Prep U NRN 162/163

The nurse is caring for a 4-year-old with oral vesicles and ulcers from herpangina. The child is refusing fluids due to the pain and the mother is concerned about his hydration status. Which of the suggestions would be most appropriate? a) "Offer 'magic mouthwash' followed by a popsicle." b) "Encourage him to have some soda." c) "Try some Anbesol or Kank-A." d) "Offer him some orange juice."

"Offer 'magic mouthwash' followed by a popsicle." Correct Explanation: Children are more likely to cooperate with interventions if play is involved. "Magic" analgesic mouthwash followed by a popsicle is most likely to alleviate some pain and then provide hydration. Soda should be avoided because it can cause stinging and burning. Orange juice should be avoided because it can cause stinging and burning. Anbesol might be helpful but it will likely be difficult to apply. Additionally, oral analgesics are often necessary.

A nurse is caring for a Latino client after internal fixation of a compound fracture in the tibia. The nurse finds that the client has not had his dinner, seems restless, and is tossing on the bed. What is the most appropriate response by the nurse?

"Tell me what you feeling."

A client has been diagnosed with a gastrointestinal bleed and the health care provider has ordered a transfusion. At what rate should the nurse administer the client's packed red blood cells?

1 unit over 2 to 3 hours, no longer than 4 hours

Anxiolytic drugs can be used in the management of which conditions? (Select all that apply.)

Alcohol withdrawal Seizures Panic attacks

The nurse is preparing a client who will begin chemotherapy in a few days. The nurse knows that which are the most common adverse effects encountered by most clients who receive chemotherapy? (Select all that apply.)

Alopecia Thrombocytopenia Anemia

What is the leading cause of neonatal sepsis and death?

Group B streptococcus

Which is the most common cause of acute encephalitis in the United States?

Herpes simplex virus (HSV)

A client is receiving rifampin and isoniazid in combination for treatment of tuberculosis. What would the nurse need to monitor closely?

Liver function studies

A nurse documents the presence of chronic pain on an electronic health record. Choose a description that could be used. The pain can be:

Prolonged in duration.

What does the administration of a calcium channel blocker result in? (Select all that apply.)

Relaxation of blood vessels Increase oxygen supply to the heart Reduce the workload on the heart Decrease blood pressure

Which nursing actions limit overstimulation of the preterm infant? Select all that apply.

Speak softly to the infant Keep lights low in the nursery Coordinate nursing care

Which of the following techniques least exhibits surgical asepsis?

Suctioning the nasopharyngeal cavity of a client

The nurse is trying to establish a trusting relationship with a client experiencing pain. When the client asks for pain medication, the nurse notes that it is not time to give the medication. What is the best action by the nurse to facilitate a trusting relationship?

Tell the client when the medication is due and return promptly at that time.

A nurse on your unit sustains a needlestick injury while caring for a client whose infectious status is unknown. What would be the best course of action for the nurse to follow? -Avoid notifying the supervisor of the injury until the client's infectious status is confirmed. -Be tested for disease antibodies at appropriate intervals. -Document the injury in writing after the client's infectious status is confirmed. - Avoid revealing the identity of the client or source of blood.

Be tested for disease antibodies at appropriate intervals.

While administering aminoglycosides to clients, the nurse must be aware of what toxicities that can result from their use? (Select all that apply.)

Nephrotoxicity Ototoxicity Neurotoxicity

Clients taking isoniazid (INH) can experience a variety of adverse reactions but should be monitored carefully for which of the following that indicate toxicity? Select all that apply.

Peripheral neuropathy Jaundice

While preparing to teach a group of nursing students the history of maternity care, which factor will the instructor include to explain as the etiology of most infections in females after birthing in the 1700s?

Reproductive tract infection

The nurse is preparing a community education program about preventing hepatitis B infection. Which information should be incorporated into the teaching plan?

The use of a condom is advised for sexual intercourse.

Which client is most likely to exhibit dehydration?

an 8-month-old infant with persistent diarrhea for 24 hours Infants and elderly persons have the greatest risk of fluid-related health problems. An infant's body weight is 70% to 80% water content. An infant who is ill and has had persistent diarrhea for 24 hours will quickly lose a significant amount of fluid and electrolytes if the diarrhea is not stopped and replacement fluids given. Healthy young adults have a higher tolerance for fluid loss and can quickly regain their fluid balance when fluids are lost through normal activity. The 75-year-old woman who was placed on NPO status before surgery is not likely to develop a fluid volume deficit within 8 hours, unless there are other fluid conditions present that would precipitate fluid loss. The 60-year-old client with pneumonia and a fever should be monitored for a fluid deficit, but he is not as likely to develop one as a client who is actively losing fluids through diarrhea.

A postpartum woman who gave birth vaginally has unrelenting rectal pain despite the administration of pain medication. Which action is most indicated?

assessing the perineum Pain after childbirth is generally well managed with pain control medications; since they did not help this woman, further assessment is necessary. The first nursing action would be to assess the source of the pain; the woman may have sustained a laceration or a hematoma as a result of childbirth. Assessing the perineum may help the nurse to determine the source of the pain and may require follow-up by the health care provider (HCP) . Subsequent nursing interventions may include pain medication, sitz bath, or education regarding the healing process.

The nurse is assessing a client who has benign prostatic hypertrophy (BPH). The nurse should ask the client if he has:

difficulty starting the urinary stream

When obtaining a history from the parents of a child diagnosed with diarrhea due to Salmonella, the nurse should ask the parents if the child has been exposed to which possible source of infection?

undercooked eggs

A client with marked oliguria is ordered a test dose of 0.2 g/kg of 15% mannitol solution intravenously over 5 minutes. The client weighs 132 lb. How many grams would the nurse administer? Record your answer as a whole number.

12 g First, convert the client's weight from pounds to kilograms: 132 lb ÷ 2.2 lb/kg = 60 kg. Then, to calculate the number of grams to administer, multiply the ordered number of grams by the client's weight in kilograms: 0.2g/kg X 60 kg = 12 g.

The nurse is aware that oral contraceptives are effective but associated with potential health risks that must be carefully considered. Which client has the highest risk of experiencing the adverse effects of oral contraceptive use?

A 38-year-old diabetic woman who smokes one-and-a-half packs of cigarettes daily.

In prenatal classes, the nurse teaches pregnant clients to use meditation during labor contractions to ease the pain. Which elements of meditation are important for the nurse to emphasize? Select all that apply.

Comfortable position Quiet environment Focus of attention

Although naloxone (Narcan) is given to counter opioid medication side effects such as respiratory depression, what additional issues (if any) may result from administration of an opioid antagonist?

Increase in the client's pain rating

A male client is scheduled for an electroencephalogram (EEG). When the nurse caring for the client is preparing him for the test, the client states that during childhood he was mildly electrocuted but miraculously lived. Therefore, he is quite afraid of going through an EEG. In what ways can the nurse help dispel the client's fear regarding the test?

Inform the client that he will not experience any electrical shock

Two hours after the vaginal birth under epidural anesthesia, a client with a midline episiotomy ambulates to the bathroom to void. After voiding, the nurse assesses the client's bladder, finding it distended. The nurse interprets this finding based on the understanding that the client's bladder distention is most likely caused by which factor?

edema in the lower urinary tract area

A client who has been recently diagnosed with acquired immunodeficiency syndrome (AIDS) inquires about hospice services. The nurse explains that hospice care is appropriate:

for clients with an inevitable death within weeks to months

To help prevent hip flexion deformities associated with rheumatoid arthritis, the nurse should help the client assume which position in bed several times a day?

prone