PassPoint practice exam 1

A client discusses with the nurse the possibility of using alternative therapies for management of hypertension and diabetes. Which is an expected alternative therapy used by the client?

ginseng Explanation: Ginseng is used as an antihypertensive and lowers blood glucose. Kava is used for the treatment of anxiety and stress. Jojoba promotes hair growth and relief of skin problems. Melatonin aids in the treatment of insomnia.

One hour after receiving nalbuphine for pain during labor, a primigravida gives birth to a full-term neonate with symptoms of respiratory depression. The nurse anticipates that the neonate will require the administration of which drug?

naloxone Explanation: The drug of choice to reverse opioid-induced respiratory depression in a neonate is naloxone, which reverses the effects of opioids. Betamethasone is administered to enhance surfactant production in preterm neonates. Naltrexone is used to relieve pruritus from epidural narcotics. Promethazine is used to control nausea and vomiting in the mother.

The nurse is teaching the client about home blood glucose monitoring. Which blood glucose measurement indicates hypoglycemia?

59 mg/dL (3.3 mmol/L)

A nurse is documenting a variance that has occurred during the shift, and this report will be used for quality improvement to identify high-risk patterns and potentially initiate in-service programs. This is an example of which type of report?

Incident report.

A client who has been experiencing depression for 3 months was recently placed on sertraline. The client calls a nurse and reports that significantly improved mood and optimism about the future. Which piece of additional information would require a rapid nursing intervention?

The client is sleeping only 3 hours per night and does not feel fatigued in the morning.

Which method is reliable for identifying a preschooler before administering a medication?

Check the hospital identification bracelet. Explanation: The only safe method for identifying the child is to check the identification band for the client's name and medical record number and then compare that information with the medication record. Children sometimes exchange beds during play, so checking the name on the bed isn't reliable. Infants are unable to give their names, toddlers, or preschoolers may admit to any name, and school-age children may deny correct identities in an attempt to avoid the medication. Parents aren't always at the bedside, so the nurse shouldn't be relied on parents for identification.

Which is a priority nursing action for a child with croup?

continually assessing respiratory status Explanation: Respiratory status should be assessed continually as the child may have laryngeal spasms without notice. Antipyretics may be given as well as oxygen, but respiratory status takes priority. Parents would be encouraged to stay with their child but this is not an immediate priority.

When developing a care plan for a hospitalized client, the nurse knows that children in which age-group are most likely to view illness as a punishment for misdeeds?

preschool age Explanation: Preschool-age children are most likely to view illness as a punishment for misdeeds. Separation anxiety, although seen in all age-groups, is most common in older infants. Fear of death is typical of older school-age children and adolescents. Adolescents also fear mutilation.

A client is taking large doses of aspirin daily to treat rheumatoid arthritis. The nurse should instruct the client to tell the health care provider (HCP) when having:

tinnitus Explanation: Tinnitus or ringing in the ears is a sign of aspirin toxicity and should be reported. Clients should be instructed to take aspirin as prescribed and to avoid overdosage. Gastrointestinal symptoms associated with aspirin include nausea, heartburn, and epigastric discomfort caused by gastric irritation. Abdominal cramps, rash, and hypotension are not related to aspirin therapy.

A client has been receiving chlorpromazine to treat psychosis. Which findings should alert the nurse that the client is experiencing pseudoparkinsonism?

tremors, shuffling gait, and masklike face

A nurse is teaching a client with a leg ulcer about tissue repair and wound healing. Which statement by the client indicates understanding?

"I'll eat plenty of fruits and vegetables." Explanation: For effective tissue healing, adequate intake of protein and vitamins A, B complex, C, D, E, and K are needed. Therefore, the client should eat a high-protein diet with plenty of fruits and vegetables to take in these nutrients. The treatment of the ulcer may or may not include covering it; a wound nurse would create the best plan for the client. Redness in a wound is a sign of inflammation.

A client with chronic pancreatitis is discharged with a prescription for pancrelipase. Which instruction must the nurse include when providing discharge instructions regarding this medication?

"Swallow this medication whole. Do not chew it." Explanation: Digestion begins in the mouth. Pancrelipase needs to be swallowed whole in order to reach the stomach before digestion begins and cannot be crushed, chewed, or held in the mouth. In order for the medication to be effective, it must be taken before meals or snacks. The medication needs to be stored in a dry place but does not require refrigeration.

Which sentence correctly describes the prone position?

The body is facedown.

