2400: EAQ- Unit 4

Pancreatitis A client is admitted with the diagnosis of acute pancreatitis. Which clinical manifestations would the nurse assess in the client? Select all that apply. A. Jaundice B. Acute pain C. Hypertension C. Hypoglycemia E. Increased amylase

A, B, E Obstruction of the common bile duct by inflammation leads to jaundice. Autodigestion of the pancreas causes severe abdominal pain. Obstruction of the pancreatic duct leads to elevated levels of amylase and lipase. Hypotension, not hypertension, is caused by fluid shifting out of the intravascular space. Decreased pancreatic function causes hyperglycemia, not hypoglycemia.

Cystic Fibrosis A 15-year-old with cystic fibrosis (CF) is admitted with a respiratory infection. The nurse determines that the adolescent is cyanotic, has a barrel-shaped chest, and is in the 10th percentile for both height and weight. Which is the priority nursing intervention? A. Increasing physical activities B. Performing postural drainage C. Maintaining dietary restrictions D. Administering prescribed pancreatic enzymes

B Postural drainage, including percussion and vibration, aids in removal of respiratory secretions that provide a medium for further bacterial growth. Children with CF must cope with impaired gas exchange that results in intolerance to activity. Increasing activity at this time may be too taxing. There must be a balance between activity and rest within the child's limitations. There are no dietary restrictions. Children with CF should have a balanced nutritional intake that is high in calories. Although important, administration of prescribed pancreatic enzymes is not the priority.

Endometriosis The nurse is obtaining a health history from a client with endometriosis. Which consequences can occur as a result of this disorder? Select all that apply. A. Menopause B. Metrorrhagia C. Impaired fertility D. Bowel strictures E. Voiding difficulties

B, C, D, E Metrorrhagia is a possible complication; bleeding between periods is due to the bleeding of endometrial tissue outside the uterus. The excessive tissue in endometriosis may impinge on the colon and cause ribbonlike stools. The endometrial tissue may impinge on the bladder and ureters and cause voiding difficulties. Impaired fertility may result from adhesions around the uterus that pull the uterus into a fixed, retroverted position. Endometriosis does not cause menopause.

Complication of Prematurity Supplemental oxygen is ordered for a preterm neonate with respiratory distress syndrome (RDS). Which action would the nurse take to reduce the possibility of retinopathy of prematurity? A. Humidifying oxygen flow to prevent dehydration B. Uncovering the entire body to increase exposure to the oxygen C. Applying eye patches to both eyes to protect them from the oxygen D. Verifying oxygen saturation frequently to adjust flow on the basis of need

D Determining oxygen saturation identifies the need for oxygen supplementation; prolonged use of oxygen concentrations exceeding those required to maintain adequate oxygenation contributes to the occurrence of retinopathy of prematurity. Preventing dehydration by humidifying the oxygen will not prevent retinopathy of prematurity. The skin does not absorb oxygen; it must enter the lungs through inhalation. Retinopathy of prematurity is caused by a high blood concentration of oxygen, not by exposure of the eyes to oxygen.

TPN The nurse assesses a client who is receiving total parenteral nutrition (TPN) for which complication? A. Infection B. Renal failure C. Anorexia D. Dysrhythmias

A The concentration of glucose in the solution (20%-25%) is a rich culture medium for bacterial and fungal growth. Renal failure is not associated with TPN. Anorexia often is present before the medical decision to begin TPN; it is not a complication. Dysrhythmias are not related directly to TPN, but rather to concomitant hypokalemia, which can occur if potassium is not added to the solution.

TPN The nurse is caring for a client who is receiving total parenteral nutrition (TPN). The nurse will assess for which complications? Select all that apply. A. Infection B. Hyperglycemia C. ABO incompatibility D. Electrolyte imbalance E. Cardiac dysrhythmias

A, B, D Hyperglycemia is a common complication with TPN because of the high-glucose formulas used; blood glucose levels need to be monitored carefully during therapy. TPN formulas may need to be adjusted daily based on the client's daily electrolyte levels. ABO incompatibility is not associated with TPN. Cardiac dysrhythmias are not related to TPN.

Pancreatitis A client who is obese and has a history of alcohol abuse is admitted to the hospital with a diagnosis of acute pancreatitis. Which is an appropriate initial client treatment goal? A. Decreased pain B. Selection of appropriate food choices C. Joining Alcoholics Anonymous D. A loss of 4 pounds (1.8 kg) per week

A Pain relief is the priority. Severe pain is associated with acute pancreatitis caused by inflammation of the pancreas, peritoneal irritation, and biliary tract obstruction. Selection of appropriate food choices, losing weight, and joining Alcoholics Anonymous are later goals.

