pass point pt 8

A client with asthma is receiving a theophylline preparation to promote bronchodilation. Because of the risk of drug toxicity, the nurse must monitor the client's serum theophylline level closely. When reviewing this client's chart, which range will the nurse identify as the therapeutic theophylline concentration? 1 to 2 mcg/ml 3 to 5 mcg/ml 6 to 9 mcg/ml 10 to 20 mcg/ml

10 to 20 mcg/ml Explanation: The therapeutic serum theophylline concentration ranges from 10 to 20 mcg/ml. Values below 10 mcg/ml aren't therapeutic.

A nurse administered NPH insulin to a diabetic client at 7 a.m. At what time would the nurse expect the client to be most at risk for a hypoglycemic reaction? 6 p.m. 8 p.m. 4 p.m. 10 p.m.

4 p.m. Explanation: NPH is an intermediate-acting insulin that peaks 4 to 12 hours after administration. Because the nurse administered NPH insulin at 7 a.m., the client is at greatest risk for hypoglycemia from 11 a.m. to 7 p.m.

A client sees a dermatologist for a skin problem. Later, the nurse reviews the client's chart and notes that the chief concern was intertrigo. This term refers to which condition? Spontaneously occurring wheals A fungus that enters the skin's surface, causing infection Inflammation of a hair follicle Irritation of opposing skin surfaces caused by friction

Irritation of opposing skin surfaces caused by friction Explanation: Intertrigo refers to irritation of opposing skin surfaces caused by friction. Spontaneously occurring wheals occur in hives. A fungus that enters the skin surface and causes infection is a dermatophyte. Inflammation of a hair follicle is called folliculitis.

A nurse prepares to discharge a client who just had a cataract removed and an intraocular lens implanted. Which instruction should the nurse reinforce to the client? "Avoid sleeping on the operative side." "Wear an eye shield continuously for 2 weeks." "Take a dose of aspirin for mild pain."' "Straining during bowel movements is allowed."

"Avoid sleeping on the operative side." Explanation: Clients who have had cataract surgery should avoid sleeping on the operative side as well as lifting heavy objects and straining, all of which could cause bleeding in the eye. Due to its anticoagulant properties, aspirin should be avoided for the same reason. An eye shield should be worn continuously for the first 24 hours postoperatively. Straining during a bowel movement should be avoided because it increases intraocular pressure.

A 2-year-old is brought to the clinic by his mother for his annual examination. Which statement by the mother alerts the nurse to the toddler's risk for malnutrition? "He eats peanut butter and jelly sandwiches every day." "He loves cheese, crackers, and all kinds of fruit." "He's so busy at meal time so I give him frequent snacks of a variety of foods throughout the day." "He drinks a bottle of whole milk several times a day."

"He drinks a bottle of whole milk several times a day." Explanation: A 2-year-old should consume 2% milk with meals from a cup, not a bottle. Drinking whole milk several times per day prevents the toddler from consuming other foods that are essential to his diet, leaving him at risk for malnutrition. Toddlers commonly develop preferences for foods that they consume on a regular basis, such as peanut butter and jelly sandwiches. This food preference doesn't place the toddler at risk for malnutrition. Toddlers are typically unable to sit still for meals; therefore, small, frequent feedings are recommended. Cheese, crackers, and fruit are good food choices for toddlers.

A client is brought to the psychiatric clinic by family members, who tell the admitting nurse that the client repeatedly drives while intoxicated despite their pleas to stop. During an interview with the nurse, which statement by the client most strongly supports a diagnosis of psychoactive substance abuse? "I'm not addicted to alcohol. In fact, I can drink more than I used to without being affected." "I only spend half of my paycheck at the bar." "I just drink to relax after work." "I know I've been arrested three times for drinking and driving, but the police are just trying to hassle me."

"I know I've been arrested three times for drinking and driving, but the police are just trying to hassle me." Explanation: According to the Diagnostic and Statistical Manual of Mental Disorders, 4th edition, Text Revision, diagnostic criteria for psychoactive substance abuse include a maladaptive pattern of such use, indicated either by continued use despite knowledge of having a persistent or recurrent social, occupational, psychological, or physical problem. The problem is caused or exacerbated by substance abuse or recurrent use in dangerous situations (for example, while driving). For this client, psychoactive substance dependence must be ruled out. Criteria for this disorder include a need for increasing amounts of the substance to achieve intoxication (option 1), increased time and money spent on the substance (option 2), inability to fulfill role obligations (option 3), and typical withdrawal symptoms.

A child, age 5, is diagnosed with mycoplasma pneumonia and has a persistent productive cough. When monitoring the child's respirations, the nurse should keep in mind that children normally use which muscles to breathe? Accessory Thoracic Abdominal Intercostal

Abdominal Explanation: Normally, children and men use the abdominal muscles to breathe, whereas women use the thoracic muscles. Use of the accessory or intercostal muscles would indicate a respiratory problem.

A nurse is gathering data on a client diagnosed with appendicitis. Which signs and symptoms would the nurse expect to find? rigid abdomen, Levine sign, and pain relief when leaning forward rebound tenderness, McBurney sign, and low-grade fever right lower quadrant pain, Chvostek sign, and muscle guarding periumbilical pain, Trousseau sign, and pain relief with pressure

rebound tenderness, McBurney sign, and low-grade fever Explanation: Rebound tenderness, McBurney sign (pain midway between the umbilicus and right iliac crest), and low-grade fever are all signs of appendicitis. Other clinical findings include a rigid abdomen, a preference to lie still with right leg flexed, right lower quadrant pain, muscle guarding, periumbilical pain, anorexia, nausea, and vomiting. The other findings are not signs and symptoms of appendicitis.