A client who was prescribed clozapine 2 months ago arrives in the clinic and informs the nurse that the they have been feeling extremely fatigued and feverish and has a sore throat. The nurse observes that the client has two small ulcerations of the oropharynx. Which does the nurse suspect may be occurring with this client?

agranulocytosis Explanation: Clozapine has a potential side effect of agranulocytosis, which can develop suddenly or over a period of time. It is characterized by fever, malaise, a sore throat with ulcerations, and leukopenia. The drug must be immediately discontinued. It is important for the client to have weekly blood counts for 6 months of therapy and then every 2 weeks. Thiamine deficiency is exhibited by shortness of breath and other symptoms of congestive heart failure. Tardive dyskinesia is a side effect of antipsychotic medications and is characterized by lip smacking, tongue protrusion, chewing, blinking, grimacing, and choreiform movements of the limbs and feet. Dystonic reactions are an extrapyramidal side effect characterized by spasms in several muscle groups.

A woman at 22 weeks' gestation has right upper quadrant pain radiating to her back. She rates the pain as 9 on a scale of 1 to 10 and says that it has occurred 2 times in the last week for about 4 hours at a time. She does not associate the pain with food. Which nursing measure is the highest priority for this client?

Refer the client to her health care provider for evaluation and treatment of the pain. Explanation: The nurse seeing this client should refer her to an HCP for further evaluation of the pain. This referral would allow a more definitive diagnosis and medical interventions that may include surgery. Referral would occur because of her high pain rating as well as the other symptoms, which suggest gallbladder disease. During pregnancy, the gallbladder is under the influence of progesterone, which is a smooth muscle relaxant. Because bile does not move through the system as quickly during pregnancy, bile stasis and gallstone formation can occur. Although education should be a continuous strategy, with pain at this level, a brief explanation is most appropriate. Major emphasis should be placed on determining the cause and treating the pain. It is not appropriate for the nurse to diagnose pain at this level as heartburn. Discussing nutritional strategies to prevent heartburn are appropriate during pregnancy, but not in this situation. Acetaminophen is an acceptable medication to take during pregnancy but should not be used on a regular basis as it can mask other problems.

A client doesn't make eye contact with the nurse during an interview. The nurse suspects that the client's behavior has a cultural basis. What should the nurse do first?

Observe how the client and the client's family and friends interact with one another and with other staff members.

A client with heart failure has assessment findings of jugular vein distension (JVD) when lying flat in bed. What is the best nursing intervention?

Elevate the head of the bed to 30 to 45 degrees and reassess JVD. Explanation: Jugular vein distension should be measured when the head of the client's bed is at 30 to 45 degrees. The healthcare provider may or may not need to be notified, based on the assessment findings with the head of the bed elevated. Further assessment should be performed, but this further assessment does not include obtaining orthostatic blood pressure readings, since these readings do not affect JVD.

Following an emergency cholecystectomy, the client has a Jackson-Pratt drain with closed suction. After 4 hours, the drainage unit is full. What should the nurse do?

Empty the drainage unit.

A male with an antisocial personality disorder is court-mandated to receive counseling after being detained by law enforcement officials. The chart entry reads: 10/15 1130 The client came to the group therapy session and was verbally aggressive to other clients. The group leader set limits on his behavior, reinforced the group rules and guidelines. At two different times the client made excuses for his behavior, stating, "I really don't have to be here," and minimized the comments of other group members. Which priority action must the nurse group leader initiate?

Formulate an individual contract for appropriate behavior during the group. Explanation: The documented client behavior indicates a need for limits during group. Formulating a contract that addresses the appropriate behavior, and the consequences for violating the contract, is the priority strategy. Medication for a client with antisocial personality disorder is only used to manage the symptoms of depression or disordered thinking. The first action to be taken is setting limits on inappropriate behavior, not role playing skills and arranging for a coach.

A nurse is caring for a client with pheochromocytoma. What is the most important intervention by the nurse?

promoting an environment free from emotional distress Explanation: The child experiencing hyperfunctioning of the adrenal gland or pheochromocytoma has excessive epinephrine resulting in an accelerated metabolism. Symptoms include hypertension, headaches, hyperglycemia with weight loss, diaphoresis, and hyperventilation. Through provision of a low-stress environment, analgesia as needed, a high-calorie diet, and supportive parents, the child will be able to prepare for surgery to eliminate the tumor causing the hypersecretion of epinephrine.

The nurse is aware that antihypertensives should be used cautiously in clients already taking

thioridazine. Explanation: Thioridazine affects the neurotransmitter norepinephrine, which causes hypotension and other cardiovascular effects. Administering an antihypertensive to a client who already has hypotension could have serious adverse effects. Ibuprofen is an anti-inflammatory that doesn't interfere with the cardiovascular system. Although diphenhydramine does have histaminic effects such as sedation, it isn't known to decrease blood pressure. Vitamins are not drugs and don't interfere with cardiovascular function.

The nurse teaches a parent of a child with congenital heart disease about the prescribed medications. What does the nurse explain is the primary reason for giving the child digoxin?

to improve the strength of the heartbeat Explanation: Digitalis preparations such as digoxin act to improve and strengthen the heartbeat. They increase cardiac output by increasing the strength of the heart's contraction and decreasing the heart rate. Digoxin does not relax the heart's arterial walls, prevent irregularities in ventricular contractions, or decrease inflammation of the heart wall.