Complication of Prematurity Which component of nursing care is most important for a newborn with respiratory distress syndrome (RDS)? A. Keeping the infant in a warm environment B. Turning the infant frequently to prevent apnea C. Tapping the infant's toes to stimulate deep breathing D. Maintaining the infant's oxygen administration level at the same rate

A The infant is kept in a warm environment because any attempt by the infant's body to maintain body temperature further compromises physical status by increasing metabolic activity and oxygen demands. Turning the infant frequently will decrease the respiratory complications, but will not prevent apnea. Tapping the infant's toes will stimulate the infant to cry and increase oxygen demands. The amount of oxygen administered should vary with the infant's laboratory values.

Endometriosis A client with endometriosis asks the nurse which side effects to expect from leuprolide. Which would the nurse include in the response? A. Weight gain B. Increased libido C. Frequent urination D. Heavy menstrual bleeding

A The side effects of leuprolide include edema, which causes an increase in weight. Leuprolide decreases libido. Frequent urination is not a side effect of leuprolide. Clients who take leuprolide do not experience menstrual periods because follicle-stimulating hormone and luteinizing hormone are suppressed.

Cystic Fibrosis The parents of an adolescent child with cystic fibrosis (CF) should be alert for which potential complications of CF? Select all that apply. A. Diabetes B. Hematuria C. Nasal polyps D. Prolapsed rectum E. Pulmonary infections F. Urinary tract infections

A, C, D, E By adolescence almost 50% of children with CF will have abnormal glucose tolerance test results as a result of the disease's effects on the pancreas. The viscous mucous secretions contribute to nasal polyp development. The fatty, bulky stools cause rectal prolapse in many affected children. Children with CF also have an increased incidence of pulmonary infection, a result of the viscous mucus. Individuals with CF are not at increased risk for hematuria. Children with CF are not at increased risk for urinary tract infections.

Medications- Pancreatitis Which medication will the nurse question when it is prescribed for a client with acute pancreatitis? A. Ranitidine B. Cimetidine C. Meperidine D. Promethazine

C Meperidine should be avoided because accumulation of its metabolites can cause central nervous system irritability and even tonic-clonic seizures (grand mal seizures). Ranitidine and Cimetidine are useful in reducing gastric acid stimulation of pancreatic enzymes. Promethazine is useful as an antiemetic for clients with pancreatitis.

Pneumothorax Which action would the nurse take to prevent complications when caring for a client with a chest tube to water seal drainage system for a pneumothorax? Select all that apply. A. Emptying the drainage system when full B. Keeping the drainage system at heart level C. Notifying the health care provider of drainage greater than 50 mL/h D. Marking the time on the drainage unit every shift E. Laying the drainage system on its side during transport

D The nurse would mark the drainage system every shift to determine the amount of drainage. The drainage system is a closed system, so the nurse would switch out the drainage system when it is full. Emptying the system would break sterility. The drainage system should remain below chest level to prevent fluid from backing up into the lungs. The nurse would notify the health care provider if drainage is greater than 100 mL/h. The nurse would keep the drainage system upright.

Cleft Palate/Lip A newborn with a severe bilateral cleft lip and palate is shown to the father. The father says, "How could this happen to us? My wife is going to be so upset!" Which is the best response by the nurse? A. "This must be very hard on you. I can go with you when your wife sees the baby." B. "You have a healthy baby, and the clefts can be closed so they won't be noticeable." C. "This feeling won't last. Soon you'll love your baby so much that you won't even notice the clefts." D. "I know this is difficult for you, but you can't think of yourself now, because your wife needs you to be strong."

A Identifying feelings and providing support during stressful times are ways of demonstrating concern during a crisis. Telling the father that the clefts can be closed so they won't be noticeable or that the feeling won't last is not a supportive or insightful reply. Telling the father that he can't think of himself now is an inappropriate reply that may instill guilt feelings; the father and the mother need support through this crisis.

Complication of Prematurity Respiratory distress syndrome (RDS) develops 6 hours after birth in a neonate born at 33 weeks' gestation. Which would the nurse's assessment of the newborn at this time reveal? A. Intercostal retractions B. High-pitched cry C. Heart rate of 140 beats/min D. Respirations of 30 breaths/min

A Intercostal retractions are a classic sign of respiratory distress in the newborn. A high-pitched cry is associated with neurological impairment, not respiratory distress. Heart rate of 140 beats/min is within expected limits. The lowest respiratory rate of a healthy, resting newborn is 35 breaths/min. With RDS the respiratory rate increases, not decreases.

Endometriosis A client with a history of endometriosis has abdominal surgery to remove abdominal adhesions. Which actions would the client's postoperative plan of care include? A. Encouraging the client to ambulate in the hallway B. Placing the bed in the Trendelenburg position C. Helping the client dangle her legs over the side of the bed D. Maintaining the client on bed rest until the dressings have been removed

A Muscle contraction during ambulation improves venous return, which prevents venous stasis and thrombus formation. The Trendelenburg position, where the head is lower than the trunk, would not be indicated after this surgery. Dangling the legs places pressure on the popliteal spaces, limiting venous return and increasing the risk of thrombus formation. Bed rest is associated with venous stasis, which increases the risk of thrombus formation.

