Physiological Adaptation

The nurse developed a plan of care for an adolescent who is receiving chemotherapy for lymphoma and has developed stomatitis. What statement made by the adolescent demonstrates understanding of the education provided from the plan of care?

"I will rinse my mouth every 2-4 hours with baking soda and water."

A 15-month-old client is being discharged after treatment for severe otitis media and bacterial meningitis. Which statement by the caregivers indicates effective discharge teaching?

"We'll go to the physician if our child pulls on the ears or won't lie down."

A nurse is caring for a client immediately following an appendectomy. The nurse should assign which nursing diagnosis the highest priority?

Acute pain

A client with sepsis begins having labored breathing, confusion, and lethargy. What complication should the nurse assess for in this client?

Acute respiratory distress syndrome (ARDS)

A client with diabetes mellitus develops sinusitis and otitis media accompanied by a temperature of 100.8° F (38.2° C). What should the nurse anticipate in this client's plan of care?

An increased need for insulin and blood glucose monitoring

The nurse enters the hospital room and finds the client unresponsive to verbal stimulation. What would be the next action by the nurse?

Apply physical stimulation.

A nurse is caring for a client with a central venous pressure (CVP) of 4 mm Hg. Which nursing intervention is appropriate?

Continue to monitor the client as ordered.

A client has been hospitalized with pancreatitis for 3 days. The nurse assesses the client and documents the accompanying results. The nurse realizes these findings are a manifestation of what sign?

Cullen's sign

The nurse is caring for a client with a Jackson-Pratt drain. Which action by the nurse would be the most appropriate?

Ensure that the drainage receptacles are kept compressed to maintain suction.

A client has a C7 spinal cord injury. Which would be the most important nursing intervention during the acute stage of the injury?

Maintain a patent airway.

A woman who gave birth to a healthy baby 6 hours ago is having cramps in her legs. Upon further assessment, the nurse identifies leg pain on dorsiflexion. What action should the nurse take?

Notify the health care provider (HCP).

An infant underwent surgery to remove a myelomeningocele. The infant has bulging fontanels. Which is the nurse's best action?

Notify the healthcare provider.

When preparing a client for surgery to treat appendicitis, the nurse formulates a nursing diagnosis of Risk for infection related to inflammation, perforation, and surgery. What is the rationale for choosing this nursing diagnosis?

Obstruction of the appendix reduces arterial flow, leading to ischemia, inflammation, and rupture of the appendix.

A nurse hears an irregular heart rate of 110 bpm when listening to a client's chest. After assessing the client and noting the new onset of shortness of breath, which action should the nurse take next?

Obtain a prescription for a stat electrocardiogram.

To provide oral hygiene for a client recovering from transsphenoidal hypophysectomy, what should the nurse instruct the client to do?

Rinse the mouth with saline solution.

During assessment, a nurse measures a client's respiratory rate at 32 breaths/minute with a regular rhythm. When documenting this pattern, the nurse should use which term?

Tachypnea

A nurse is caring for a child with intussusception. Which of the following is an expected client outcome related to the nursing diagnosis Acute pain related to cramping, which might be made for this child?

The child exhibits no manifestations of discomfort.

A child is brought to the emergency department with a full-thickness burn involving the epidermis, dermis, and underlying subcutaneous tissue, but does not report pain at this time. Which statements by the nurse are correct about this type of burn? Select all that apply.

This is a severe burn and nerve endings have been destroyed. The child must be monitored for signs of fluid shift. Rehabilitation and skin grafting will be necessary.

A client with left-sided heart failure complains of increasing shortness of breath and is agitated and coughing up pink-tinged, foamy sputum. The nurse should recognize these findings as signs and symptoms of

acute pulmonary edema.

A nurse is assessing a client with Cushing's syndrome. Which observation should the nurse report to the physician immediately?

an irregular apical pulse

The nurse is assessing the progression of jaundice in a neonate who requires phototherapy. Place the assessment areas in the expected order. All options must be used.

face chest abdomen extremities

The nurse is caring for a client with a burn injury who is experiencing hypersecretion of gastric acid. The nurse should monitor for development of what complication?

gastrointestinal ulceration

A client with a progressively enlarging neck comes into the clinic. The client mentions that they have been in a foreign country for the previous 3 months and that they didn't eat much while there because they didn't like the food. The client also mentions that they become dizzy when lifting their arms to do normal household chores or when dressing. What endocrine disorder should the nurse expect the physician to diagnose?

goiter

A client complains of vertigo. The nurse anticipates that the client may have a problem with which portion of the ear?

inner ear

A client with burns to 40% of the body arrives at the emergency room. Which prescriptions by the primary healthcare provider should the nurse anticipate? Select all that apply.

inserting a nasogastric tube administering 100% humidified oxygen monitoring the client's body temperature administering lactated Ringer's (LR) solution intravenously

A client is brought to the emergency department with suspected croup. Which assessment finding reflects increasing respiratory distress?

intercostal retractions

When the nurse is assessing a 34-year-old multigravid client at 34 weeks' gestation experiencing moderate vaginal bleeding, which symptom would most likely alert the nurse that placenta previa is present?

painless vaginal bleeding

A client at 24 weeks' gestation comes to the clinic for a prenatal check-up and reports that she has been "seeing double." The nurse checks the urine and determines that there is 3+ proteinuria. What does the nurse determine is the potential priority problem?

preeclampsia

A client has arterial blood gas results of pH 7.32; PaCO2 50; HCO3 23; and SaO2 80%. These results indicate:

respiratory acidosis.