A school-age client has a fever, joint inflammation, and a nonpruritic rash. Knowing that these are signs of rheumatic fever, the nurse should ask the parents

"Has your child had strep throat recently?"

The parent of a premature infant asks the nurse how to do the paced bottle feeding technique. Which of the following would be the most appropriate response from the nurse?

"Hold the bottle nearly horizontally and take frequent breaks as the baby pauses between sucks." Explanation: Paced bottle feeding allows the premature infant to have more control with feeding and mimics more natural feeding. The baby can pause and take a break when needed. The bottle is held nearly horizontal when it's in the infant's mouth. This way the milk won't pour into the newborn as it would with holding the bottle vertically or keeping the nipple full of milk. The baby should be burped at least once during the feeding to remove air bubbles.

A client is admitted with an eating disorder. Which client response should the nurse address first?

"I feel dizzy and light-headed when I get up." Explanation: The priority intervention, by the nurse, would be to assess the client's vital signs to note any alterations. A client stating "My life is over if I gain weight" is an example of catastrophizing. Dental erosion and caries are commonly found in a client with an eating disorder. Muscle weakness is also commonly found in a client with an eating disorder.

The nurse is assessing an infant who has been brought for a scheduled clinic visit by a parent. When asked about the infant's immunization status, the parent pauses and then states, "I am just not comfortable pumping my baby full of mercury and causing autism." How should the nurse best address the parent's statement?

"It sounds like you have some serious concerns about the safety of vaccines. Can we talk about those concerns?"

A multigravid client admitted to the labor area is scheduled for a cesarean birth under spinal anesthesia. Which client statement indicates that teaching about spinal anesthesia has been understood?

"The anesthetic may cause a severe headache, which is treatable." Explanation: Spinal anesthesia is used less commonly today because of preference for epidural block anesthesia. One of the adverse effects of spinal anesthesia is a "spinal headache" caused by leakage of spinal fluid from the needle insertion. This can be treated by applying a cool cloth to the forehead, keeping the client in a flat position, or using a blood patch that can clot and seal off any further leakage of fluid. Spinal anesthesia is administered with the client in a sitting position or side lying. Another adverse effect of spinal anesthesia is hypotension caused by vasodilation. General anesthesia provides immediate anesthesia, whereas the full effects of spinal anesthesia may not be felt for 20 to 30 minutes. General anesthesia can be discontinued quickly when the anesthesiologist administers oxygen instead of nitrous oxide. Epidural anesthesia may take 1 to 2 hours to wear off.

A client is refusing to take the prescribed oral medication. Which measure by the nurse can be used to get the client to take the medication? Select all that apply.

*suggesting a liquid form of the medication instead of a pill *asking the client the reason for not taking the medication *explaining the purpose of the medication to the client Explanation: The correct answers provide an alternative solution for the client and provide the client an opportunity to consent to taking the medication in another form, neither of which would be considered abuse. Providing health education regarding the medications to ensure the client has all the information needed to make an informed consent would be appropriate. Hiding medication or disguising it in food knowing that the client has refused the medication would be considered abuse. The client has the right to refuse care, including medication, and a family member should not be placed in a position of having to give the medication.

A child with a body surface area (BSA) of 0.82 m2 has been prescribed actinomycin 2.5 mg/m2 intravenously. What is the correct amount to be given? Record your answer using two decimal places.

2.05 Explanation: 0.82 m2 × 2.5 mg/m2 = 2.05 mg

A client has renal colic due to renal lithiasis. What is the nurse's first priority in managing care for this client?

Administer an opioid analgesic as prescribed. Explanation: If infection or blockage caused by calculi is present, a client can experience sudden severe pain in the flank area, known as renal colic. Pain from a kidney stone is considered an emergency situation and requires analgesic intervention. Withholding fluids will make urine more concentrated and stones more difficult to pass naturally. Forcing large quantities of fluid may cause hydronephrosis if urine is prevented from flowing past calculi. Straining urine for small stones is important, but does not take priority over pain management.

A 30-year-old multiparous client in active labor is admitted to the labor and delivery unit. She has received no prenatal care for this pregnancy. Which data would the nurse obtain first?

date of last menstrual period (LMP)

On the second postpartum day after a cesarean birth, the client reports having gas pains. What should the nurse should instruct the client to do?

Ambulate more often.

A nurse is evaluating an external fetal monitoring strip. Identify the area on this strip that causes her to be concerned about uteroplacental insufficiency.

Answer: TOP PICTURE Explanation: This fetal monitoring strip illustrates a late deceleration. The decrease in fetal heart rate begins at the end of the contraction and doesn't return to baseline until the contraction is over. Late decelerations are associated with uteroplacental insufficiency, shock, or fetal metabolic acidosis.