Cystic Fibrosis What information should be considered before replying to the parents of a child with cystic fibrosis (CF) who ask why he needs a glucose tolerance test? A. Pancreatic scarring predisposes the child to diabetes. B. The thickened mucus blocks the insulin-secreting glands. C. The test reveals the degree to which the child adheres to the diet. D. Adjustments of the dosage of pancreatic enzymes are based on the results of the test.

A Pancreatic scarring affects the ability of the islets of Langerhans to produce insulin; about half of all children with CF have altered glucose tolerance. The endocrine glands, which produce insulin, are ductless and are not affected by the thickened mucus in the ducts. However, the general scarring throughout the pancreas does affect the insulin-producing glands. The glucose tolerance test is a measure of the body's ability to produce and metabolize carbohydrates, not a measure of the child's adherence to the diet. The dosage of pancreatic enzymes is based on food consumption, not the blood glucose level.

Endometriosis A 15-year-old adolescent is diagnosed with endometriosis. The client has severe, acute, and incapacitating symptoms. Which would be the anticipated line of treatment? A. Surgical intervention B. Continuous combined hormone therapy and NSAIDs C. Nonsteroidal anti-inflammatory drugs (NSAIDs) during menstruation D. Oral contraceptive pills (OCPs) with low estrogen-to-progestin ratio

A Surgical intervention is needed in adolescents with severe, acute, and incapacitating symptoms. NSAIDs can be used for symptomatic pain relief. Women having mild symptoms and desire for future pregnancy are treated with limited use of NSAIDs during menstruation. Women having mild symptoms and who can postpone pregnancy are treated with oral contraceptive pills that have low estrogen-to-progestin ratios. In adolescents younger than 16 years of age diagnosed with endometriosis, continuous combined hormone therapy and NSAIDs are the treatment option.

TPN Which action would the nurse take when administering total parenteral nutrition (TPN)? A. Change the TPN solution bag every 24 hours, even if there is solution left in the bag. B. Monitor the client's blood glucose level every 2 hours at the bedside with a glucometer. C. Instruct the client to breathe shallowly when changing the TPN tubing using sterile techniques. D. Speed up the rate of the TPN infusion if the amount delivered has fallen behind the prescribed hourly rate.

A TPN solutions are high in glucose and are administered at room temperature, factors that increase the risk of microbial growth in the solution; they should be changed daily or sooner if they appear cloudy. Monitoring the blood glucose level every 2 hours is too frequent in ordinary circumstances; the client's blood glucose level should be monitored every 4 to 6 hours to identify the presence of hyperglycemia, a metabolic complication of TPN. The client should not breathe while the TPN catheter is changed because it may result in an air embolus; the Valsalva maneuver should be performed by the client for the few seconds it takes to switch the tubing. An excess amount of glucose will be infused if the rate of the TPN is increased, and the endogenous insulin will be inadequate to meet this demand, resulting in hyperglycemia.

Cleft Palate/Lip Which is the best response from the nurse when asked why a 4-month-old infant is having a cleft lip repair at such an early age? A. Has an emotional effect on the parents B. Tends to obstruct breathing C. Can cause severe feeding problems D. May cause respiratory tract infections

A The visual effect of the cleft lip on the parents may significantly affect the parent-child attachment process and is often considered a reason for early surgical intervention. The best age to have cleft lip surgery varies, but preferably between 4 months and 12 months of age. The infant also uses the nose to breathe; a cleft lip does not obstruct breathing. Feeding may be accomplished with breastfeeding or the use of specially designed bottles and nipples; this is not, by itself, an indication for early surgery. Infants with cleft palate have severe feeding problems. Precautions other than surgery can be taken to prevent ear and upper respiratory tract infections.

TPN The nurse is administering total parenteral nutrition (TPN) to a client who asks why the solution is yellow. Which explanation would the nurse provide? A. "Vitamin B complex makes it yellow." B. "Preservatives in the solution change its color." C. "I will have the pharmacist come to speak with you." D. "All TPN is yellow."

A Vitamin B complex is a yellow solution. When it is added to a base solution of TPN, it turns the solution yellow. Preservatives in intravenous (IV) solutions are colorless. Having the pharmacist come speak to the client abdicates the nurse's responsibility to answer the question. TPN is prescribed individually and may not always contain vitamin B complex and thus may not be yellow.

Pneumothorax A client with a spontaneous pneumothorax asks, "Why did they put this tube into my chest?" Which information would the nurse provide about the purpose of the chest tube? A. It removes air from the pleural space. B. It checks for bleeding in the lung. C. It monitors the function of the lung. D. It drains fluid from the pleural space.

