Semester 4, Unit 4

____________________ and ____________________ limit the spread of hospital-acquired infections.

Thorough hand washing and aseptic techniques

A client has recently developed osteomyelitis. The client's laboratory reports show strains of Escherichia coli. What might be a possible reason for this condition?

Urinary tract infections, which can be caused by Escherichia coli, can predispose a client to developing osteomyelitis

Which event cause increased ICP?

Vasodilation Blood vessel compressionEdema from initial brain insult.

The nurse is providing instructions about foot care for a client with diabetes mellitus. What should the nurse include in the instructions? Select all that apply.

Wear shoes when out of bed. Dry between the toes after bathing.

What determines if a client will develop AIDS from an HIV infection?

Whether HIV becomes AIDS depends upon the number of CD4+ T-cells.

A client with a head injury is admitted to the hospital. Which assessment finding alerts the nurse to increasing intracranial pressure?

Widening pulse pressure

A nurse is caring for a client with type 1 diabetes who developed ketoacidosis. Which laboratory value supports the presence of diabetic ketoacidosis?

With diabetic ketoacidosis blood urea nitrogen or B U N level generally is increased because of dehydration.

A nurse identifies 12 mm of induration at the site of a Mantoux test when a client returns to the health office to have it read. Which explanation of this result should the nurse give to the client?

additional tests, including chest x-ray and sputum cultures, a

A which is a small, tender, erythematous nodule that becomes pus-filled and more tender over time. It is most commonly seen in areas of hair-bearing skin, especially buttocks, thighs, abdomen, and axillae.

furuncle

Potassium iodide is prescribed for hyperthyroidism because

it inhibits the release of thyroid hormones.

Whipple procedure leads to _______________________ because of impaired delivery of bile to the intestine and interruption of glucose metabolism; interference with fat digestion occurs.

malabsorption

Clients require

small, frequent low-fat, high-protein, moderate-carbohydrate meals and supplemental feedings.

A male client diagnosed with bipolar disorder is prescribed medication that has caused a decreased libido. Which drugs would be appropriate to be prescribed by the primary healthcare provider to treat this condition? Select all that apply.

the primary healthcare provider should prescribe second-generation antipsychotics such as asenapine, quetiapine, or aripiprazole.

The nurse suspects the presence of an arterial epidural hematoma inthe patient who experiences

unconsciousness at the time of the head injury with brief period of consciousness followed by a decrease in L O C.

The health care provider prescribes one tube of glucose gel for the client with type 1 diabetes. The nurse recognizes that this is for treatment of which diabetes complication?

Insulin-induced hypoglycemia

Why is a low-calorie diet is contraindicatedin pregnancy?

It will not meet the demands of pregnancy on the client's body or the needs of the growing fetus.

An unconscious patient with increased ICP is on ventilory support. Which arterial blood gas measurement would prompt the RN to notify the PCP?

PaO2 of 70. Indication of hypoxia. The goal is to keep PaCO greater than or equal to 100.

Which complication may be caused by sepsis in burns?

Paralytic ileus, or hypoactive bowel, is a complication caused by sepsis in clients with burns.

The serum potassium level of a client who has diabetic ketoacidosis is 5.4 mEq/L . What would the nurse expect to see on the ECG tracing monitor?

Peaked T waves and widened QRS complexes

Priority decision: Whle the nurse performs range of motion on an unconscious patient with ICP, the patient experiences decerebrate posturing reflexes. What should the nurse do first?

Perform the exercises less frequently due to increased ICP.

The primary healthcare provider prescribes daily fasting blood glucose levels for a client with diabetes mellitus. What is the goal of treatment with glucose levels for this client?

70 to 105 mg/dL (4 to 6 mmol/L) of blood is the expected range for blood glucose.

A client experiences a traumatic brain injury. Which finding identified by the nurse indicates damage to the upper motor neurons?

A Babinski response dorsiflexion of the first toe and fanning of the other toes is a reaction to stroking the lateral sole of the foot with a blunt object; it is indicative of damage to the corticospinal tract when seen in adults.

What does a shift to the left indicate in the white blood cell count differential?

A shift to the left in the white blood cell count differential indicates that immature neutrophils are being released into the blood. The infection is continuing, not resolving.