Following a splenectomy, a client has a hemoglobin (Hb) level of 7.5 g/dl and has vertigo when getting out of bed. The nurse suspects abnormal orthostatic changes. What vital sign values most support the nurse's analysis?

Blood pressure of 80/40 mm Hg and pulse of 130 beats per minute. Explanation: The client had blood loss during the splenectomy and developed subsequent anemia. With a subnormal Hb level and vertigo when getting out of bed, the nurse is accurate in suspecting orthostasis. Orthostatic changes develop from hypovolemia and cause a drop in blood pressure (evidenced by a blood pressure of 80/40 mm Hg) and a compensatory rise in the heart rate (evidenced by a pulse of 130 beats per minute) when the client rises from a lying position.

The nurse is reviewing laboratory values on a client with heart failure. The client has a potassium level of 4.6 mEq/L (4.6 mmol/L). The client is scheduled to receive the 0900 dose of furosemide. What should the nurse do next?

Give the furosemide dose to the client. Explanation: The potassium level is within normal limits and the nurse should administer the medication as prescribed. Administering half the furosemide dose, notifying the healthcare provider, and withholding the furosemide is not necessary as the laboratory value is safe.

A female client enjoys wearing men's clothing. Her sibling tells the nurse that the client would like to have gender reassignment surgery. The client tells the nurse that she just wants to be left alone. Which nursing intervention should the nurse take first?

Inform the client's sibling of medical privacy laws.

The primigravid client is at +1 station and 9 cm dilated. Based on these data, what should the nurse do first?

Encourage the client to breathe through the urge to push. Explanation: The urge to push is often present when the fetus reaches + stations. This client does not have a cervix that is completely dilated and pushing in this situation may tear the cervix. Encouraging the client to breathe through the urge to push is the most appropriate strategy and allows the cervix to dilate before pushing. Increasing the level of the epidural is inappropriate as nursing would like to have the client be able to push when she is fully dilated. Comfort measures are important for the client at this time but are not the highest priority for the nurse.

A physician orders an I.V. bolus injection of diltiazem hydrochloride for a client with uncontrolled atrial fibrillation. What should the nurse do before administering an I.V. bolus?

Gently aspirate the I.V. catheter to check for a blood return. Explanation: Before administering an I.V. bolus, the nurse should gently aspirate the I.V. catheter for a small amount of blood to ensure correct placement of the I.V. catheter. Then the nurse may inject the medication over the recommended time interval. The nurse doesn't need to insert another I.V. line unless the ordered medication is incompatible with the medication in the I.V. solution. Warming the medication could alter the drug's action. Placing a tourniquet on the arm would close off the venous system and prevent drug injection.

An older adult client presents at the emergency department (ED) with reports of fatigue and diarrhea. The client reveals areas of ecchymoses and burn marks. Which nursing actions are most appropriate? Select all that apply.

You Selected: *Attend to the client's physical needs. *Report any signs of abuse to appropriate agencies. *Provide explanations and support to the client. Explanation: Physical needs are met first, and then the determination of the existence of abuse will wait until the client's physical condition is stable. It is the duty of the nurse to tell the client the truth about what will happen and to support the client should not be turned away for telling a lie. A nurse should not tell the client that a secret will be held, as the client or another person may be put in danger if the abuser is not stopped.

During the first few weeks after a cholecystectomy, the client should follow a diet that includes:

a limited intake of fat distributed throughout the day so that there is not an excessive amount in the intestine at any one time. Explanation: Bile flows almost continuously into the intestine for the first few weeks after gallbladder removal. Limiting the amount of fat in the intestine at any one time ensures that adequate bile will be available to facilitate digestion. Eating large amounts of meat, cheese, and peanut butter would be undesirable because these foods are often high in fat. There is no need to eliminate high-fiber foods, and doing so would tend to increase pressure within the large intestine, not decrease pressure in the small intestine. Removing the gallbladder does not decrease pancreatic secretions.

A client is brought to the emergency department unconscious. An empty bottle of aspirin was found in the car, and a drug overdose is suspected. Which medication should the nurse have available for further emergency treatment?

activated charcoal powder Explanation: Activated charcoal powder is administered to absorb remaining particles of salicylate. Vitamin K is an antidote for warfarin sodium Dextrose 50% is used to treat hypoglycemia. Sodium thiosulfate is an antidote for cyanide.

A nurse is assessing an elderly client with senile dementia. Which neurotransmitter condition is most likely to contribute to this client's cognitive changes?

decreased acetylcholine level Explanation: A decreased acetylcholine level has been implicated as a cause of cognitive changes in healthy elderly clients and in the severity of dementia. Choline acetyltransferase, an enzyme necessary for acetylcholine synthesis, has been found to be deficient in clients with dementia. Norepinephrine is associated with aggression, sleep-wake patterns, and the regulation of physical responses to emotional stimuli, such as the increased heart and respiratory rates caused by panic.