A With a pneumothorax, a chest tube attached to a closed chest drainage system removes trapped air and helps reestablish negative pressure within the pleural space; this results in lung reinflation. A closed chest drainage system may be inserted to remove blood related to a hemothorax, not to assess for bleeding. Monitoring the function of the lung is not the purpose of inserting chest tubes; the function of the lungs is monitored through the assessment of vital signs, breath sounds, arterial blood gases, and chest x-ray. Draining fluid from the pleural space is the reason for use of a closed chest drainage system when there is fluid in the pleural space.

Cleft Palate/Lip Which parent teaching would the nurse provide to minimize regurgitation in an infant with a cleft lip? A. Offer a thickened formula. B. Burp frequently during a feeding. C. Place the child in an infant seat during feedings. D. Position the child on the side with the bottle propped.

B Because of the cleft (opening) in the lip, infants with this condition tend to suck in excessive air; burping helps prevent regurgitation of formula. Thickened formula is given to infants with reflux problems, such as vomiting after each feeding. This infant should be held during feedings, not positioned in an infant seat. The bottle should never be propped, because aspiration may occur.

Cystic Fibrosis When teaching parents of children with cystic fibrosis (CF) ways to help their children achieve optimal growth and development, the nurse encourages a high-calorie diet. Which other important detail of the diet would be included in the teaching? A. Low protein B. High fat C. High calcium D. High potassium

B High fat is recommended because of the need for increased calories in response to growth and development requirements. A high-protein, not a low-protein, diet is recommended to overcome protein maldigestion. A high-calcium diet is not indicated in CF. Unless the potassium level is low, a high potassium intake is contraindicated because it may contribute to a dangerous increase in the serum potassium level that could result in the development of cardiac dysrhythmias.

Cleft Palate/Lip Which nursing intervention is indicated for an infant born with a cleft lip? A. Changing the infant's position often B. Using modified techniques for feeding C. Monitoring the infant's daily intake and output D. Keeping the infant's head elevated during feedings

B Infants with a cleft in the lip are unable to suck like other newborns because they cannot form a vacuum to draw milk from the nipple. Frequent position changes are common for all infants, not just ones with cleft lip. Monitoring of intake and output is not necessary because hydration is maintained once a feeding method has been established. All infants should be fed with the head elevated to avoid pooling of milk in the mouth, which could result in aspiration.

Spina Bifida Which skin care parent education would the nurse provide to the parents of an infant with spina bifida? A. Diapers should be changed at least every 4 hours. B. Frequent diaper changes with cleansing are needed. C. Medicated ointment should be applied six times a day. D. Powder may be used in the perineal area when it becomes wet.

B Infants with spina bifida often exhibit dribbling of urine; they need meticulous skin care and frequent diaper changes to prevent skin breakdown. Changing diapers every 4 hours is insufficient and may result in skin breakdown. Medicated ointments are unnecessary; if a skin irritation develops and an ointment becomes necessary, it should be prescribed by the health care provider. Powder will not keep the skin dry; when powder mixes with urine, it forms a pastelike substance that promotes skin breakdown. Also, powder is toxic if inhaled and should be avoided.

Medications- Endometriosis A client with endometriosis reports having hot flashes. Which of the client's medications would the nurse identify as the cause of this side effect? A. Estrogen B. Leuprolide C. Diclofenac D. Ergonovine

B Leuprolide decreases the levels of luteinizing hormone and follicle-stimulating hormone, as well as hormone-dependent tissue. One of its side effects is hot flashes. Estrogen affects the release of pituitary gonadotropins and inhibits ovulation; it is contraindicated because the goal of treatment is to suppress the action of estrogen on the endometrial tissue. Diclofenac is used for primary dysmenorrhea; it is a nonsteroidal anti-inflammatory medication that inhibits prostaglandin synthesis. Ergonovine is used to induce contraction of the postpartum uterus.

Pancreatitis The nurse is caring for a client with acute pancreatitis. Which elevated laboratory test result is indicative of acute pancreatitis? A. Blood glucose B. Serum lipase C. Serum bilirubin level D. White blood cell count

B Lipase concentration is increased in the pancreas and is elevated in the serum when the pancreas becomes acutely inflamed; this distinguishes pancreatitis from other acute abdominal problems. An elevated blood glucose level is not indicative of pancreatitis but rather diabetes mellitus; however, hyperglycemia and glycosuria may occur in some people with acute pancreatitis if the islets of Langerhans are affected. Serum bilirubin level occurs in other disease processes such as cholecystitis. White blood cell count is not specific to pancreatitis; white blood cells are elevated in other disease processes.

Cleft Palate/Lip Which postoperative nursing care would the nurse provide to a 3-week-old infant after surgery to repair a cleft lip? A. Using a spoon to administer oral feedings B. Cleansing the suture line to prevent infection C. Offering a pacifier for sucking to prevent crying D. Using wrist restraints to keep the infant's hands away from the face

B Meticulous care of the suture line is necessary to prevent infection and to help ensure the best cosmetic outcome. Using a spoon is contraindicated, because it could disrupt the suture line; the infant may be fed with a device designed especially for this purpose. Offering a pacifier is contraindicated, because sucking will put tension on the suture line and may result in disruption of the sutures. Elbow restraints are used; this allows the infant to move the arms without bending the elbows and thus prevents the infant from touching the face.