A nurse is formulating a teaching plan for a client recently diagnosed with type 2 diabetes. What interventions should the nurse include to decrease the risk of complications? Select all that apply.

1. Examine the feet daily 2. Wear well-fitting shoes 3. Perform regular exercise

Which drug can be administered via the intramuscular route to treat anaphylaxis?

Epinephrine is administered through the intramuscular route to treat anaphylaxis.

A nurse moves into the working phase of a therapeutic relationship with a depressed client who has a history of suicide attempts. What question should the nurse ask the client when exploring alternative coping strategies?

"How will you manage the next time your problems start piling up?" focuses the interaction toward the future and invites the client to explore alternative coping strategies.

The nurse is assessing the client admitted with diabetic ketoacidosis. Which statement made by the client indicates a need for further education on sick day management?

"I need to stop taking my insulin when I am ill because I am not eating." The diabetic client's metabolic needs will require the same amount of insulin and sometimes more when in a stressed state, including illness.

A nurse teaches a client with type 2 diabetes how to provide self-care to prevent infections of the feet. Which statement made by the client shows that teaching was effective?

"I should control my blood glucose with diet, exercise, and medication."

A registered nurse is evaluating the statements of a client after teaching the client measures to decrease the risk for antibiotic-resistant infections. Which statements made by the client indicate a need for more education? Select all that apply.

"I should skip doses when I am completely well." "I should save unfinished antibiotics for later emergency use."

A registered nurse is teaching a student nurse regarding the precautions to be followed while caring for a client infected with Ebola virus. Which statement by the student nurse indicates the need for further teaching?

"I will not touch the prepared food for the infected client." The Ebola virus is not spread via air, water, or food. Prepared food for the client will not be a mode of transfer.

The nurse is teaching a client about the prescribed diet after a Whipple procedure for cancer of the pancreas. Which statement should the nurse include in the dietary teaching?

"Low-fat meals should be eaten to prevent interference with your fat digestion mechanism."

A nurse is precepting a senior-level nursing student. The preceptor knows the nursing student understands the concept of screening for sepsis when the student makes what statement?

"Sepsis mortality is affected greatly by treatments performed in the first 6 hours."

A client scheduled to begin electroconvulsive therapy to treat severe depression that has not responded antidepressant medications tells the nurse, "I'm scared that I'll lose my memory forever after the treatment." What is the most therapeutic response?

"You'll experience a temporary loss of memory, and feeling frightened about it is expected"

A nurse is caring for a client newly diagnosed with type 1 diabetes. In attempting to regulate this client's insulin regimen, the client experiences episodes of hypoglycemia and hyperglycemia, and 15 g of a simple sugar is prescribed. What is the reason this is administered?

A simple sugar provides glucose to the blood for rapid action.

When using the AMPLE memory aid to conduct a health history during the emergency assessment, which questions will the nurse ask? Select all that apply.

A- assess for drug allergies. M- assess for prescribed medications. P- assess for a previous health history. L- last meal was eaten. E- events or environmental factors that lead to the illness or injury.

A nurse is caring for a client admitted to the hospital for diabetic ketoacidosis. Which clinical findings related to this event should the nurse document in the client's clinical record?

Acetone breath Decreased arterial carbon dioxide level

The nurse recognizes that a client is experiencing an anaphylactic reaction secondary to drug hypersensitivity. What action should the nurse take first?

Administering oxygen should be the first action of the nurse for this client.

A client calls the emergency department of the hospital after taking 24 sleeping pills. Which statement best describes the psychodynamics of calling the emergency department during the very act of a suicide attempt?

Ambivalence about dying

A client with type 1 diabetes receives Humulin R insulin in the morning. Shortly before lunch the nurse identifies that the client is diaphoretic and trembling. What is the nurse's most appropriate action?

Assess the client's blood glucose level

A client with an intractable infection is receiving vancomycin. Which laboratory blood test result should the nurse report?

Blood urea nitrogen (BUN): 30 mg/dL. Vancomycin is a nephrotoxic medication.

which components are able to change to adapt to small increases in ICP?

Blood, Brain tissue and Cerebral spinal fluid

A client with a traumatic brain injury is demonstrating signs of increasing intracranial pressure, which may exert pressure on the medulla. What should the nurse assess to determine involvement of the medulla? Select all that apply.