When the nurse is developing a teaching plan for a client about the medications prescribed for depression, which component is most important for the nurse to include?

management of common adverse effects Explanation: Compliance with medication therapy is crucial for the client with depression. Medication noncompliance is the primary cause of relapse among psychiatric clients. Therefore, the nurse needs to teach the client about managing common adverse effects to promote compliance with medication. Teaching the client about the medication's pharmacokinetics may help the client to understand the reason for the drug. However, teaching about how to manage common adverse effects to promote compliance is crucial. Current research about the medication is more important to the nurse than to the client. Teaching about dosage regulation and adjustment of medication may be helpful, but typically the HCP, not the client, is the person in charge of this aspect.

After receiving the shift report, a registered nurse in the cardiac step-down unit must prioritize the client care assignment. The nurse has an ancillary staff member available to help care for the clients. Which of these clients should the registered nurse assess first?

the client with heart failure who is having some difficulty breathing Explanation: The registered nurse should care for the client with heart failure who is experiencing difficulty breathing. Breathing takes precedence over the other client needs. Although anxiety can be detrimental to a client with myocardial infarction, anxiety does not take precedence over another client's breathing difficulty. The ancillary staff member can answer the call light of the client admitted with controlled atrial fibrillation. The coronary bypass client in pain needs an analgesic, but that does not take priority over a client with difficulty breathing.

A nurse is developing a plan to teach a parent how to reduce an infant's risk of developing otitis media. Which direction should the nurse include in the teaching plan?

Place the infant in an upright position when giving a bottle. Explanation: Feeding an infant a bottle in an upright position reduces the pooling of formula or breast milk in the nasopharynx. Formula, in particular, provides a good medium for the growth of bacteria, which can travel easily through the short, horizontal eustachian tubes. Administering antibiotics whenever the infant has a cold, avoiding getting the ears wet, and cleaning the external ear canal daily don't reduce the risk of an infant developing otitis media.

To promote effective airway clearance in a client with acute respiratory distress, what should the nurse do?

Suction if cough is ineffective.

A postpartum client is concerned about how long to keep her newborn at the breast. She has been timing her infant to nurse for 5 to 10 minutes on each breast during each feeding. Which of the following is an appropriate response from the nurse?

"Duration of breastfeeding should be determined by the newborn's signs of satiety." Explanation: While many older babies can take in the majority of their milk in the first 5 to 10 minutes, this cannot be generalized to all babies. Newborns, who are learning to nurse and are not always efficient at sucking, often need much longer to feed. The ability to take in milk is also subject to the mother's let-down response. While many mothers may let down immediately, some may not. Some may eject their milk in small batches several times during a nursing session. It is best to allow the infant to suck until the infant shows signs of satiety such as self-detachment and relaxed hands and arms. Therefore, providing women with a specific timeline to breastfeed, such as 5 to 30 minutes, is not helpful, particularly if the infant does not have a deep latch and is not able to be satiated

A nurse is caring for multiple grieving clients. Which client is most likely to experience disenfranchised grief?

A 50-year-old client whose ex-spouse died suddenly in a motor vehicle accident Explanation: The 50-year-old client whose ex-spouse died suddenly in a motor vehicle accident is most likely to experience disenfranchised grief, as this is not a loss that is typically recognized by others, because they are divorced. The 60-year-old client whose child has been diagnosed with terminal cancer is probably currently experiencing anticipatory grief, as the client is anticipating the death of a child. The 70-year-old client whose best friend died from a heart attack and the 80-year-old client whose spouse died from Alzheimer disease do not have any indications that they will experience disenfranchised grief, as the loss of a close friend or spouse is well-recognized by others.

A client returns to the nursing division after a procedure. The client tells the nurse that the client was awake during the procedure and recalls certain events. What is the nurse's priority intervention?

Ask for additional information from the client. Explanation: The client experienced an event that needs follow up. The nurse should ask for additional information and from there determine what further action is needed. The nursing supervisor should be contacted after additional information is received. The hospital administrator does not need to be contacted.

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

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

A nurse is working as part of team on the unit on a performance improvement initiative to address a concern that clients are not receiving adequate preoperative teaching. Now that the problem has been identified, which action would the nurse do next?

Meet with the parties involved to develop a strategy. Explanation: Performance improvement involves four steps: discover a problem (which has already been identified); plan a strategy using indicators based on a meeting with the parties involved; implement a change; and last, assess the change, and if the outcome is not met, plan a new strategy or refocus the strategy to effect change.

A client with heart failure is taking furosemide, digoxin, and potassium chloride. The client has nausea, blurred vision, headache, and weakness. The nurse notes that the client is confused. The telemetry strip shows first-degree atrioventricular block. What other sign should the nurse assess next?

digoxin toxicity. Explanation: Early symptoms of digoxin toxicity include anorexia, nausea, and vomiting. Visual disturbances can also occur, including double or blurred vision and visual halos. Hypokalemia is a common cause of digoxin toxicity associated with arrhythmias because low serum potassium can enhance ectopic pacemaker activity. Although vomiting can lead to fluid deficit, given the client's history, the vomiting is likely due to the adverse effects of digoxin toxicity. Pulmonary edema is manifested by dyspnea and coughing.