Which of the following changes is demonstrated when a nurse helps a young mother adjust to the birth of her child? unplanned situational maturational physiologic

situational Explanation: Adjustment to the birth of a child is an example of a situational change, which arises from the interaction between individuals and the environment. Because pregnancy is a nine-month process, the change isn't unplanned. Adjustment to maturational change refers to that associated with puberty. Physiologic change refers to the events associated with aging and menopause.

A client with a spontaneous pneumothorax has a chest tube connected to a drainage system and suction. Which situation does the nurse identify could cause a problem in proper functioning of the chest tube drainage system? Keeping the chest drainage system at floor level Blood clots in the drainage tubing Bubbling in the suction chamber Fluctuating levels in the underwater seal chamber

Blood clots in the drainage tubing Explanation: The chest tube may occlude if a blood clot lodges in the drainage tubing, which could result in tension pneumothorax. To ensure proper drainage, the chest drainage system should remain at floor level. Bubbling normally occurs in the suction chamber if the water suction system is working properly. Fluctuation in the underwater seal is normal with inspiration and expiration.

To treat a urinary tract infection (UTI), a client is prescribed sulfamethoxazole-trimethoprim. The nurse should teach the client that sulfamethoxazole-trimethoprim is most likely to cause which adverse effect? Anxiety Headache Diarrhea Dizziness

Diarrhea Explanation: Sulfamethoxazole-trimethoprim is most likely to cause diarrhea. Nausea and vomiting are other common adverse effects. This drug rarely causes anxiety, headache, or dizziness.

Which nursing intervention would be the priority when caring for a client with a dissociative disorder? Encouraging the client to participate in unit activities and meetings Questioning the client about the events triggering the dissociative disorder Allowing the client to remain in the client's room anytime the client is experiencing feelings of dissociation Encouraging the client to form friendships with other clients in his therapy groups to decrease his feelings of isolation

Encouraging the client to participate in unit activities and meetings Explanation: Individuals with certain dissociative disorders feel detached from their environment and can experience impaired social functioning. Attending unit activities and meetings helps decrease the client's sense of isolation. Often, the client can't recall the events that triggered the dissociative disorder, so the client would need to be isolated from others only if the client couldn't interact appropriately. A client with a dissociative disorder has typically had few healthy relationships. Forming friendships with others in therapy could result in the client establishing unhealthy relationships.

A 1-year-old infant with bronchopulmonary dysplasia has just received a tracheostomy. Which intervention by the nurse is appropriate? Keep extra tracheostomy tubes at the bedside. Secure ties at the side of the neck. Change the tracheostomy tube 2 weeks after surgery. Secure the tracheostomy ties tightly to prevent dislodgment of the tube.

Keep extra tracheostomy tubes at the bedside. Explanation: Extra tracheostomy tubes should be kept at the bedside in case of an emergency, including one size smaller in case the appropriate size doesn't fit due to edema. The ties should be placed securely but should allow some space (the width of a pinky finger) to prevent excessive pressure or skin breakdown. The first tracheostomy tube change is usually performed by the health care provider after 7 days. Ties are placed at the back of the neck.

A client is undergoing a left modified radical mastectomy for breast cancer. Postoperatively, blood pressure should be obtained from the client's right arm, and the left arm and hand should be elevated as much as possible to prevent which condition? Lymphedema Trousseau's sign I.V. infusion infiltration Muscle atrophy related to immobility

Lymphedema Explanation: Lymphedema is a common postoperative adverse effect of modified radical mastectomy and lymph node dissection. Elevation of the arm on the affected side will allow gravity to assist lymph drainage. Other preventive measures include exercises in which the arms are elevated. Trousseau's sign is a sign of hypocalcemia and wouldn't be expected in this situation. Neither I.V. infusions nor venipunctures should be given in the left arm. Although muscle atrophy is a potential adverse effect if the client doesn't exercise her left arm, it wouldn't be prevented by elevating the arm.

A client in active labor is sweating profusely and has minimal urine output. Which of the following is how the nurse should intervene? Suggest that the client drink more water Offer the client ice chips and ask the charge nurse to notify the physician of the low urine output Do not intervene because this is a normal finding during active labor Supply the client with beverages that she enjoys drinking

Offer the client ice chips and ask the charge nurse to notify the physician of the low urine output Explanation: This client is showing signs of dehydration; therefore, the nurse should offer the client ice chips and then ask the charge nurse to notify the physician of the client's low urine output. The client may not be able to tolerate other fluids. Oral fluids may not be sufficient to combat the dehydration. Failing to intervene may lead to severe dehydration.

A client reports severe pain in the back and joints. Upon reviewing the client's history, the nurse notes a diagnosis of depression and frequent hospitalizations for somatic illnesses. What should the nurse encourage this client to do? Tell the physician about the pain so that its cause can be determined. Remember all of the previous "health problems" that weren't real. Try to get more rest and use relaxation techniques . Ignore the pain and focus on happy things.

Tell the physician about the pain so that its cause can be determined. Explanation: Initially, the nurse should treat all symptoms as indicators of possible pathology because a history of psychophysiological illness doesn't rule out a purely physical illness as a cause of the client's current symptoms. The other options assume that the client has a psychophysiological illness, which could lead to ignoring a physical illness or condition.

The nurse is working with a group of adolescents reviewing information regarding the human immunodeficiency virus (HIV). What fact is important for the nurse to include in the review? The incidence of HIV in the adolescent population has declined since 1995. The virus can be spread through many routes, including sexual contact. Knowledge about HIV spread and transmission has led to a decrease in the spread of the virus among adolescents. About 50% of all new HIV infections in the United States occur in people younger than age 22.

