adaptive quiz pt 2

What are the priority nursing interventions for a client with neutropenia in an emergency department? Select all that apply.

Obtain blood cultures immediately. Administer antibiotic STAT as prescribed

A pregnant client is diagnosed with gestational hypertension. The client tells the nurse that she has been following the recommended pregnancy diet. What should the nurse teach her about her diet at this time?

change nothing

A client is receiving a 2-gram sodium diet. The family members ask whether they can bring snacks from home. Which food item will the nurse suggest?

fresh orange wedges

Which statement by the registered nurse is true regarding the mitigation phase of disaster management?

Correct 4 It is a process of minimizing of the disaster's influence on human health and community

A nurse is assessing a client with a diagnosis of primary insomnia. Which findings from the client's history may be the cause of this disorder? Select all that apply.

Fatigue Loss of motivation Reduced concentration Irritability

An emergency management team is removing foreign bodies and performing cricothyroidotomy on a client post burn injury. Which emergency assessment has been performed on this client?

Airway with simultaneous cervical spine stabilization

A pale, lethargic 1-year-old infant weighs 28 lb (12.7 kg) and has a hemoglobin level of 9 g/dL (90 mmol/L). The parent tells the nurse that the infant refuses solid food when it is offered by spoon and drinks between four and six full bottles of milk per day. What should the nurse recommend? Beginning the weaning process immediately Taking the infant to the metabolic clinic for an examination Giving the infant finger foods such as dry cereal and chopped meat Poking a large hole in the nipple of the bottle and adding puréed baby foods to the milk

3 A diet of only milk is not sufficient to meet the infant's iron needs. Meat and fortified cereals are high in iron. Finger foods are appropriate for older infants. At this age, weaning from the bottle is not the issue; supplementary iron intake is. Although health care and monitoring will be required, the metabolic clinic is not the appropriate referral. Although adding pureed baby foods to the milk would increase iron intake, a large hole in the nipple of the bottle is not desirable at this point.

client is being discharged from the hospital with an indwelling urinary catheter. The client asks about the best way to prevent infection and keep the catheter clean. Which would be appropriate for the nurse to include in the client teaching? Once a day, clean the tubing with a mild soap and water, starting at the drainage bag and moving toward the insertion site. After cleaning the catheter site, it is important to keep the foreskin pushed back for 30 minutes to ensure adequate drying. Clean the insertion site daily using a solution of one part vinegar to two parts water. Replace the drainage bag with a new bag once a week

4

what is a major nursing concern when caring for a client diagnosed with hyperthyroidism? Monitoring for hypoglycemia Protecting visitors and staff from radiation exposure Providing foods to increase appetite Arranging for sufficient rest periods

4

A client is being treated for influenza A (H1N1). The nurse has provided instructions to the client about how to decrease the risk of transmission to others. Which client statement indicates a need for further instruction?

"I should obtain a pneumococcal vaccination each year."

A client has excessive edema. Which is the most objective method a nurse can use to assess the extent of edema? Weighing the client Monitoring the intake and output Performing the Trendelenburg test Assessing the extent of pitting edema

1

Sitz baths are prescribed for a client with an episiotomy during the postpartum period. How do the sitz baths aid the healing process? Promoting vasodilation Cleansing perineal tissue Softening the incision site Tightening the rectal sphincter

1

An adolescent who is undergoing chemotherapy for the treatment of bone cancer has stomatitis as a result of chemotherapy. What should the nurse include when teaching the child about self-care? Select all that apply. Clean the teeth with a swab. Drink fluids through a straw. Brush the teeth three times a day. Rinse frequently with a mouthwash. Avoid foods served at extremes of temperature.

1, 2, 5

A healthcare provider prescribes dietary and medication therapy for a client with the diagnosis of gastroesophageal reflux disease (GERD). What is most appropriate for the nurse to teach the client about meal management? Snack daily in the evenings Divide food into four to six meals a day Eat the last of three daily meals by 8:00 PM Suck a peppermint candy after each meal

2

While assessing the nails of a client with diabetes, the nurse finds that the skin on the client's hands and feet are dry due to infection. What could be the reason for this dryness? Applying moisturizing lotion between toes Cutting nails after soaking them for 10 minutes in warm water Cutting nails straight across and even with the tops of the fingers or toes Using sharp objects to poke or dig under the toenail or around the cuticle

2

The nurse is caring for a client who is wearing a prosthesis after a single-leg amputation three months ago. Which crutch gait should the nurse teach the client to use? Tripod Four-point Three-point Swing-through

2 A four-point gait provides for weight bearing on all points that touch the floor and maximum support during ambulation. A tripod is for clients learning to do a swing-to gait pattern. A three-point gait is used when one extremity cannot bear weight. A swing-through gait does not simulate ambulation; it is used when the individual can bear weight but lacks the muscular control needed for ambulation without an assistive device.

What is the most important nursing intervention for a 3-year-old child with a diagnosis of nephrotic syndrome? Regulating diet Encouraging fluids Preventing infection Maintaining bed rest

3

A client is admitted to the hospital for cancer of the larynx, and a laryngectomy is scheduled. What should the nurse include in the postoperative teaching plan? Importance of cleanliness around the site of the stoma Necessity of covering the tube opening while swimming Establishment of a regular schedule for suctioning the tube Usage of sterile technique when caring for the tracheostomy tube

1

A multiparous client presents to the labor and delivery area in active labor. The initial vaginal examination reveals that the cervix is dilated 4 cm and 100% effaced. Two hours later the client experiences rectal pressure, followed by delivery 5 minutes later. How is this delivery best documented? Precipitous vaginal delivery Prolonged transitional phase Primigravida primary delivery Normal spontaneous vaginal delivery

1

A young adult is being treated in the emergency department for injuries sustained as a result of physical battering by her partner. On learning that there is a history of such abuse, the nurse plans which tertiary nursing interventions? Select all that apply.

Identifying the benefits of attending a support group for battered women Providing her with information regarding local domestic violence shelters

A nurse has inserted a nasogastric tube to intermittently gavage feed a preterm newborn. Place in order the steps the nurse will take to perform the gavage.

The first step is to ensure that the nasogastric tube is clamped and properly placed into the stomach and not inadvertently into the lungs. Second, the newborn's parent should be encouraged to hold the newborn during the gavage feeding, if possible. This action contributes to bonding and comfort for both parent and newborn as well as placing the newborn in an upright position to avoid tube feeding aspiration into the lungs. Next, the nurse connects the syringe to the tubing, pours the prescribed volume of formula into it, and then unclamps the tubing to allow the feeding to flow to gravity as tolerated (approximately 1 ml/min). After the feeding is complete, the nurse should add 1 to 2 ml of sterile water to the syringe to clear the tubing of formula and then clamp it.