Parathyroid hormone (PTH) has which effects on the kidney?

stimulation of calcium reabsorption and phosphate excretion

A client is suspected of having a slow gastrointestinal bleed. The nurse should evaluate the client for which sign?

tarry stools

The nurse is caring for a client post myocardial infarction (MI). Orders include strict bed rest and a clear, liquid diet. What is the nurse's best response to the client who is inquiring about the purpose of the new diet?

to reduce the metabolic workload of digestion

A client with type 1 diabetes is admitted to the emergency department with dehydration following the flu. The client has a blood glucose level of 325 mg/dL (18 mmol/L) and a serum potassium level of 3.5 mEq (3.5 mmol/L). The health care provider (HCP) has prescribed 1,000 mL 5% dextrose in water to be infused every 8 hours. What should the nurse do before implementing the HCP's prescriptions?

verify the prescription for 5% dextrose in water.

When the nurse is assessing an infant with suspected inguinal hernia, which finding would be most concerning?

The inguinal swelling is reddened, and the abdomen is distended.

The nurse is monitoring a client with a pacemaker. Which finding shows that the client's pacemaker is functioning correctly?

The nurse observed a spike on the electrocardiogram (EKG) with pacing initiated.

A nurse is changing a dressing and providing wound care. Place the following activities in the correct order. All options must be used.

Wash hands thoroughly. Put on latex gloves. Slowly remove the soiled dressing. Assess the drainage in the dressing

A 9-month-old, well-nourished boy who lives with his extensive extended family tests positive for tuberculosis. What is a risk factor for tuberculosis in this child?

being an infant

When a client is diagnosed with aplastic anemia, the nurse should assess the client for changes in which physiologic functions?

bleeding tendencies

Which finding requires immediate intervention when planning care for an adolescent with cystic fibrosis (CF)?

chest pain with dyspnea

A 3-year-old child with cystic fibrosis is admitted to the hospital with bronchopneumonia. Identifying which factors would be most helpful in planning care for this child? Select all that apply.

cough fever

A nurse is assessing a client with hyperparathyroidism. Which finding should the nurse report immediately to the physician?

flank pain

A primary health care provider prescribes regular insulin 10 units intravenously (I.V.) along with 50 ml of dextrose 50% for a client with acute renal failure. What electrolyte imbalance is this client most likely experiencing?

hyperkalemia

The nurse is caring for a client in the coronary care unit when the cardiac monitor reveals ventricular fibrillation and the client becomes unresponsive. The nurse should anticipate which intervention?

immediate defibrillation

Which findings best correlate with a diagnosis of osteoarthritis?

joint stiffness that decreases with activity

The nurse makes a home visit to a primiparous client and her neonate at 1 week after a vaginal birth. Which finding should be reported to the health care provider (HCP)?

neonatal central cyanosis

A client is returned to the hospital room after a subtotal thyroidectomy. Which piece of equipment is most important for the nurse to keep at the client's bedside?

tracheostomy set

A nurse is providing cardiopulmonary resuscitation (CPR) to a child, age 4. The nurse should

use the heel of one hand for sternal compressions.

After teaching the multiparous mother about hemolytic disease of the newborn and Rh sensitization, the nurse determines that the client understands why she was not sensitized during her other pregnancy when she makes which statement?

"Antibodies are not usually formed until after exposure to an antigen."

The nurse is using evidence-based practice to ensure the patency of a client's arterial line. Which action should the nurse perform?

Flush the line each time a port is used.

Which condition most commonly results in coronary artery disease (CAD)?

atherosclerosis

A nurse is caring for a client with active upper GI bleeding. What is the appropriate diet for this client during the first 24 hours after admission?

nothing by mouth

An adolescent client scheduled for an emergency appendectomy is to be transferred directly from the emergency department to the operating room. Which statement by the client should the nurse interpret as most significant?

"All of a sudden it does not hurt at all."

A nurse is caring for a client admitted to the psychiatric unit with anxiety and depression. The client refused to take the prescribed fluoxetine and bupropion. Which statement by the nurse is best?

"Can you tell me why you do not want to take these mediations?

An enterostomy nurse is providing an in-service session on caring for colostomies. Which statement by a nurse indicates the need for further teaching?