The virus can be spread through many routes, including sexual contact. Explanation: HIV can be spread through many routes, including sexual contact and contact with infected blood or other body fluids. The incidence of HIV in the adolescent population has increased since 1995, even though more information about the virus is targeted to reach the adolescent population. Only about 25% of all new HIV infections in the United States occurs in people younger than age 22.

A client seeks medical evaluation for fatigue, night sweats, and a 20-lb weight loss in 6 weeks. To confirm that the client has been infected with the human immunodeficiency virus (HIV), the nurse expects the physician to order: E-rosette immunofluorescence. quantification of T-lymphocytes. enzyme-linked immunosorbent assay (ELISA). Western blot test with ELISA.

Western blot test with ELISA. Explanation: HIV infection is detected by analyzing blood for antibodies to HIV, which form approximately 2 to 12 weeks after exposure to HIV and denote infection. The Western blot test — electrophoresis of antibody proteins — is more than 98% accurate in detecting HIV antibodies when used in conjunction with the ELISA. It isn't specific when used alone. E-rosette immunofluorescence is used to detect viruses in general; it doesn't confirm HIV infection. Quantification of T-lymphocytes is a useful monitoring test but isn't diagnostic for HIV. The ELISA test detects HIV antibody particles but may yield inaccurate results; a positive ELISA result must be confirmed by the Western blot test.

The physician orders chest physiotherapy for a client with respiratory congestion. When should the nurse plan to perform chest physiotherapy? After meals Before meals When the client has time When the nurse has time

Before meals Explanation: Chest physiotherapy is best performed before meals to avoid tiring the client or inducing vomiting. Scheduling chest physiotherapy around client or nurse convenience is inappropriate.

Propranolol is used in the mental health setting to manage which condition? Antipsychotic-induced akathisia and anxiety The manic phase of bipolar illness as a mood stabilizer Delusions for clients suffering from schizophrenia Obsessive-compulsive disorder (OCD) to reduce ritualistic behavior

Antipsychotic-induced akathisia and anxiety Explanation: Propranolol is a potent beta-adrenergic blocker and produces a sedating effect; therefore, it's used to treat antipsychotic induced akathisia and anxiety. Lithium is used to stabilize clients with bipolar illness. Antipsychotics are used to treat delusions. Some antidepressants have been effective in treating OCD.

A client comes to the emergency department complaining of severe pain in the right flank, nausea, and vomiting. The physician tentatively diagnoses right ureterolithiasis (renal calculi). When planning this client's care, the nurse should assign highest priority to which nursing diagnosis? Acute pain Risk for infection Deficient knowledge related to medication regimen Imbalanced nutrition: Less than body requirements

Acute pain Explanation: Ureterolithiasis typically causes such acute, severe pain that the client can't rest and becomes increasingly anxious. Therefore, the nursing diagnosis of Acute pain takes highest priority. Diagnoses of Risk for infection and Deficient knowledge related to medication regimen are appropriate when the client's pain is controlled. A diagnosis of Imbalanced nutrition: Less than body requirements isn't pertinent at this time.

A client is confused and continuously attempts to get out of bed. The health care provider prescribes a vest restraint. When applying the vest restraint, what should the nurse keep in mind? Crisscross the straps in the back. The vest must be wrapped tightly. Tie a regular knot to secure the straps. Allow room for the client to turn.

Allow room for the client to turn. Explanation: When applying a vest restraint to a confused client who continuously attempts to get out of bed, the nurse should allow room for the client to turn. The nurse should never crisscross the straps in the back because the client may choke himself. Wrapping the vest tightly may impede breathing. Tying a quick release knot, rather than a regular knot, is the standard required by the Joint Commission; this knot secures the straps but allows for quick release.

A 6-year-old child has been hospitalized with rheumatic fever for 4 weeks. Symptoms have gradually subsided, and the child is ready for discharge. The nurse is reinforcing education with the parents. What is a priority nursing action for the child's future well-being? Arrange for the child to return to school as soon as possible to promote psychosocial development. Encourage the child to engage in unrestricted physical activity to regain physical strength. Arrange for the administration of prophylactic antibiotics to prevent a recurrence of rheumatic fever. Maintain seizure precautions because central nervous system involvement may persist for several months.

Arrange for the administration of prophylactic antibiotics to prevent a recurrence of rheumatic fever. Explanation: Children who have had rheumatic fever are more susceptible to contracting it again. Prophylactic antibiotics are typically maintained for at least 5 years following the initial attack, or until they are 18 years of age. Psychosocial development can be promoted even before the child's return to school is appropriate. Physical activity should be limited until the child's cardiac status is normal. Choreic movements are signs of rheumatic fever, are more common than seizures, and are not permanent.

When preparing a client with a draining vertical incision for ambulation, where should the nurse apply reinforced dressings? At the top of the wound In the middle of the wound At the base of the wound Over the total wound

At the base of the wound Explanation: When a client is ambulating, gravity causes the drainage to flow downward. Covering the base of the wound with extra dressing will contain the drainage. Reinforcing the dressing at the top, in the middle, or over the total wound won't contain the drainage.

Which food should be included in a client's diet during the first 6 to 8 weeks after ileostomy surgery? Fresh corn Celery Bran cereal Banana

Banana Explanation: Bananas are considered one of the most nutritious foods and are low in fiber. High-fiber foods such as fresh corn, celery, and bran cereal should be avoided during the first 6 to 8 weeks after placement of an ileostomy.

