pain, either severe or moderate, is expected with a burn injury. The client's urine output is adequate.

The nurse is caring for a client with acute pyelonephritis. Which nursing intervention is most important? Encouraging the client to drink cranberry juice to acidify the urine Increasing fluid intake to 3 L/day Administering a sitz bath twice per day Using an indwelling urinary catheter to measure urine output accurately

Increasing fluid intake to 3 L/day Explanation: Acute pyelonephritis is a sudden inflammation of the interstitial tissue and renal pelvis of one or both kidneys. Infecting bacteria are normal intestinal and fecal flora that grow readily in urine. Pyelonephritis may result from procedures that involve the use of instruments (such as catheterization, cystoscopy, and urologic surgery) or from hematogenic infection. The most important nursing intervention is to increase fluid intake to 3 L/day. This helps empty the bladder of contaminated urine and prevents calculus formation. Administering a sitz bath would increase the likelihood of fecal contamination. Using an indwelling urinary catheter could cause further contamination. Encouraging the client to drink cranberry juice to acidify urine is helpful but isn't the most important intervention.

A client is scheduled for surgery at 8 a.m. While completing the preoperative checklist, the nurse sees that the surgical consent form hasn't been signed. It's time to administer the preoperative analgesic. Which nursing action takes the highest priority in this situation? Giving the preoperative analgesic at the scheduled time Asking the client to sign the consent form Notifying the surgeon that the consent form hasn't been signed Canceling the surgery

Notifying the surgeon that the consent form hasn't been signed Explanation: Notifying the surgeon takes priority because informed consent must be obtained before the client receives drugs that can alter cognition. Giving the preoperative analgesic at the scheduled time would alter the client's ability to give informed consent. Obtaining consent for surgery isn't within the scope of nursing practice, although the nurse may confirm or witness consent. Canceling surgery also isn't within the scope of nursing practice.

A client with metastatic brain cancer is admitted to the oncology floor. According to the Patient Self-Determination Act of 1991 (PSDA), what is the hospital required to do concerning the execution of advance directives? Decide on a treatment plan if the client can't. Inform the client or legal guardian of his right to execute an advance directive. Respect individuals' moral rights. Advise clients not to execute an advance directive because it limits treatment options.

Inform the client or legal guardian of his right to execute an advance directive. Explanation: The PSDA of 1991 requires all health care facilities to notify clients upon admission of their right to execute an advance directive. The facility's ethics committee can decide on a treatment plan if the client is unable to do so, and a durable power of attorney hasn't been appointed. Hospitals aren't required by law to respect individuals' moral rights; however, health care professionals should do so as part of their professional responsibility. Health care professionals are sometimes concerned that advance directives prevent treatment that might help the client. However, the hospital shouldn't advise clients not to execute an advance directive.

The nurse is reinforcing education with the parents of a child with a recurrent urinary tract infection (UTI). Which statement should the nurse include? Antibiotics should be discontinued 48 hours after symptoms subside. Follow-up urine cultures are necessary to detect recurrent infections and antibiotic effectiveness. Complicated UTIs are related to poor perineal hygiene practice. Recurrent symptoms should be treated by renewing the antibiotic prescription.

Follow-up urine cultures are necessary to detect recurrent infections and antibiotic effectiveness. Explanation: A routine follow-up urine specimen is usually obtained 2 or 3 days after the completion of the antibiotic treatment. All of the antibiotic should be taken as ordered and not stopped when symptoms disappear. If recurrent symptoms appear, a urine culture should be obtained to see whether the infection is resistant to antibiotics. Simple, not complicated, UTIs are generally caused by poor perineal hygiene.

A client has been admitted to the clinic with primary syphilis. Which signs or symptoms should the nurse expect to see with this diagnosis? copper-colored macules on the palms and soles that appeared after a brief fever one or more flat, wart-like papules in the genital area that are sensitive to touch patchy hair loss and red, broken skin involving the scalp, eyebrows, and beard areas a painless genital ulcer that appeared about 3 weeks after unprotected sex

a painless genital ulcer that appeared about 3 weeks after unprotected sex Explanation: A painless genital ulcer is a symptom of primary syphilis. Macules on the palms and soles after fever are indicative of secondary syphilis, as is patchy hair loss. Wartlike papules are indicative of genital warts.