Breathing, Heart rate. The medulla, part of the brainstem just above the foramen magnum, is concerned with vital functions such as breathing and heart rate.

Which antiseizure drugs are used to stabilize a client's mood by suppressing mania associated with bipolar disorder? Select all that apply.

Carbamazepine, Divalproex sodium. Antiepileptic drugs are used to suppress mania.The three important antiepileptic drugs used to treat BPD are divalproex sodium, carbamazepine, and lamotrigine.

Priority decision: When assessing the body function of a patient with increased ICP, what should the nurse assess first?

Cardiopulmonary status is always priority

During a teaching session about insulin injections, a client asks the nurse, "Why can't I take the insulin in pills instead of taking shots?" What is the nurse's best response?

Insulin in tablet form is inactivated by gastric juices; insulin given by injection avoids exposure to digestive enzymes. Insulin is not given orally at this time because it is inactivated by digestive enzymes.

A nurse should employ which technique to maintain surgical asepsis?

Change the sterile field after sterile water is spilled on it.

Following surgery, T P N is instituted via a central venous infusion. During the 4th hour of the infusion the client c/o nausea, fatigue, and a headache. The hourly urine output is 2x the amount of the previous hour. After contacting the primary health care provider, what is the next nurse action?

Check the serum glucose level. Rapid administration can cause glucose overload, leading to osmotic diuresis and dehydration

A client reports disturbed sleep due to itching caused by an allergy. Which medication would be prescribed to help the client sleep well and treat the allergic symptoms?

Chlorpheniramine is an antihistamine. Sedation is a side effect of chlorpheniramine; therefore this drug is prescribed to clients experiencing sleep issues due to allergic symptoms.

A client with a severe allergy has been administered a high dose of antihistamine. The nurse finds that the client is drowsy and dizzy. Which type of need would the nurse prioritize in the client according to Maslow's hierarchy of needs?

Clients suffering from the effects of a high dose of antihistamines have strong safety needs

Assessment of a newborn reveals congenital cataracts, microcephaly, deafness, and cardiac anomalies. Which infection does the nurse suspect that the newborn's mother contracted during her pregnancy?

Congenital rubella (German measles) syndrome results in abnormalities that vary, depending on the gestational age of the fetus when the maternal infection was contracted

The nurse assesses a client with bipolar disorder. While reviewing the laboratory reports, the nurse finds the client's lithium levels are 1.3 mEq/Liter. Which nursing intervention would be appropriate in this client?

Continuing to administer the drug. The normal range of lithium is below 1.5 mEq/Liter

When a client is receiving dexamethasone for adrenocortical insufficiency, what action does the nurse take to monitor for an adverse effect of the medication?

Corticosteroids, such as dexamethasone, have a hyperglycemic effect, and blood glucose levels should be monitored routinely.

A nurse instructs a client with a history of frequent urinary tract infections to drink cranberry juice. Which goal is the nurse trying to achieve with this suggestion?

Cranberry juice keeps the bacteria from attaching to the bladder wall.

While assessing a client with acquired immunodeficiency syndrome, the nurse suspects that the client has developed cryptosporidiosis. Which symptoms support the nurse's suspicion? Select all that apply.

Cryptosporidiosis is an intestinal infection caused by Cryptosporidium. The symptoms of cryptosporidiosis are diarrhea and weight loss.

Which treatment intervention should be provided to a client diagnosed with Cushing's disease?

Cushing's disease affects the glucose metabolism and results in reduced glucose uptake by tissues and increased blood glucose levels; therefore interventions to regulate blood glucose levels should be undertaken.

A client at 40 weeks' gestation is admitted to the birthing unit. She tells the nurse that she awakened at 8:00 am with regular contractions that were 6 minutes apart. Her last full meal was eaten at about 6:00 pm yesterday. She did not eat breakfast. potential problem?

Decreased blood glucose level. Labor is hard work and can cause depletion of the pregnant woman's glucose stores, especially if she had not eaten for more than 14 hours.

Early sign of ICP?

Decreased level of consciousness

Cushing's triad

Decreased pulse, irregular respirations, widened pulse pressure.

An insulin pump is instituted for a client with type 1 diabetes. The nurse plans discharge instructions. Which short-term goal is the priority for this client?

Demonstrating correct use of the insulin pump is the short-term, client-oriented goal necessary for the client to manage the pump, avoid hypo/hyper glycemia; observing a return demonstration by the client.