When monitoring a client receiving amitriptyline therapy, the nurse should be alert for which potentially life-threatening adverse effect? Cardiac arrhythmias Hypertensive crisis Priapism Orthostatic hypotension

Cardiac arrhythmias Explanation: Tricyclic antidepressants such as amitriptyline affect norepinephrine and may cause cardiac electrical conduction problems (arrhythmias). An overdose can produce arrhythmias that may result in death. The nurse monitors clients receiving monoamine oxidase inhibitors for hypertensive crisis. Trazodone can cause the medical emergency priapism (persistent abnormal erection of the penis). Orthostatic hypotension isn't usually a life-threatening adverse effect.

The nurse is caring for a terminally ill client with cancer who is receiving hospice services with an advance directive. Which nursing action is a priority? Maintain hydration status with IV fluids. Care for elimination needs. Assist with the administration of chemotherapeutic agents. Monitor airway status and prepare to assist with intubation.

Care for elimination needs. Explanation: Caring for a client's elimination needs is a basic comfort measure and should be a priority. If the client is using hospice services, intubation, IV fluids, and chemotherapy are not part of the plan of care. Comfort measures should be the priority.

A nurse must evaluate a client's splinted extremity for neurovascular damage. What is the priority action by the nurse? Evaluate all extremities, ensuring that the extremity with the splint feels cooler. Manually move the client's fingers and toes to test movement. Compare color and capillary refill of both extremities. Be aware that edema and pulse checks are not part of a neurovascular evaluation.

Compare color and capillary refill of both extremities. Explanation: During a complete neurovascular check, the nurse should compare the extremities, including color and capillary refill of both extremities. Normal color should be pink. A dusky or cyanotic appearance would suggest circulatory compromise. Capillary refill should be the same bilaterally. The extremities should be equally warm. Movement should be checked by having the client move the fingers and toes. Edema and pulse checks are part of a neurovascular evaluation.

A client must take streptomycin for tuberculosis. Before therapy begins, the nurse should instruct the client to notify the physician if which health concern occurs? Impaired color discrimination Increased urinary frequency Decreased hearing acuity Increased appetite

Decreased hearing acuity Explanation: Decreased hearing acuity indicates ototoxicity, a serious adverse effect of streptomycin therapy. The client should notify the physician immediately if it occurs so that streptomycin can be discontinued and an alternative drug can be prescribed. The other options aren't associated with streptomycin. Impaired color discrimination indicates color blindness; increased urinary frequency and increased appetite accompany diabetes mellitus.

A pregnant client is prescribed an iron supplement. Which point should the nurse include when teaching the client about taking the supplement? Take the supplement with bran, milk, or eggs to increase absorption of the supplement. Avoid taking the supplement on an empty stomach. Eat a diet rich in vitamin C to promote iron absorption. Avoid taking the supplement at bedtime to prevent GI upset.

Eat a diet rich in vitamin C to promote iron absorption. Explanation: The nurse should teach the client that iron absorption is enhanced by a diet rich in vitamin C. Bran, milk, eggs, coffee, tea, and foods containing oxalate, such as spinach and Swiss chard, inhibit iron absorption when consumed at the same time. Iron supplements are best absorbed on an empty stomach; however, if taking the supplement on an empty stomach causes GI distress, the client may take it just before bedtime to lessen discomfort.

A client with type 1 diabetes has a leg infection that is being treated with antibiotics, wet-to-dry dressings, and whirlpool therapy. Since the infection began, the client's blood glucose levels have been unstable. Which data collected by the nurse indicate a serious complication? Flushed cheeks, dry mouth, and acetone breath odor Mental changes, fever, and hand tremors Headache, sweating, and nervousness Periods of rapid breathing followed by absence of breathing, picking at the bed linens, and nausea

Flushed cheeks, dry mouth, and acetone breath odor Explanation: Diabetic ketoacidosis in a client with type 1 diabetes is characterized by flushed skin, signs of dehydration (such as dry mouth), and fast, deep, labored breathing with a smell of acetone on the breath. Mental changes, fever, hand tremors, headache, sweating, nervousness, breathing abnormalities, picking at bed linens, and nausea are not classic signs of hyperglycemia.

A nurse is caring for a client with a nasogastric (NG) tube 2 days after a subtotal gastrectomy. Which intervention should the nurse perform? Apply suction to the NG tube every 1 to 2 hours. Clamp the NG tube if the client reports flatus. Gently irrigate the tube with normal saline. Reposition the NG tube whenever it moves.

Gently irrigate the tube with normal saline. Explanation: The nurse can gently irrigate the NG tube as prescribed for a client who has had a subtotal gastrectomy but must take care not to reposition or dislodge it. Repositioning can cause bleeding or perforation. Low suction is applied continuously, not every 1 to 2 hours. The NG tube should not be clamped postoperatively because secretions and gas can accumulate, stressing the suture line.

A nurse is monitoring a client for signs of early alcohol withdrawal. Which most consistent assessment finding associated with early alcohol withdrawal would the nurse expect to find? Heart rate of 120 to 140 beats/minute Heart rate of 50 to 60 beats/minute Blood pressure of 100/70 mm Hg Blood pressure of 140/80 mm Hg

Heart rate of 120 to 140 beats/minute Explanation: Tachycardia, a heart rate of 120 to 140 beats/minute, is a common sign of alcohol withdrawal. Blood pressure may be labile throughout withdrawal, fluctuating at different stages. Mild hypertension typically occurs in early withdrawal; hypertension with diastolic pressure greater than 100 is associated with later symptoms. Hypotension, although rare during the early withdrawal stages, may occur in later stages. Hypotension is associated with cardiovascular collapse and most commonly occurs in clients who don't receive treatment. The nurse should monitor the client's vital signs carefully throughout the entire alcohol withdrawal process.