When preparing for the discharge of a newborn after surgery to correct tracheoesophageal fistula (TEF), the nurse teaches the parents about the need for long-term health care because their child has a high probability of developing which complication?

esophageal stricture Explanation: Dilatation at the anastomosis site is needed during the first years of childhood in about 50% of children who have had corrective surgery for TEF. Recurrent mild diarrhea with dehydration is not likely to develop with this surgery. Speech problems can occur if other abnormalities are present to produce them; the larynx and structures of speech are not affected by TEF. Dysphagia and strictures may decrease food intake, and poor weight gain may be noted, but gastric ulcers should not develop from surgery to repair TEF.

The nurse is caring for a newborn of a primiparous woman with insulin-dependent diabetes. When the mother visits the neonate at 1 hour after birth, the nurse explains to the mother that the neonate is being closely monitored for symptoms of hypoglycemia because of which reason?

interrupted supply of maternal glucose and continued high neonatal insulin production Explanation: Glucose crosses the placenta, but insulin does not. Hence, a high maternal blood glucose level causes a high fetal blood glucose level. This causes the fetal pancreas to secrete more insulin. At birth, the neonate loses the maternal glucose source but continues to produce much insulin, which commonly causes a drop in blood glucose levels (hypoglycemia), usually at 30 to 60 minutes postpartum. Most neonates do not develop hypoglycemia if their mothers are not insulin dependent unless they are preterm. Therefore, hypoglycemia is not a normal response as the neonate transitions to extrauterine life.

Which expected outcome about nutrition would be appropriate for a client who has had a total gastrectomy for gastric cancer? The client will:

maintain adequate nutrition through oral or parenteral feedings. Explanation: An appropriate expected outcome is for the client to maintain nutrition either through oral or total parenteral feedings. Oral and total parenteral nutrition may also be used concurrently. It is not realistic to expect the client to regain weight loss within 4 weeks of surgery. After surgery, it is recommended that the client eat six small meals a day rather than three full meals to decrease symptoms of dumping syndrome. Enteral feedings are not part of the expected outcome for gastric surgery.

An older adult is receiving morphine to manage pain after abdominal surgery. The nurse should observe the client for which side effect of this drug?

respiratory depression Explanation: It is especially important for the nurse to carefully assess the elderly client for respiratory depression after administering a dose of meperidine. It may be necessary to reduce the dosage to prevent respiratory depression. Dysrhythmias, constipation, and seizures are all potential adverse effects of meperidine, but respiratory depression is most significant in the elderly.

A 30-year-old client is being treated for epididymitis. What information should the nurse include in the teaching plan about the likely cause of epididymitis?

sexually transmitted infection Explanation: Among men younger than age 35, epididymitis is most frequently caused by a sexually transmitted infection. Causative organisms are usually chlamydia or Neisseria gonorrhoeae. The other major form of epididymitis is bacterial, caused by the Escherichia coli or Pseudomonas organisms. The nurse should always include safe sex teaching for a client with epididymitis. The client should also be advised against anogenital intercourse because this is a mode of transmission of gram-negative rods to the epididymis.

A nurse has been caring for an adolescent client in a residential facility. The child has been through a series of foster placements since infancy with no success in any placement until the age of 7 when placed with a middle-aged single woman. The client thrived there until the woman was killed in a car accident. The client attempted suicide after her foster mother died in response to the loss and the child was placed in the residential facility. The nurse has become close to this client and wants to help her address her issues and move on with her life. Which comment to the manager demonstrates that the nurse understands the client's issues and is able to respond appropriately to the client's needs?

"It's difficult for her to love and trust again after her losses. In this facility, she can learn to deal with her loss in a less emotionally charged environment than a foster home." Explanation: The severe emotional trauma the girl has experienced will likely make it difficult for her to be successful in an adoptive placement at the present time, whether that placement is with someone she knows (the nurse) or another adoptive family. Additionally, adoption by the nurse is inappropriate because it blurs the lines between her professional and personal life and is likely to confuse the client. It is clear that the client has many issues and that love alone is not likely to solve all her problems. Treatment at the residential facility will allow her to work through emotional issues in a more therapeutic environment. Though not currently ready for adoption, she may be ready for adoption in the future after sufficient treatment.

The client has had hypertension for 20 years. The nurse should assess the client for?

Renal insufficiency and failure. Explanation: Renal disease, including renal insufficiency and failure, is a complication of hypertension. Effective treatment of hypertension assists in preventing this complication. Valvular heart disease, endocarditis, and peptic ulcer disease are not complications of hypertension.

The client in balanced suspension traction is transported to surgery for closed reduction and internal fixation of a fractured femur. What should the nurse do when transporting the client to the operating room?