Pneumothorax A client develops subcutaneous emphysema after a chest injury with a suspected pneumothorax. Which method would the nurse use to assess for this complication? A. Percussing the neck and chest B. Palpating the neck or face C. Auscultating for abnormal breath sounds D. Observing for asymmetry of chest movement

B Subcutaneous emphysema refers to the presence of air in the tissue that surrounds an opening in the normally closed respiratory tract; the tissue appears puffy and a crackling sensation is detected when trapped air is compressed between the nurse's palpating fingertips and the client's tissue. Percussion is not an appropriate method for assessment; breath sounds are not affected. Asymmetry of chest movements may occur because of the pneumothorax but is not indicative of subcutaneous emphysema.

Spina Bifida Which components would the nurse encourage the parent to increase in the diet of a 4-year-old child with spina bifida who spends many hours in a wheelchair? Select all that apply. A. Fat B. Fiber C. Protein D. Calories E. Carbohydrates

B, C Extra fiber is needed to combat constipation resulting from immobility. Extra protein is needed for maintaining muscle mass and to help prevent pressure ulcers. Of this child's dietary intake, 25% should consist of fat; this is the lowest recommended daily intake for fat. It should not be increased because more fat calories may lead to obesity in an immobilized child. Calories should be limited because energy needs are less for immobile children than for children who are active. Carbohydrates, especially simple sugars, should be limited to help prevent obesity.

Pneumothorax Which clinical indicators would the nurse expect to identify when assessing an individual with a spontaneous pneumothorax? Select all that apply. A. Hematemesis B. Shortness of breath C. Unilateral chest pain D. Increased thoracic motion E. Mediastinal shift toward the affected side

B, C With the reduction of surface area for gaseous exchange, the client experiences shortness of breath, tachycardia, and rapid, shallow respirations. Sudden chest pain occurs on the affected side; it may also involve the arm and shoulder. Bloody vomitus is unrelated to pneumothorax. Decreased chest motion occurs because of failure to inflate the involved lung. The shift toward the unaffected side results from pressure with the pneumothorax.

Pneumothorax Which actions will the nurse include in the plan of care for a client with a left pneumothorax who has a chest tube in place? Select all that apply. A. Immobilize the left arm in a sling. B. Check the water-seal chamber for air bubbling. C. Avoid use of nonsteroidal anti-inflammatory drugs. D. Keep the client on bed rest in semi-Fowler position. E. Observe frequently for drainage in the collection chamber. F. Assist the client to cough and deep breathe every hour while awake.

B, F The nurse would assess for air bubbling in the water-seal chamber to determine whether the client's pneumothorax is resolved. Hourly coughing and deep breathing helps reexpand the lung and prevents atelectasis. Immobilization of the left arm is not needed and may lead to decreased shoulder and arm function. Nonsteroidal anti-inflammatory drugs are helpful in decreasing pain from the chest tube. Bed rest is not needed and would increase risk for complications such as deep vein thrombosis. With a pneumothorax, there will be minimal drainage in the collection chamber.

Cleft Palate/Lip An ultrasound scan of a 23-week fetus reveals a cleft palate. Which nursing intervention is most appropriate? A. Abort the pregnancy. B. Suggest that the client use oral medication. C. Explain that surgery can correct the palate at a later date. D. Determine the time and duration of exposure to the teratogen.

C A cleft palate is a minor congenital anomaly that may occur as a result of exposure to a teratogen. The nurse would suggest that the parents consider surgery after the child's birth. An abortion is not required because a cleft palate is not a major congenital anomaly. The use of oral medications will not affect the deformity. The determination of the time and duration of exposure to a teratogen would be helpful before organogenesis but not after the deformity is seen.

Complication of Prematurity The nurse is caring for a preterm neonate who is receiving gastric feedings. Which neonatal clinical finding unique to necrotizing enterocolitis (NEC) leads the nurse to suspect that the neonate is experiencing this complication? A. Persistent diarrhea B. Decreased abdominal circumference C. Increased amount of residual gastric aspirate D. Small amount of vomitus after each gastric feeding

C An increasing residual volume from earlier feedings without increasing intake indicates that absorption is decreasing, a sign of NEC. Diarrhea may or may not be related to NEC. The abdominal circumference increases, not decreases, with NEC. Small amounts of vomitus (spitting up) are common in the neonate, because the cardiac (lower esophageal) sphincter of the stomach is weak.