Which clinical findings should cause the nurse to suspect that an adolescent child with type 1 diabetes is hypoglycemic?

Difficulty concentrating, hunger, and diaphoresis are the most common signs and symptoms of hypoglycemia. I

The nurse educates a client on decreasing the risk of developing antibiotic-resistant infections. Which statement made by the nurse will be most significant?

Do not skip any dose of your antibiotics."

What actions should the nurse take when a client develops an anaphylactic reaction? Select all that apply.

Emergency care of the client with anaphylaxis includes applying oxygen at 90 to 100%, calling the Rapid Response Team, elevating the head of the bed to 45 degrees, and ensuring that emergency airway equipment is at the bedside.

A nurse may find that for optimum nutrition a client with a cerebrovascular accident needs assistance with eating. What should the nurse do?

Encourage the client to participate in the feeding process

A client with type 2 diabetes is taking one oral hypoglycemic tablet daily. The client asks whether an extra tablet should be taken before exercise. What is the best response by the nurse?

Exercise improves glucose metabolism; with exercise there is a risk of developing hypoglycemia, not hyperglycemia.

A client with cellulitis of the leg asks why bed rest has been prescribed to prevent sepsis. Which purpose will the nurse explain to the client?

Exercise will promote extension of the local infection from the leg into the circulation, causing septicemia or sepsis.

During a client's routine physical examination, a chest x-ray film reveals a lesion in the right upper lobe. Which information in the client's history supports the healthcare provider's diagnosis of pulmonary tuberculosis? Select all that apply.

Fever, Night sweats, Blood-tinged sputum

A client develops peritonitis and sepsis after the surgical repair of a ruptured diverticulum. What signs should the nurse expect when assessing the client? Select all that apply.

Fever, Tachypnea, Abdominal rigidity

The nurse suspects the Jarisch-Herxheimer reaction in a client with syphilis who is on antibiotic therapy. Which symptoms in the client support the nurse's suspicion? Select all that apply.

Fever, generalized ache, and pain at the injection site are signs of the Jarisch-Herxheimer reaction in a client with syphilis receiving antibiotic therapy.

A client is admitted with full-blown anaphylactic shock that developed due to a type 1 latex allergic reaction. Which findings will the nurse observe upon assessment? Select all that apply.

Full-blown anaphylactic shock produces stridor, hypotension, and dyspnea.

A nurse in the clinic is assessing a teenager with a tentative diagnosis of primary syphilis. What is an early sign of this infection?

Genital lesion. Rationale: A chancre is the earliest sign of syphilis; a dark-field examination of a scraping will reveal the Treponema organism.

The patient has been diagnosed with a cerebral concussion/ What should the nurse expect to see in this patient?

Headache, retrograde amnesia and transient reduction in LOC.

A client has an anaphylactic reaction after receiving intravenous penicillin. What does the nurse conclude is the cause of this reaction?

Hypersensitivity results from the production of antibodies in response to exposure to certain foreign substances (allergens). Earlier exposure is necessary for the development of these antibodies.

The nurse knows that the newborns of mothers with diabetes often exhibit tremors, periods of apnea, cyanosis, and poor suckling ability. With which complication are these signs associated?

Hypoglycemia

An infant of a diabetic mother is admitted to the neonatal intensive care unit. What is the priority nursing intervention for this infant?

Hypoglycemia may be present because of the sudden withdrawal of maternal glucose and increased fetal insulin production, which continues after birth.

Which factors decrease cerebral blood flow? SATA

Increased ICP PaCO of 30 Decreased mean arterial pressure

Cingulate Herniation

Increased ICP in the left hemisphere caused by intracranial bleeding causes the displacement of the brain tissue to the right hemisphere beneath the falix cerebri.

A nurse is caring for a postoperative client with diabetes. Which is the most common cause of diabetic ketoacidosis that the nurse needs to consider when caring for this client?

Infection increases the body's metabolic rate, and insulin is not available for increased demands.

What causes vasogenic cerebral edema? SATA

Ingested toxins Fluid flowing from intravascular to extravascular space.

A registered nurse is evaluating the actions of a nursing student who is injecting an allergen in a client having a severe anaphylactic reaction to insect venom. Which action of the nursing student requires correction?