Which of these findings best correlates with a diagnosis of osteoarthritis? Joint stiffness that decreases with activity Erythema and edema over the affected joint Anorexia and weight loss Fever and malaise

Joint stiffness that decreases with activity Explanation: A characteristic feature of osteoarthritis (degenerative joint disease) is joint stiffness that decreases with activity and movement. The other options are associated with rheumatoid arthritis, a more severe and destructive form of arthritis.

What is an appropriate nursing intervention for a client with a soft wrist restraint? Applying the restraint loosely to prevent pressure on the skin Tying the restraint to the side rail Positioning the restrained arm in full extension Monitoring circulatory status every 15 minutes if the client is agitated, or every 2 hours if the client is calm

Monitoring circulatory status every 15 minutes if the client is agitated, or every 2 hours if the client is calm Explanation: The nurse must monitor the circulatory status of a restrained extremity every 15 minutes if the client is agitated, or every 2 hours if the client is calm to prevent circulatory impairment. To make sure the restraint is secure without compromising the circulation, the nurse should leave approximately one fingerbreadth between the restraint and the extremity. Tying a restraint to the side rail or an immovable bed part may cause client injury if the rail or bed is moved before the restraint is released. The restrained arm or leg should be flexed slightly to allow slight joint movement without reducing the effectiveness of the restraint.

A postpartum client with diabetes wants to breast-feed but is concerned about the effects of breast-feeding on her health. Which response would be most appropriate? Mothers with diabetes who breast-feed have a hard time controlling their insulin needs. Mothers with diabetes shouldn't breast-feed because of potential complications. Mothers with diabetes shouldn't breast-feed; insulin requirements usually are doubled. Mothers with diabetes may breast-feed; insulin requirements may decrease from breast-feeding.

Mothers with diabetes may breast-feed; insulin requirements may decrease from breast-feeding. Explanation: Breast-feeding has an antidiabetic effect. Insulin needs are decreased because carbohydrates are used in milk production. Breast-feeding clients are at a higher risk for hypoglycemia in the first postpartum days after birth because glucose levels are lower. Diabetic clients should be encouraged to breast-feed.

A nurse is caring for four clients and determines which client is at the highest risk for suicide? One who appears depressed, frequently thinks of dying, and gives away all personal possessions One who plans a violent death and has the means readily available One who tells others that he or she might do something if life does not get better soon One who talks about wanting to die

One who plans a violent death and has the means readily available Explanation: The client at highest risk for suicide is one who plans a violent death (for example, by gunshot, jumping off a bridge, or hanging), has a specific plan (for example, after the spouse leaves for work), and has the means readily available (for example, a rifle hidden in the garage). A client who gives away possessions, thinks about death, or talks about wanting to die or attempting suicide is considered a lower risk for suicide. This behavior typically serves to alert others that the client is contemplating suicide and wishes to be helped.

A client has been admitted to the hospital with signs of dehydration. Which action would be least beneficial in increasing the client's fluid intake? Explaining the need for increased fluid Placing the client's choices of beverages at the bedside Serving fluids in large amounts Serving fluids at appropriate temperatures

Serving fluids in large amounts Explanation: Fluids should be served in small amounts at frequent intervals. It's overwhelming to the client to have large amounts of fluids to drink. Educating the client about the need for fluid increase and including him in the selection of beverages will enhance compliance. Fluids should be served at the appropriate temperatures to increase enjoyment and palatability.

Vaginal examination of a client in labor reveals the fetus's larger, diamond-shaped fontanel is toward the anterior portion of the client's pelvis. The nurse interprets this finding as indicative of what situation? The client can expect a brief and intense labor, with potential for lacerations. The client is at risk for uterine rupture and needs constant monitoring. The client may need interventions to ease her back labor and change the fetal position. The client must be told that birth of the fetus will require forceps or a vacuum extractor.

The client may need interventions to ease her back labor and change the fetal position. Explanation: The fetal position is occiput posterior, a position that commonly produces intense back pain during labor. Most of the time, the fetus rotates during labor to occiput anterior position. Positioning the client on her side can facilitate this rotation. An occiput posterior position would most likely result in prolonged labor. Occiput posterior position alone doesn't create a risk of uterine rupture. Forceps or vacuum extractor would be necessary only if the fetus didn't rotate spontaneously.

A client is diagnosed with a herniated nucleus pulposus (HNP) or herniated disk. Which statement should the nurse include when reinforcing education about a herniated disk? The disk slips out of alignment. The disk shatters, and fragments place pressure on nerve roots. The nucleus tissue itself remains centralized, and the surrounding tissue is displaced. The nucleus of the disk puts pressure on the anulus, causing pressure on the nerve root.

The nucleus of the disk puts pressure on the anulus, causing pressure on the nerve root. Explanation: With a herniated nucleus pulposus, or herniated disk, the nucleus of the disk puts pressure on the anulus, causing pressure on the nerve root. The disk itself doesn't slip, rupture, or shatter. The nucleus tissue usually moves from the center of the disk.

A client admitted with deep vein thrombosis of the left leg is prescribed bed rest. The client states that she's unable to void in the bedpan. Which action should the nurse take? Notify the physician and request an order to insert an indwelling urinary catheter. Place a urinary incontinence pad on the client's bed and change it immediately if it becomes soiled. Obtain a bedside commode. When the client has the urge to void, assist her to a sitting position on the bedpan.

When the client has the urge to void, assist her to a sitting position on the bedpan. Explanation: The nurse should assist the client to a sitting position on the bedpan when the client has the urge to void. The sitting position is the natural position assumed to void, and assisting her to this position may enable her to void on the bedpan. An indwelling urinary catheter isn't indicated at this time; inserting one unnecessarily places the client at risk for infection. The client isn't incontinent so there's no need to place incontinence pads on the client's bed. Obtaining a bedside commode for the client to use violates the bed rest order.