Cleft Palate/Lip Which nursing intervention would the nurse provide for an infant with an unrepaired cleft lip? A. Preventing crying B. Preventing infection C. Modifying feeding D. Minimizing handling

C Because of the anomalous structure of the upper lip, the infant with cleft lip may have difficulty sucking on a nipple. Adaptive shields are available for breastfeeding. Haberman feeders and other mterm-26odified devices are used for formula feeding. Preventing crying is not an immediate concern; after surgery it becomes necessary to help prevent tension on the suture line. Cleft palate, not cleft lip, may predispose the infant to infection. The infant should be cuddled and held.

Cleft Palate/Lip Which information concerning a safe feeding technique would the nurse provide to a mother whose newborn infant son has a cleft lip and palate? A. "Because he tires easily, it's best to have him lying in bed while he is being fed." B. "Hold him in a horizontal position and feed him slowly to help prevent aspiration." C. "Give him frequent rest periods and frequent burpings during feedings so he can get rid of swallowed air." D. "Try using a soft nipple with an enlarged opening so he can get the milk through a chewing motion."

C Cleft lip and palate, a congenital defect, prevents the infant from creating a tight seal with the lips to facilitate suckling. As a result, the infant swallows large amounts of air when feeding. The mother should be taught to provide frequent rest periods and to burp the infant often to expel excess air in the stomach. Infants with cleft lip and palate should be held upright during feedings. Newborn infants cannot chew and do not make chewing movements.

Complication of Prematurity The nurse is caring for a preterm infant with necrotizing enterocolitis (NEC). Which nursing intervention is most important for this infant? A. Diluting the formula mixture as prescribed B. Administering oxygen before the gastric feeding C. Measuring abdominal girth frequently D. Using half-strength formula for gavage feeding

C NEC is marked by prolonged gastric emptying; an increase in abdominal girth of more than 1 cm in 4 hours is significant and requires immediate intervention. Formula feeding is stopped and parenteral fluids, usually total parenteral nutrition (TPN), are started instead. Administering oxygen before the gastric feeding will have no therapeutic value for an infant with NEC.

Pneumothorax A client experiences a complete pneumothorax. The nurse recognizes that there is danger of a mediastinal shift, which could cause which life-threatening condition? A. Rupture of the pericardium B. Infection of the subpleural lining C. Decreased ventricular filling of one side of the heart D. Increased volume of the unaffected lung

C Pressure within the pleural cavity causes a shift of the heart and great vessels to the unaffected side. This not only decreases the capacity of the unaffected lung but also impedes the filling of the right or left side of the heart and leads to a decreased cardiac output. Rupture of the pericardium might occur with severe chest trauma, not with a mediastinal shift. Infection is not caused by a mediastinal shift. The volume of the unaffected lung may decrease because of pressure from the shift.

Cystic Fibrosis Which verbalization by the parents of a child who has cystic fibrosis (CF) provides evidence that they understand the child's dietary needs? A. Restrict fluids during mealtimes. B. Discontinue the use of salt when cooking. C. Provide high-calorie foods between meals. D. Add whole-milk products from the diet.

C The caloric intake should be 150% to 200% more than the expected intake for size and age because absorption of fats and nutrients is compromised by the disease process. Fluids are encouraged to keep bronchial secretions from becoming too thick and tenacious. Salt is added to the diet to compensate for excessive sodium losses in saliva and perspiration. Whole milk may not be tolerated because of its high fat content; skim milk products should be substituted.

Endometriosis A client at the women's health clinic tells the nurse that she has endometriosis. Which factors associated with endometriosis would the nurse anticipate the client will report? Select all that apply. A. Insomnia B. Ecchymosis C. Rectal pressure D. Abdominal pain E. Skipped periods F. Pelvic infections

C, D Endometriosis is the presence of aberrant endometrial tissue outside the uterus. The tissue responds to ovarian stimulation and bleeds during menstruation, which causes rectal pressure and abdominal pain. Insomnia, ecchymosis, and skipped periods are not related to endometriosis. Pelvic infections are not caused by endometriosis; most frequently they are sexually transmitted.

Medications- Endometriosis Which gonadotropin-releasing hormone agonists are used to treat endometriosis? Select all that apply. A. Trazodone B. Diclofenac C. Leuprolide D. Isotretinoin E. Nafarelin acetate

C, E Leuprolide and nafarelin acetate are gonadotropin-releasing hormone (GnRH) agonists used to treat endometriosis. Trazodone is used in cases of erectile dysfunction. Diclofenac is a nonsteroidal anti-inflammatory drug used to relieve pain in endometriosis. Isotretinoin is an oral agent that is effective against severe cystic acne.

Cleft Palate/Lip Which item would the nurse use to feed an infant after a cleft lip repair? A. Preemie nipple B. Nasogastric tube C. Gravity-flow nipple D. Rubber-tipped syringe

D A rubber-tipped syringe minimizes sucking and is not irritating to the suture line. Using a preemie nipple and gravity-flow nipple are an acceptable methods of feeding before surgery. A nasogastric tube is unnecessary; the infant is hungry enough to feed.