Injecting in an extremity close to a joint

The laboratory findings of an obese hypertensive adolescent reveal hyperinsulinemia and dyslipidemia. Which condition is the adolescent likely to have?

Insulin resistance syndrome, also known as metabolic syndrome or syndrome X is a condition seen mostly in obese clients that manifests as hyperinsulinemia and dyslipidemia.

A nurse is caring for a client with a diagnosis of type 1 diabetes who has developed diabetic coma. Which element excessively accumulates in the blood to precipitate the signs and symptoms associated with this condition?

Ketones are produced when fat is broken down for energy. Although rarely used, sodium bicarbonate may be administered to correct the acid-base imbalance resulting from ketoacidosis; acidosis is caused by excess acid

Which complication of anaphylactic shock in the adolescent client is most important for the nurse to detect early?

Laryngeal edema with severe acute upper airway obstruction may be life threatening in anaphylactic shock and requires rapid intervention.

A client is admitted to the hospital with a head injury sustained while playing soccer. For which early sign of increased intracranial pressure should the nurse monitor this client?

Lethargy. Lethargy is an early sign of a changing level of consciousness; changing level of consciousness is one of the first signs of increased intracranial pressure.

The nurse identifies a 5-cm indurated region on the upper arm of a client with type 1 diabetes. The client says to the nurse, "That is where I give myself insulin shots." The nurse concludes that the nodule, which is neither warm nor painful, is a result of what condition?

Lipodystrophy is a noninflammatory reaction causing localized atrophy or hypertrophy and a localized increase in collagen deposits.

______________________is prescribed for hypomagnesemia or to treat pregnant women who have preeclampsia.

Magnesium sulfate

A nurse is teaching a 15-year-old adolescent with newly diagnosed type 1 diabetes about self-care. What is the primary long-term goal this nurse and client should agree on?

Maintaining normoglycemia is a realistic goal because it decreases the risk of complications such as neuropathy, retinopathy, and atherosclerosis.

A client is concerned about contracting malaria while visiting relatives in Southeast Asia. What should the nurse teach the client to avoid to prevent malaria?

Malaria is caused by the protozoan Plasmodium falciparum, which is carried by mosquitoes.

The nurse is caring for a client who is receiving treatment via intrathecal therapy. The client reports a headache and neck stiffness. Upon assessment, the nurse finds that the client's body temperature is 103 °F. Which condition should the nurse suspect in the client?

Meningitis

Which leukocyte values should be assessed to determine the adequacy of a client's response to inflammation? Select all that apply.

Monocytes, Neutrophils, macrophages

A client has increased intracranial pressure resulting from a traumatic brain injury. Assessment: client is unconscious V/S: pulse 60 beats/min, respirations 16 breaths/min, and blood pressure 142/64. The nurse reviews the treatment plan and questions which prescription?

Morphine. Morphine injection is contraindicated for an unconscious, neurologically impaired client because it depresses respirations.

A nurse is teaching the parents of an infant with a cleft lip and palate how to prevent infection. What information should the nurse include about why the infant is predisposed to infection?

Mouth breathing dries the oropharyngeal mucous membranes

A client's laboratory report shows severe neutropenia and thrombocytopenia. Which medication may have caused this condition?

Mycophenolate mofetil is a cytotoxic drug that may cause neutropenia and thrombocytopenia.

Which nursing intervention prevents footdrop in a client with osteomyelitis?

Neutral positioning of the foot with the use of a splint can reduce the risk of footdrop in the client with osteomyelitis.

What is the mechanism of action of norepinephrine in managing anaphylaxis?

Norepinephrine is a vasopressor that elevates the blood pressure and cardiac output in clients suffering from anaphylactic reactions.

A nurse is caring for an 11-year-old child with type 1 diabetes. Two hours after breakfast the child becomes pale, diaphoretic, and shaky. What action should the nurse take?

Obtaining a current blood glucose level

During the postpartum period a nurse determines that a client's rubella titer is negative. Which action should the nurse plan to take next?

Obtaining a prescription for immunization at discharge. A negative rubella titer indicates no immunity.

A client scheduled for surgery has a history of M R S A since developing an infection in a surgical site 9 months ago. What should the nurse do to determine if the infecting organism is still present?