A client has a phenytoin level of 32 mg/dl. Which symptoms should the nurse monitor based on the result? ataxia and confusion sodium depletion tonic-clonic seizure urinary incontinence

ataxia and confusion Explanation: A therapeutic phenytoin level is 10 to 20 mg/dl. A level of 32 mg/dl indicates phenytoin toxicity. Symptoms of toxicity include confusion and ataxia. Phenytoin doesn't cause hyponatremia, seizure, or urinary incontinence. Incontinence may occur during or after a seizure.

An adolescent who's depressed and reported by the parents as having difficulty in school is brought to the community mental health center to be evaluated. Which other health problem would the nurse suspect? anxiety disorder behavioral difficulties cognitive impairment labile moods

behavioral difficulties Explanation: Adolescents tend to demonstrate severe irritability and behavioral problems rather than simply a depressed mood. Anxiety disorder is more commonly associated with small children rather than adolescents. Cognitive impairment is typically associated with delirium or dementia. Labile mood is more characteristic of a client with cognitive impairment or bipolar disorder.

A client is placed on several medications after having a myocardial infarction (MI). Which drug class is part of the medication regimen for this client that will protect the ischemic myocardium by decreasing catecholamines and sympathetic nerve stimulation? beta blockers calcium channel blockers opioids nitrates

beta blockers Explanation: Beta blockers work by decreasing catecholamines and sympathetic nerve stimulation. They protect the myocardium, helping to reduce the risk of another infarction by decreasing the heart's workload. Calcium channel blockers reduce workload by decreasing the heart rate and dilating arteries. Opioids reduce myocardial oxygen demand. Nitrates reduce myocardial oxygen consumption and decrease blood pressure.

A primigravida woman in her second trimester who has a history of rheumatic fever tells a nurse her fingers feel tight and sometimes she feels as though her heart skips a beat. Which symptom indicates the client may be experiencing heart failure? clear breath sounds a heart rate of 102 beats per minute bilateral crackles runs of paroxysmal atrial tachycardia

bilateral crackles Explanation: Crackles should alert the nurse to cardiovascular compromise and heart failure. Cardiac dysrhythmias (other than sinus tachycardia or paroxysmal atrial tachycardia) and persistent crackles at the bases, not clear breath sounds, are also symptoms of heart failure.

A child presents in the emergency department after being hit in the head by a baseball. The child begins to excrete extremely large amounts of urine and becomes dehydrated. Which condition does the nurse suspect the child has developed? diabetes mellitus diabetes insipidus syndrome of inappropriate ADH secretion parathyroid hypofunction

diabetes insipidus Explanation: Diabetes insipidus is the principal disorder caused by posterior pituitary hypofunction. The disorder results from hyposecretion of antidiuretic hormone, producing a state of uncontrolled diuresis. Diabetes insipidus can be acquired as the result of a head injury or tumor.

A client with second- and third-degree burns on the arms receives autografts. Two days later, the nurse finds the client doing arm exercises. The nurse knows that this client should avoid arm exercise because it may: dislodge the autografts. increase edema in the arms. increase the amount of scarring. decrease circulation to the fingers.

dislodge the autografts. Explanation: Because exercising the autograft sites may dislodge the grafted tissue, the nurse should advise the client to keep the grafted extremity in a neutral position. None of the other options results from exercise.

A nurse is assisting a postpartum client to breast-feed her newborn. The client is having difficulty in establishing an adequate supply of breast milk. The nurse understands that which factor might play a role? supplemental formula feedings maternal diet high in vitamin C an alcoholic drink frequent feedings

supplemental formula feedings Explanation: Routine formula supplementation may interfere with establishing an adequate milk volume because decreased stimulation to the client's nipples affects hormonal levels and milk production. Vitamin C levels haven't been shown to influence milk volume. One drink containing alcohol generally tends to relax the client, facilitating letdown. Excessive consumption of alcohol may block letdown of milk to the infant, though supply isn't necessarily affected. Frequent feedings are likely to increase milk production.

A client is admitted to the facility in preterm labor. To halt her uterine contractions, the nurse expects the health care provider to prescribe: betamethasone. dinoprostone. oxytocin. terbutaline.

terbutaline. Explanation: Terbutaline, a selective beta2-receptor agonist, is used to inhibit preterm uterine contractions. Betamethasone is used to accelerate surfactant production in preterm labor. Dinoprostone is used to induce fetal expulsion and promote cervical dilation and softening. Oxytocin is used to impede uterine blood flow — for example, in hemorrhage.

When preparing a client scheduled for a thyroid function test, the nurse questions the client about medications. Which medications contain iodine and could alter the results? acetaminophen and aspirin estrogen and amphetamines insulin and oral antidiabetic agents topical antiseptics and multivitamins

topical antiseptics and multivitamins Explanation: Topical antiseptics and multivitamins contain iodine and can alter thyroid function test results. Estrogen and amphetamines don't contain iodine but may alter thyroid function test results. Insulin, oral antidiabetic agents, acetaminophen, and aspirin won't affect a thyroid test.

The nurse is completing the admission assessment of a client in the labor and delivery area, when the client and her husband ask whether their sons, ages 8 and 10, can witness the childbirth. Which statement made by the nurse is accurate? "The children and client should share a support person during the childbirth." "Children should attend childbirth only if it takes place at home." "Children shouldn't attend childbirth because it will frighten them." "Each child attending the childbirth should have a separate support person."