"I can make a small pin hole in the bag to let the gas out, so I don't have to change the appliance frequently."

A client diagnosed with ulcerative colitis also experiences obsessive compulsive anxiety disorder (OCD). In helping the client understand her illness, the nurse should respond with which statement?

"It's possible that your desire to have everything be perfect has caused stress that may have worsened your colitis, but there is no proof that either disorder caused the other."

The nurse is preparing to discharge a 9-month-old infant recovering from gastroenteritis and dehydration and teaching a parent regarding the infant's dietary and fluid requirements. Which of the following statements made by the parent indicates that further instruction is required?

"We can go ahead and begin to the feed the baby whatever they want to eat and drink."

Which statements would indicate that the parents of a child being treated with antibiotics for an ear infection understand the reason for a follow-up visit after the child completes the course of therapy?

"We need to make sure that her ear infection has completely cleared."

An occupational nurse is called to treat an employee who experienced a finger injury on a piece of equipment. When the nurse arrives, it is discovered that the finger tip was cut off at the first digit and is bleeding profusely. What should be the nurse's first action?

Apply direct pressure to the finger with a clean, dry cloth.

An infant is receiving phototherapy using a fiberoptic pad (Biliblanket). What interventions are appropriate to include in the nursing plan of care? Select all that apply.

Document frequency and character of stools. Encourage parents to participate in the infant's care.

When developing a care plan for a client newly diagnosed with scleroderma, which nursing diagnosis has the highest priority?

Impaired skin integrity

On the fourth day after surgery, a client's incision is red and inflamed. There is moderate drainage from the incision. The client has a temperature of 102°F (38.9°C). The total white blood cell (WBC) count is 10,000/mm3 (10 × 109/L). What should the nurse do first?

Notify the health care provider (HCP).

A client with an esophageal stricture is about to undergo esophageal dilatation. As the bougies are passed down the esophagus, the nurse should instruct the client to do which action to minimize the vomiting urge?

Take long, slow breaths.

While the nurse is caring for a neonate born at 32 weeks' gestation, which finding would most suggest the infant is developing necrotizing enterocolitis (NEC)?

abdominal distention

Which type of surgery is most likely to cause the client to experience postoperative nausea and vomiting?

abdominal hysterectomy

A client who had a splenectomy yesterday has a nasogastric (NG) tube. What should the nurse assess to determine the effectiveness of the NG tube?

absence of abdominal distention

Which outcome would the nurse identify as the priority to achieve when developing the plan of care for a primigravid client at 38 weeks' gestation who is hospitalized with severe preeclampsia and receiving intravenous magnesium sulfate?

absence of any seizure activity during the first 48 hours

A child is admitted with a 5-day history of severe vomiting and diarrhea. Which intervention is the priority for the nurse?

administering IV fluids

A client has a blockage in the proximal portion of a coronary artery. After learning about treatment options, the client decides to undergo percutaneous transluminal coronary angioplasty (PTCA). During this procedure, the nurse expects to administer an

anticoagulant

A 22-year-old client reports substernal chest pain and states that their heart feels like "it's racing out of my chest." The client reports no history of cardiac disorders. The nurse attaches the client to a cardiac monitor and notes sinus tachycardia with a rate of 136 beats/minute. Breath sounds are clear, and the respiratory rate is 26 breaths/minute. When a cardiorespiratory basis is eliminated, which drug would the nurse question about usage?

cocaine

On the second postoperative day after repair of a cleft palate, what should the nurse use to feed a toddler?

cup

The nurse assesses a child with ketoacidosis. What manifestations are supportive of the diagnosis of ketoacidosis?

deep, rapid respirations.

A parent brings a preschool child to the emergency department after the child ingested an unknown quantity of acetaminophen. Which treatment does the nurse anticipate?

gastric lavage and administration of activated charcoal

The nurse is explaining the nature of the fracture to the parents of a school-age client who has a greenstick fracture. Which drawing should the nurse choose to explain the fracture to the parents?

not broken all the way through

A client with acute appendicitis develops a fever, tachycardia, and hypotension. Based on these findings, the nurse should further assess the client for which complication?

peritonitis

A 14-month-old child returns from surgery for an undescended testicle. When planning for the child's discharge, the nurse should remind the parents to observe their child for which complication?

redness or swelling at the incision site

A client with multiple sclerosis (MS) lives with her daughter and 3-year-old granddaughter. The daughter asks the nurse what she can do at home to help her mother. Which measure would be most beneficial?

regular exercise

At birth, a neonate weighs 7 lb, 3 oz (3,267 g). When assessing the neonate 1 day later, the nurse obtains a weight of 7 lb (3,182 g) and an axillary temperature of 98° F (36.7° C) and notes that the sclerae are slightly yellow. The neonate has been breast-feeding once every 2 to 3 hours. Based on these findings, the nurse should add which nursing diagnosis to the care plan?

risk for injury related to hyperbilirubinemia