Obtaining blood cultures is the most reliable method of determining the presence of an infecting microorganism

A nurse adds 20 mEq of potassium chloride to the intravenous solution of a client with diabetic ketoacidosis. What is the primary purpose for administering this drug?

Once treatment with insulin for diabetic ketoacidosis is begun, potassium ions reenter the cell, causing hypokalemia; therefore potassium, along with the replacement fluids, is needed.

. After assessing a client, a nurse concludes that the client may be experiencing hyperglycemia. Which clinical findings commonly associated with hyperglycemia support the nurse's conclusion? Select all that apply.

Polyuria is excessive urination. Polydipsia is excessive thirst Polyphagia is associated with the catabolic state induced by insulin deficiency.

Which of the following assessment findings would the nurse state are common integumentary manifestations in clients with acquired immunodeficiency syndrome (AIDS)?

Poor wound healing is an integumentary manifestation in a client with AIDS.

for hypokalemia.

Potassium chloride is prescribed

The cerebral perfusion pressure or CPP is the pressure needed to ensure blood flow to the brain. What is the normal CCP?

Ranges from 60 to 100.

Six hours after initiation of total parenteral nutrition, the client's serum glucose level increases to 240. What does the nurse conclude is the most likely cause of the increase?

Rapid infusion of concentrated glucose into the vascular system does not allow time for adequate insulin release to transport glucose to the cells.

The nurse is assessing a client for recall memory. Which statements made by the client indicate that the client's recall memory is intact?

Recall memory can be tested by asking questions related to the recent past, such as mode of transportation to the hospital, time and date of admission, and history of appointments with healthcare providers.

A client is diagnosed with diabetic ketoacidosis. Which insulin should the nurse expect the health care provider to prescribe?

Regular insulin is rapid acting and should be used for diabetic coma. I

Daily regular insulin has been prescribed for a client with type 1 diabetes. The nurse administers the insulin at 8 am. When should the nurse monitor the client for a potential hypoglycemic reaction?

Regular insulin is short acting and peaks in 2 to 4 hours, which in this case will be at or before lunch.

A client who sustained a large open wound as a result of an accident is receiving daily sterile dressing changes. To maintain sterility when changing the dressing, what should the nurse do?

Remove the sterile drape from its package by lifting it by the corners.

After an automobile collision involving a fatality and a subsequent arrest for speeding, a client has amnesia regarding the events surrounding the accident. Which defense mechanism is being used by the client?

Repression is coping with overwhelming emotions by blocking awareness or memory of the stressful event.

Which infection caused by droplets larger than 5 microns would the nurse explain is found in children between 3 to 6 years of age?

Rubella is a droplet infection that is found in preschoolers. It is caused by droplets larger than 5 microns.

A nurse is caring for a client who is scheduled for a gastric bypass to treat morbid obesity. Which diet should the nurse teach the client to maintain because it will help minimize clinical manifestations of dumping syndrome?

Small feedings reduce the amount of bulk passing into the jejunum and therefore reduce the fluid that shifts into the jejunum.

A nurse is precepting an orientee (newly hired nurse). The nurse observes the orientee caring for an unconscious client with increasing intracranial pressure. The nurse should question which intervention that the orientee performs?

Suctioning the oropharynx routinely. Although suctioning is done to maintain an airway, it is not done routinely because it increases intracranial pressure.

A nurse is preparing to change a client's dressing. What is the reason for using surgical asepsis during this procedure?

Surgical asepsis means that practices are employed to keep a defined site or objects free of all microorganisms.

How is cranial nerve 3 , originating from the mid-brain, assessed by the nurse for an early indication of pressure on the brain stem?

Test pupillary reaction to light.

A patient with a head injury has bloody drainage from the ear. What should the nurse do to determine if CSF is present in the drainage?

Test the fluid for a halo sign on a white dressing.

A client with diabetes is being taught to self-administer a subcutaneous injection of insulin. Identify the preferred site for the self-administration of this drug.

The abdomen is the preferred site for an insulin injection because it is easily accessible and absorption is more even and rapid than when it is injected in the extremities.

A client with a history of alcoholism is found to have Wernicke encephalopathy associated with Korsakoff syndrome. What does the nurse anticipate will be prescribed?

Thiamine is a coenzyme necessary for the production of energy from glucose. If thiamine is not present in adequate amounts, nerve activity is diminished and damage or degeneration of myelin sheaths occurs.