Cystic Fibrosis A healthy couple whose child has cystic fibrosis (CF) is concerned about having another child with the disease. Knowing that this disorder has an autosomal-recessive mode of inheritance, how would the nurse respond? A. "There is a 50% chance that this baby will also be affected." B. "If this baby is male, there is a 50% chance of his being affected." C. "If this baby is female, there is no chance of her being affected, but she will be a carrier." D. "There is a 25% chance the baby will be affected and a 50% chance that the baby will be a carrier."

D According to Mendelian law, because both parents are carriers, this baby has a 50% chance of being a carrier, a 25% chance of having the disease, and a 25% chance of being unaffected. Because this is an autosomal-recessive gene and not X-linked, there is no difference in prevalence between male and female genetic distribution. Regardless of sex, the infant will have the same risk of being a carrier or noncarrier or having the expressive trait for CF.

Pancreatitis Which action is likely to reduce the pancreatic and gastric secretions of a client with pancreatitis? A. Encourage clear liquids. B. Obtain a prescription for morphine. C. Assist the client into a semi-Fowler position. D. Administer prescribed anticholinergic medication.

D Anticholinergic medications block the neural impulses that stimulate pancreatic and gastric secretions. Oral fluids stimulate pancreatic secretion. Morphine sulfate is an analgesic and does not decrease gastric secretions. The semi-Fowler position decreases pressure against the diaphragm to help relieve discomfort, but it does not decrease pancreatic secretions.

Pneumothorax A client is diagnosed with a spontaneous pneumothorax. Which physiological effect of a spontaneous pneumothorax would the nurse include in a teaching plan for the client? A. The heart and great vessels shift toward the affected side. B. There is greater negative pressure within the chest cavity. C. Collapse of the other lung will occur if not treated immediately. D. Air will move from the lung into the pleural space.

D As a person with a tear in the lung inhales, air moves through that opening into the intrapleural space; this creates a positive pressure and causes partial or complete collapse of the lung. Mediastinal shift occurs toward the unaffected side. Greater negative pressure within the chest cavity is normal; with a pneumothorax, there is a loss of intrathoracic negative pressure. "Collapse of the other lung will occur if not treated immediately" is not an impending problem.

Cleft Palate/Lip Which teaching would the nurse include for parents of an infant with a cleft lip and palate? A. Anticipation that these children will have psychological problems B. Emphasis that the two defects follow the laws of Mendelian genetics C. Assurance that the defect is rare and probably will not occur twice in the same family D. Expectation that once feeding is established, they should otherwise be healthy

D Children with a cleft lip and palate are otherwise healthy, and once a successful feeding technique is established they feed, gain weight, and thrive as expected, even without corrective surgery. The way in which the young child responds to these defects depends on parental responses. Mendelian laws of inheritance do not apply to these defects. These defects are familial; however, an exact pathogenesis has not been identified.

Complication of Prematurity Which complication of prematurity would the nurse monitor for in a 6-day-old preterm infant in the neonatal intensive care unit? A. Meconium ileus B. Duodenal atresia C. Imperforate anus D. Necrotizing enterocolitis

D Necrotizing enterocolitis (NEC) is an inflammatory disease of the gastrointestinal mucosa related to several factors (e.g., prematurity, hypoxemia, high-solute feedings); it involves shunting of blood from the gastrointestinal tract, decreased secretion of mucus, greater permeability of the mucosa, and increased growth of gas-forming bacteria, eventually resulting in obstruction. NEC usually manifests 4 to 10 days after birth. Meconium ileus occurs within the first 24 hours when the newborn cannot pass any stool. It is not related to the development of NEC; it is a complication of cystic fibrosis. Duodenal atresia is a congenital defect that occurs early in gestation and is present at birth. Imperforate anus is an anorectal malformation that results in the absence of an external anal opening; it is present at birth.

Complication of Prematurity The nurse is caring for a preterm infant who is receiving oxygen therapy. Which would the nurse do to prevent retinopathy of prematurity (ROP)? A. Cover the neonate's eyes with a shield. B. Place the neonate in an elevated side-lying position. C. Assess the neonate every hour with a pulse oximeter. D. Support the neonate's oxygen saturation while providing minimal FiO2.

D ROP is a complex disease of the preterm infant; hyperoxemia is one of the numerous causes implicated. Oxygen therapy is maintained at the lowest level necessary to support respiratory status. If the oxygen concentration needs to be increased to maintain life, ROP may not be preventable. Using a shield over the neonate's eyes will not prevent the development of ROP, nor does positioning or assessment of the neonate every hour with a pulse oximeter alone. If the pulse oximetry results are within an acceptable range, the oxygen concentration may be reduced.