"Each child attending the childbirth should have a separate support person." Explanation: Each child attending the childbirth should have a support person — one who isn't also serving as the client's support person. The support person explains what is happening, reassures the child, and removes the child from the area if an emergency occurs or if the child becomes frightened. Children can attend childbirth in any setting. The decision to have a child present hinges on the child's developmental level, ability to understand the experience, and amount of preparation.

A nurse is caring for a client who underwent stapedectomy. To prevent postoperative complications, what should the nurse instruct the client to do? "Sneeze with your mouth open." "Blow your nose frequently." "Clean your operated ear with a cotton-tipped applicator twice per day." "Resume bending when you are no longer experiencing any ear pain."

"Sneeze with your mouth open." Explanation: If sneezing cannot be avoided, the client should sneeze with his mouth open to prevent air pressure changes in the middle ear, which can dislodge the prosthesis and graft. Blowing the nose and coughing should be avoided. Small objects, such as cotton-tipped applicators, should not be inserted into the ear. Straining during a bowel movement and bending should be avoided for at least 2 to 3 weeks, or as instructed by the primary care provider.

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 pregnant client asks questions about labor and delivery. During the nurse's explanations, the client states, "Is it true that a lot of other people are going to be in the room while I'm giving birth? I was expecting privacy." Which response would be appropriate for the nurse to make to this client? "Didn't you know that many people get involved when someone has a baby?" "What did the health care provider tell you about the delivery room?" "You can ask anyone you don't want in the room to leave." "You won't even know they're there."

"What did the health care provider tell you about the delivery room?" Explanation: Option 2 is the most appropriate response. The client's statement indicates that she most likely requires more information about the delivery process. She shouldn't be encouraged to ask people to leave the delivery room as those who are present are typically required to ensure a safe delivery. Option 4 minimizes the client's concerns.

The nurse is caring for a client undergoing radiation therapy who is noted to have several ulcers of the mucous membranes. Which action will the nurse take as the priority? Assess for dysphagia. Collaborate with dietician for soft foods. Administer pain medication as prescribed. Document the number and characteristics of ulcers.

Assess for dysphagia. Explanation: Stomatitis is a common complication of radiation treatment that arises from destruction of the epithelial layer of tissue. The nurse must assess for dysphagia as the priority, as dysphagia can lead to aspiration, dehydration, and malnutrition. After performing this assessment, the nurse can then collaborate with the dietician to assure that soft, nonirritating foods are provided, that pain medication is given as prescribed, and that documentation takes place so that continued comparison assessments can be evaluated for progress or worsening of the condition.

Which precaution must the nurse take when giving phenytoin to a client with a nasogastric (NG) tube for feeding? Check the phenytoin level after giving the drug to check for toxicity. Elevate the head of the bed before giving phenytoin through the NG tube. Give phenytoin 1 hour before or 2 hours after NG tube feedings to ensure absorption. Verify proper placement of the NG tube by placing the end of the tube in a glass of water and observing for bubbles.

Give phenytoin 1 hour before or 2 hours after NG tube feedings to ensure absorption. Explanation: Nutritional supplements and milk interfere with the absorption of phenytoin, decreasing its effectiveness. The nurse verifies NG tube placement by checking for stomach contents before giving drugs and feedings. The head of the bed is elevated when giving all drugs or solutions and isn't specific to phenytoin administration. Phenytoin levels are checked before giving the drug, and the drug is withheld for elevated levels to avoid compounding toxicity.

A nurse is teaching family members of a client with hepatitis A (HAV). The family members were exposed to the client and, therefore, should receive immunoglobulin (Ig). What should the nurse tell the family members about Ig?' Ig prevents HAV infection in all people. Ig provides immunity to HAV for life. Ig must be administered within 2 weeks of exposure. Ig should be administered even if the client has anti-HAV antibodies.

Ig must be administered within 2 weeks of exposure. Explanation: The administration of Ig within 2 weeks of exposure usually prevents HAV. If family members do contract HAV, the course of the disease may be reduced to a subclinical infection after receiving Ig treatment. Ig provides passive immunity for only 6 to 8 weeks, not for life. A person with anti-HAV antibodies who is exposed to HAV does not need Ig.

Just after delivery, the nurse measures a neonate's axillary temperature at 94.1° F (34.5° C). What should the nurse do? Rewarm the neonate gradually. Rewarm the neonate rapidly. Observe the neonate at least hourly. Notify the physician when the neonate's temperature is normal.

Rewarm the neonate gradually. Explanation: A neonate with a temperature of 94.1° F (34.5° C). is experiencing cold stress. The nurse must correct cold stress while avoiding hyperthermia and complications caused by rapid rewarming. The nurse should rewarm the neonate gradually, observing him closely and checking his vital signs every 15 to 30 minutes. Hourly observation isn't frequent enough because cold stress increases oxygen, calorie, and fat expenditure, putting the neonate at risk for anabolic metabolism and possibly metabolic acidosis. A neonate with cold stress requires intervention; the nurse should notify the physician of the problem as soon as it's identified.

A client with anorexia nervosa describes herself as "a whale." However, the nurse's data collection reveals that the client is 5' 8" (1.7 m) tall and weighs only 90 lb (40.8 kg). Considering the client's unrealistic body image, which intervention should be included in the plan of care? Asking the client to compare her figure with magazine photographs of women her age Assigning the client to group therapy in which participants provide realistic feedback about her weight Confronting the client about her actual appearance during one-on-one sessions, scheduled during each shift Telling the client of the nurse's concern for her health and desire to help her make decisions to keep her healthy

Telling the client of the nurse's concern for her health and desire to help her make decisions to keep her healthy Explanation: A client with anorexia nervosa has an unrealistic body image that causes consumption of little or no food. Therefore, the client needs assistance with making decisions about health. Instead of protecting the client's health, options 1, 2, and 3 may serve to make the client defensive and more entrenched in her unrealistic body image.