Shortly after birth the nurse instills erythromycin ophthalmic ointment in the newborn's eyes. The father asks why an antibiotic is needed. The nurse explains that it is routinely administered to prevent what type of infection?

The antibiotic ointment is administered prophylactically to prevent the development of ophthalmia neonatorum, which may be contracted during a vaginal birth to a mother with gonorrhea, chlamydia, or both infections.

A client's blood gases reflect diabetic ketoacidosis. Which clinical indicator should the nurse identify when monitoring this client's laboratory values?

The bicarbonate-carbonic acid buffer system helps maintain the pH of body fluids; in metabolic acidosis, there is a decrease in bicarbonate because of an increase of metabolic acids.

After a surgical thyroidectomy a client exhibits carpopedal spasm and some tremors. The client complains of tingling in the fingers and around the mouth. What medication should the nurse expect the primary health care provider to prescribe after being notified of the client's adaptations?

The client is exhibiting signs and symptoms of hypocalcemia, which occurs with accidental removal of the parathyroid glands; calcium gluconate is administered to treat hypocalcemia.

A nurse, understanding the possible cause of alcohol-induced amnestic disorder, should take into consideration that the client is probably experiencing which imbalance?

The deficiency of thiamine (vitamin B 1) is thought to be a primary cause of alcohol-induced amnestic disorder.

The nurse is monitoring a patient for increased ICP following a head injury. What are manifestations of increased ICP?

The first sign of ICP is change in Level of consciousness, followed by dilated ipsilateral pupils, posturing, fever and changes in motor response.

A pregnant client with diabetes is referred to the dietitian in the prenatal clinic for nutritional assessment and counseling. What should the nurse emphasize when reinforcing the client's dietary program?

The need to eat a pregnancy diet that meets increased dietary needs and to adjust the insulin dosage as necessary

A client is admitted to the hospital with a diagnosis of urinary retention related to B P H. The PCP notes a secondary diagnosis of delirium related to urosepsis and prescribes the insertion of an indwelling urinary retention catheter. Which nursing action is most important?

The nurse should determine whether the client is a danger to self or others before planning and implementing care. No pattern of unsafe behavior has been identified requiring the use of wrist restraints.

A nurse is caring for a client who had a traumatic brain injury with increased intracranial pressure. Which healthcare provider prescription should the nurse question?

The prescription for isometric exercises should be questioned; isometric exercises increase the basal metabolic rate and intracranial pressure.

The nurse is caring for a client with sepsis who is hemodynamically stable. The client is complaining of abdominal pain. Which of these primary health care provider prescriptions should the nurse do first?

The priority is to draw the blood cultures so the antibiotic can be initiated as soon as possible.

While questioning a rape victim, the nurse discovers that the victim does not remember anything related to the assault. Of the following, which is the most probable cause of the victim's memory loss?

The rape victim was drugged with flunitrazepam. Flunitrazepam, also known as Rohypnol and the "date rape drug," is a hypnotic drug that produces prolonged sedation and short-term memory loss.

A newborn weighing 9 lb 14 oz (4479 g) is delivered by cesarean due to cephalopelvic disproportion. The Apgar scores are 7 at 1 minute and 9 at 5 minutes. Which nursing action should be taken after the initial physical assessment?

The simple measure of determining the infant's blood glucose level will reveal hypoglycemia in this large-for-gestational-age infant.

At 4:30 pm, a client who is receiving NPH insulin every morning states, "I feel very nervous." The nurse observes that the client's skin is moist and cool. What is the nurse's most accurate interpretation of what the client is likely experiencing?

The time of the client's response corresponds to the expected peak action (4 to 12 hours after administration) of the intermediate-acting insulin that was administered in the morning; this can result in hypoglycemia.

A client with diabetic ketoacidosis who is receiving intravenous fluids and insulin complains of tingling and numbness of the fingers and toes and shortness of breath. The cardiac monitor shows the appearance of a U wave. What complication does the nurse suspect?

These are classic signs of hypokalemia that occur when potassium levels are reduced as potassium reenters cells with glucose.

A nurse places a school-aged child with bacterial meningitis in isolation with droplet precautions. What is the purpose of these precautions?

They keep the child away from uninfected people. Droplet precautions reduce the transmission of infection from the child to other individuals cross-infection.