A child has a red rash in a circular shape on the legs. The lesions are not connected. Which classification is the most appropriate for this rash? annular diffuse linear confluent

annular Explanation: An annular rash is ring-shaped. Linear rashes are lesions arranged in a line. A diffuse rash usually has scattered, widely distributed lesions. Confluent rash has lesions that are touching or adjacent to each other.

A client recovering from a spinal cord injury has a great deal of spasticity. What medication administered by the nurse may be used to control spasticity? baclofen methylprednisolone hydralazine lidocaine

baclofen Explanation: Baclofen is a skeletal muscle relaxant used to decrease spasms. Methylprednisolone, an anti-inflammatory drug, is used to decrease spinal cord edema. Hydralazine is an antihypertensive and afterload-reducing agent. Lidocaine is an antiarrhythmic and a local anesthetic agent.

A child is brought to the health care provider's office for treatment of a rash. Many petechiae are seen over the entire body. The nurse would suspect which condition? scabies varicella bleeding disorder vomiting

bleeding disorder Explanation: Petechiae are caused by blood outside a vessel, associated with low platelet counts and bleeding disorders. Petechiae are not found with varicella disease or scabies. Petechiae can be associated with vomiting, but in this case they would be present on the face, not the entire body.

A female client with genital herpes simplex is being treated in the outpatient department. The nurse teaches her about measures that may prevent herpes recurrences and emphasizes the need for prompt treatment if complications arise. Genital herpes simplex increases the risk of: cancer of the uterus. cancer of the cervix. cancer of the ovaries. cancer of the vagina.

cancer of the cervix. Explanation: A female client with genital herpes simplex is at increased risk for cervical cancer. Genital herpes simplex isn't a risk factor for cancer of the ovaries, uterus, or vagina.

Four clients are assigned to a nurse. Which client should the nurse identify who would benefit the most from hyperbaric oxygen therapy? client with a compromised skin graft client with Legionella-related pneumonia client with chronic obstructive pulmonary disease client with an open fracture of the femur

client with a compromised skin graft Explanation: A client with a compromised skin graft could benefit from hyperbaric oxygen therapy because increasing oxygenation at the wound site promotes wound healing. Hyperbaric oxygen therapy is not used to improve the oxygenation status of a client with chronic obstructive pulmonary disease or pneumonia. This type of treatment would not encourage bone healing after a fracture.

A client scheduled for a colonoscopy has received nothing by mouth since midnight. The procedure is scheduled for 8 a.m. At 6:30 a.m. the nurse collects a fingerstick glucose sample that registers 40 mg/dl on the glucose monitor. The client is alert, has clear speech, and states, "I don't feel like my sugar is too low." Initially, the nurse should: notify the registered nurse immediately so she can administer 50 g of dextrose I.V. document the finding and withhold the client's morning insulin. repeat the fingerstick glucose test. give the client an oral simple sugar.

repeat the fingerstick glucose test. Explanation: Because the client is showing no signs of hypoglycemia, yet the glucose level is abnormally low, an error may have occurred in obtaining the result. Therefore, the nurse should repeat the test. Responding to the low results takes precedence over documenting the findings. Because of the inconsistency between the 40 mg/dl reading and the absence of symptoms, the value should be rechecked before any glucose is administered.

An infant who has been in foster care since birth requires a blood transfusion. Who is authorized to give written informed consent for the procedure? the foster parent the social worker who placed the infant in the foster home a nurse caring for the infant a nurse-manager

the foster parent Explanation: When minor children are unemancipated, their parents or designated legal guardians are responsible for providing consent for medical procedures. Therefore, the foster parent, who is the legal guardian, is authorized to give consent for the blood transfusion. The social worker, the nurse, and the nurse-manager have no legal rights to give consent in this scenario.