Send the client on the bed with extra help to stabilize the traction. Explanation: The nurse should send the client to the operating room on the bed with extra help to keep the traction from moving to maintain the femur in the proper alignment before surgery. Transferring the client to a cart with manually suspended traction is inappropriate because doing so places the client at risk for additional trauma to the surrounding neurovascular and soft tissues, as would removing the traction. The surgeon need not be called because the decision about transferring the client is an independent nursing action.

To reduce the risk of pressure ulcer formation, which activity should the nurse teach the client who is wheelchair-bound as a result of a spinal cord injury?

Shift your weight every 15 minutes. Explanation: The client who is wheelchair-bound with a spinal cord injury should be taught to make small weight shifts, lifting off the sacral area every 15 minutes. This decreases the risk of pressure ulcer formation. Bathing daily promotes skin cleanliness, but by itself will not prevent pressure ulcer formation. Eating a well-balanced diet that includes proteins and carbohydrates promotes good skin integrity. Moving from the bed to the wheelchair every 2 hours is not desirable because the client should not spend excessive amounts of time in bed. Pressure sores can develop in less than 2 hours.

A client has given birth to a preterm neonate. The client tells the nurse that she wants to breast-feed her neonate. The nurse should explain to the mother that

breast milk contains antibodies that help protect her neonate.

When teaching a client with chronic obstructive pulmonary disease to conserve energy to conserve energy, what instruction should the nurse give the client about breathing when lifting heavy objects? Lift the object by:

exhaling through pursed lips. Explanation: Exhaling requires less energy than inhaling. Therefore, lifting while exhaling saves energy and reduces perceived dyspnea. Pursing the lips prolongs exhalation and provides the client with more control over breathing. Lifting after exhaling but before inhaling is similar to lifting with the breath held. This should not be recommended because it is similar to the Valsalva maneuver, which can stimulate cardiac arrhythmias.

The nurse is teaching a client about actions to control manifestations of left-sided heart failure. Which statement by the client indicates appropriate understanding?

"If I have trouble breathing, I will sit in my recliner with my head up." Explanation: The decreased cardiac output that results from left-sided heart failure causes blood to accumulate in the pulmonary system. This produces pulmonary edema and difficulty breathing when lying flat. Weight gain is common with heart failure, but small fluctuations are normal with routine intake and output of food and fluids. Therefore clients are not expected to report a weight change unless it is more than 3 pounds (1.4 kg) in 48 hours. Nitroglycerin tablets are used to treat angina, not a rapid pulse. Elastic stockings may help control peripheral edema, but they do not help left-sided heart failure.

A client is admitted to the hospital because of threatening, aggressive behavior toward his family. In the first group meeting after the client is admitted, another client sits near the nurse and says loudly, "I'm sitting here because I'm afraid of Ted. He's so big, and I heard him talk about hitting people." The nurse should say to the client:

"It's frightening to have new people on the unit. We're here to talk about things like being afraid." Explanation: The nurse needs to acknowledge the client's feelings. In doing so, the nurse helps the group accept a new member. Focusing on "everyone" and telling the client not to worry ignores the client's fears. Having the other group members introduce themselves places the focus on the other clients in the group and does not address the client's fears. Implying that getting to know someone will reduce the fear is false reassurance.

A client has massive bleeding from esophageal varices. In what order from first to last should the interprofessional team provide care for this client? All options must be used.

You Selected: *Maintain a patent airway. *Control hemorrhaging. *Replace fluids. *Relieve the client's anxiety. Explanation: The goal that has the highest priority when a client has a massive bleed from esophageal varices is to maintain a patent airway. The nurse should position the client to prevent aspiration and assess respirations and oxygen saturation. The nurse should then assist the health care provider (HCP) in controlling the hemorrhage by using esophageal balloon tamponade. Octreotide may be administered to reduce portal pressure. The third priority is to restore circulating blood volume with blood and IV fluids. Esophageal bleeding is an anxiety-provoking event for the client, and although life-saving measures are the priority, the nurse and health care team should explain procedures to the client and provide reassurance as needed.

A primiparous client who gave birth vaginally 8 hours ago desires to take a shower. The nurse anticipates remaining nearby the client to assess for which problem?

fainting Explanation: Clients sometimes feel faint or dizzy when taking a shower for the first time after birth because of the sudden change in blood volume in the body. Primarily for this reason, the nurse remains nearby while the client takes her first shower after birth. If the client becomes dizzy or expresses symptoms of feeling faint, the nurse should get the client back to bed as soon as possible. If the client faints while in the shower, the nurse should cover the client to protect her privacy, stay with the client, and call for assistance. Fatigue postpartum is common and will precede taking a shower. Diuresis is a normal physiologic response during the postpartum period and not associated with showering. Hygiene needs also precede the shower

A nursery nurse just received the shift report. Which neonate should the nurse assess first?

four-hour-old term neonate with jaundice Explanation: The nurse should assess the four-hour-old neonate with jaundice. When jaundice occurs within the first 24 hours of life, it typically indicates a life-threatening disorder, such as sepsis, hemolytic disease of the neonate, Rh incompatibility, or ABO incompatibility. Physiological jaundice, which commonly occurs later, is a benign condition. A 2-day-old term neonate in an open bassinette doesn't require immediate assessment by the nurse. A 6-day-old neonate whose gestational age is 36 weeks is a normal preterm neonate who doesn't require immediate assessment by the nurse. A 12-hour-old term neonate who is small for gestational age doesn't require immediate assessment by the nurse.