A client with a history of type 1 diabetes mellitus recently had an amputation and is in the rehabilitation unit. When the nurse enters the room to administer the client's daily insulin, the client is diaphoretic, reports having a headache, and has slurred speech. What should the nurse do next? Give the client insulin, bring the breakfast tray immediately, and assist with eating. Give the client insulin, bring a glass of orange juice, and report the findings to the charge nurse. Withhold the client's insulin, bring some milk and crackers, and report the findings to the charge nurse. Withhold the client's insulin, check the blood glucose level, bring a glass of orange juice, and report the findings to the charge nurse.

Withhold the client's insulin, check the blood glucose level, bring a glass of orange juice, and report the findings to the charge nurse. Explanation: The client with a history of type 1 diabetes mellitus who is diaphoretic, reports having a headache, and has slurred speech is showing classic signs of hypoglycemia. Obtaining a blood glucose level determines if hypoglycemia is present. Orange juice helps reverse hypoglycemia. The charge nurse needs to be informed for continuity of evaluation and intervention. Insulin should be withheld until further evaluation and treatment of the hypoglycemia. Milk and crackers do not work as fast as orange juice to increase glucose levels.

The nurse must apply an elastic bandage to a client's ankle and calf. She should apply the bandage beginning at the client's: foot. ankle. lower thigh. knee.

foot. Explanation: An elastic bandage should be applied from the distal area to the proximal area. This method promotes venous return. In this case, the nurse should begin applying the bandage at the client's foot. Beginning at the ankle, lower thigh, or knee doesn't promote venous return.

Which instruction regarding the proper administration of oral iron supplements would the nurse include in the education plan for parents? give the supplements with food stop medication if vomiting occurs decrease the dose if constipation occurs give the medicine via a dropper or through a straw

give the medicine via a dropper or through a straw Explanation: Liquid iron preparations may temporarily stain the teeth; therefore, the drug should be given by dropper or through a straw. Supplements should be given between meals, when the presence of free hydrochloric acid is greatest. If vomiting occurs, supplementation shouldn't be stopped; instead, it should be administered with food. Constipation can be decreased by increasing the intake of fruits and vegetables.

A client with human immunodeficiency virus (HIV) infection gives birth to an HIV-positive neonate. When assessing the neonate, the nurse is likely to detect: skin vesicles. limb dysmorphism. conjunctivitis. hepatosplenomegaly.

hepatosplenomegaly. Explanation: A neonate with HIV infection typically has hepatosplenomegaly, a distinctive facial dysmorphism, interstitial pneumonia, recurrent infections, behavioral deviations, and neurologic abnormalities. The other options aren't typical findings in neonates with HIV infection.

The nurse is caring for a client with multiple myeloma. Which condition should the client be closely monitored for? hypercalcemia hyperkalemia hypernatremia hypermagnesemia

hypercalcemia Explanation: Calcium is released when bone is destroyed. This causes an increase in serum calcium levels. Multiple myeloma doesn't affect potassium, sodium, or magnesium levels.

A client injured in a train derailment is admitted to an acute care facility with a suspected dysfunction of the lower brain stem. The nurse should monitor this client closely for: hypoxia. fever. visual disturbance. gait alteration.

hypoxia. Explanation: Lower brain stem dysfunction alters bulbar functions, such as breathing, talking, swallowing, and coughing. Therefore, the nurse should monitor the client closely for hypoxia. Temperature control, vision, and gait aren't lower brain stem functions.

A medication nurse is preparing to administer 9 a.m. medications to a client with liver cancer. Which consideration is the nurse's highest priority? frequency of the medication purpose of the medication necessity of the medication metabolism of the medication

metabolism of the medication Explanation: The rate and ability of the liver to metabolize medications will be altered in a client with liver cancer. Therefore, it is essential to understand how each medication is metabolized. The other considerations are important but not as vital.

A client is released from the emergency department after being treated for a sprained ankle. Which nursing action demonstrates safe practice for a client who's learning to walk with crutches? standing slightly ahead of the client ensuring that the client wears hospital socks telling the client to stand with the feet together placing a walking belt around the client's waist

placing a walking belt around the client's waist Explanation: By placing a walking belt around the client's waist, the nurse helps prevent a fall if the client who's learning to walk with crutches becomes unsteady. To ensure safety, the nurse should stand slightly behind—not ahead of—the client to provide support if the client loses their balance. Also, the nurse should ensure that the client wears supportive, nonskid shoes instead of slippers or socks. The nurse should tell the client to stand with feet slightly apart—rather than together—to provide a wide base of support.

The nurse is caring for a client diagnosed with chronic renal failure. The foods to avoid include foods high in which substance? iron carbohydrates proteins fats

proteins Explanation: Proteins are restricted in clients with chronic renal failure because of metabolites. Iron, carbohydrates, and fat are not restricted.

The nurse is reinforcing education for parents about prevention of infection in their child with sickle cell anemia. Which instruction should the nurse include as a priority? provide adequate nutrition avoid emotional stress visit the health care provider when sick avoid strenuous physical exertion

provide adequate nutrition Explanation: The nurse must emphasize adequate nutrition as the priority to prevent infection in children with sickle cell anemia. Frequent medical supervision can prevent infection, often a predisposing factor toward development of a crisis. Avoiding stress and strenuous physical exertion helps prevent sickling, but adequate nutrition remains a priority.