Pancreatitis The nurse is caring for a client with a diagnosis of acute pancreatitis and alcoholism. The client asks, "How does my drinking relate to my diagnosis?" Which effect of alcohol would the nurse include when responding? A. It promotes the formation of calculi in the cystic duct. B. It stimulates the pancreas to secrete more insulin than it can immediately produce. C. It alters the composition of enzymes so they are capable of damaging the pancreas. D. It increases enzyme secretion and pancreatic duct pressure that causes backflow of enzymes into the pancreas.

D Alcohol stimulates pancreatic enzyme secretion and an increase in pressure in the pancreatic duct. The backflow of enzymes into the pancreatic interstitial spaces results in partial digestion and inflammation of the pancreatic tissue. Although blockage of the bile duct with calculi may precipitate pancreatitis, this is not associated with alcohol. Alcohol does not deplete insulin stores; the demand for insulin is unrelated to pancreatitis. Although the volume of secretions increases, the composition remains unchanged.

Medications- Endometriosis A client with a history of liver disease is found to have endometriosis. Which medication is contraindicated in this client? A. Danazol B. Celecoxib C. Leuprolide D. Ketoconazole

A Danazol is a synthetic androgenic steroid that acts by suppressing secretion of follicle-stimulating hormone and luteinizing hormone. This results in decreased secretion of estrogen and progesterone and regression of endometrial tissue. It may result in decreased lipoprotein levels and an increase in low-density lipoprotein. It is contraindicated in clients with liver disease. Celecoxib, a nonsteroidal anti-inflammatory drug, should be used with caution in liver disease. Leuprolide is a gonadotropin-releasing hormone (GnRH) agonist; it may be safe for use in clients with liver disease. Ketoconazole is a nonsteroidal anti-inflammatory drug and should be used with caution in clients with liver disease.

Pneumothorax A client with emphysema experiences a sudden episode of shortness of breath and is diagnosed with a spontaneous pneumothorax. The client asks, "How could this have happened?" The nurse's response is based on which likely cause of the spontaneous pneumothorax? A. Pleural friction rub B. Tracheoesophageal fistula C. Rupture of a subpleural bleb D. Puncture wound of the chest wall

C The etiology of a spontaneous pneumothorax is commonly the rupture of blebs on the lung surface. Blebs are similar to blisters but are filled with air. Pleural friction rub results in pain on inspiration, not a pneumothorax. A tracheoesophageal fistula causes aspiration of food and saliva, resulting in respiratory distress. The client has no history of trauma.

Complication of Prematurity Which is an appropriate nursing intervention for a neonate with respiratory distress syndrome (RDS)? A. Avoid handling the infant to conserve energy. B. Assess the infant for congenital birth defects to enable early treatment. C. Set the incubator thermostat 10°F (12°C) below body temperature to prevent shivering. D. Position the infant to promote respiratory efforts.

D Positioning the infant with the head slightly hyperextended and changing the position every 1 to 2 hours help respiratory secretions drain; this will increase oxygenation by enhancing respiratory efforts. Extensive handling is not desired, but infants do need to be touched. All newborns, not just those with RDS, are assessed for congenital birth defects. Setting the incubator thermostat 10°F (12°C) below body temperature is too low; it may exacerbate the respiratory distress.

TPN A client is admitted to the hospital with a diagnosis of acute pancreatitis. The health care provider's prescriptions include nothing by mouth and total parenteral nutrition (TPN). The nurse explains that the TPN therapy provides which benefit? A. Is the easiest method for administering needed nutrition B. Is the safest method for meeting the client's nutritional requirements C. Will satisfy the client's hunger without the discomfort associated with eating D. Will meet the client's nutritional needs without causing the discomfort precipitated by eating

D Providing nutrients by the intravenous route eliminates pancreatic stimulation, reducing the pain experienced with pancreatitis. TPN is used to meet the client's needs, not the nurse's needs. TPN creates many safety risks for the client. Hunger can be experienced with TPN therapy.

TPN Which statement explains why total parenteral nutrition (TPN) is infused through a central line rather than a peripheral line? A. It prevents the development of infection. B. There is less chance of this infusion infiltrating. C. It is more convenient, so clients can use their hands. D. The large amount of blood helps dilute the concentrated solution.

D Unless diluted by the increased blood flow, the highly concentrated solution can cause injury to the veins. The potential of infection is high with TPN because of the increased glucose levels. The other options are not the primary reason, although the infusion at this site is more secure and promotes free use of the arms and hands.

Pneumothorax A client who reports chest pain and difficulty breathing is admitted to the emergency department. A chest x-ray reveals a pneumothorax. Which assessment finding would the nurse expect? A. Distended neck veins B. Paradoxical respirations C. Increasing amounts of purulent sputum D. Absence of breath sounds over the affected area

D When the lung is collapsed, air is not moving into and out of the area, and breath sounds are absent. Distended neck veins are associated with failure of the right side of the heart and can occur with a mediastinal shift, but there is no evidence of either. Paradoxical respirations occur with flail chest, not pneumothorax. Purulent sputum is a sign of infection, not pneumothorax.