A client who is receiving acetaminophen for osteoarthritis reports continuing pain. The healthcare provider prescribes celecoxib. What important information regarding this medication, should the nurse share with this client?

report black and tarry stools to the health care provider Explanation: Black and tarry stools are a sign of gastrointestinal (GI) bleeding, and may necessitate a medication change. Dairy products can help reduce GI irritation. The celecoxib dose should never be doubled. Constipation isn't an adverse effect of this medication.

The nurse is caring for a client with possible immune deficiency. Which subjective data would be most indicative?

"Just as I get over a virus, it seems that I get another." Explanation: Immune deficiencies make it harder for the body to fight infection. With a low resistance, the client is susceptible to obtaining more circulating viruses. Having morning stuffiness and a sore throat is indicative of sinus congestion. Having a leg sore is indicative of cardiovascular insufficiency or diabetes. Sneezing with watery eyes is indicates seasonal allergies.

A hospital client's health status has declined sharply, and a referral to palliative care has been made. A nurse has suggested a referral to spiritual care, but a colleague states, "That is not likely necessary because the client's health record states 'no religion.'" How should the nurse best respond to the colleague's statement?

"The absence of an identified religion does not mean that a client does not have spiritual needs."

A school-age child has just spilled hot liquid on his arm, and a 4-in (10-cm) area on his forearm is severely burned. His mother calls the emergency department. What should the nurse advise the mother to do?

Apply cool water to the burned area. Explanation: To prevent further injury to the skin, the mother should apply cool water to the burn site. Doing so causes vasoconstriction, retards further damage to tissues, and decreases fluid loss. Keeping the child warm promotes vasodilation, increases fluid loss, and decreases blood pressure and, thus, circulation to the area. Applying ointment to the burn is contraindicated because it does not allow healing to occur and may need to be removed in the hospital. Only a clean cloth should be used to cover the wound to prevent contamination or decrease pain or chilling. If only the arm is burned, a call to 911 for emergency care is not necessary, but the mother should seek health care services immediately.

Which instruction is most important for the nurse to include in the teaching plan for a client who is taking phenelzine?

Avoid foods high in tyramine. Explanation: A client who is taking phenelzine, a monoamine oxidase inhibitor, needs to avoid foods that are rich in tyramine because this food-drug combination can cause hypertensive crisis. The client should be given a list of foods to avoid and should report headaches, palpitations, and a stiff neck to the health care provider (HCP) immediately. The client does not need to restrict or add salt to the diet. Drinking 10 to 12 glasses of water each day is important to teach the client who is receiving lithium therapy. Antidepressant drugs take 2 to 4 weeks to achieve therapeutic effects.

The nurse is recording a client's intake and output at the end of an 8-hour shift. The client had 300 ml in nasogastric suction container and 200 ml of urine in the foley bag.There was 300 ml of D5W infused from a 1000-ml bag during the shift, and the client was documented to have consumed 500 ml of liquids. What conclusion should the nurse reach regarding the client's intake and output?

The client's intake was 300 ml greater than output. Explanation: The nurse should conclude that the client's intake was 300 ml greater than output. To reach this conclusion, the nurse should add the nasogastric drainage (300 ml) and the urinary output (200 ml) to get an output of 500 ml. The nurse should add the amount of IV fluid that infused during the shift (300 ml) to the amount of liquid consumed (500 ml) to get 800 ml for the client's intake. The nurse should then compare the output (500 ml) to the intake (800 ml) and determine that the intake was 300 ml greater than the output (800 ml - 500 ml = 300 ml).

Which action demonstrates the role of the psychiatric nurse in primary prevention?

providing sexual education classes for adolescents Explanation: The psychiatric nurse participates in primary, secondary, and tertiary prevention activities. Primary prevention includes education programs that promote mental health and prevent future psychiatric episodes such as sexual education classes for adolescents. Secondary prevention involves treatment to reduce psychiatric problems (for example, handling crisis intervention in an outpatient setting, administering and supervising medication regimens, and participating in the therapeutic milieu). Tertiary prevention involves helping clients who are recovering from psychiatric illness; activities directed toward providing aftercare and rehabilitation are part of this role. Conducting a postdischarge support group is a tertiary prevention activity.