Chapter 31-45
A 14 month-old child ingested half a bottle of aspirin tablets. Which finding should the nurse expect to see in this child? Edema Dyspnea Hypothermia Epistaxis
Epistaxis
The registered nurse is giving instructions to a unlicensed assistive person (UAP) regarding patient care activities for the shift. Which directive provides the best communication for the delegated tasks? "Ambulate the client in room 214 A today and replace the sequential compression device (SCD) afterwards." "You will need to frequently take an oral temperature for the client in room 212 B today and report the results to me immediately if it is too high." "Beginning at 0800, empty the urinary catheter bag hourly for the client in room 210 A and write the amount with the time on the whiteboard." "Stop by room 215 A and let me know how the new admission is doing and if you need any help."
"Beginning at 0800, empty the urinary catheter bag hourly for the client in room 210 A and write the amount with the time on the whiteboard."
The school nurse is teaching the faculty the most effective methods to prevent the spread of lice (Pediculus humanus capitis) in the school. The information that would be most important to include is reflected in which of these statements? "Nit combs should be used to remove the eggs (nits) from your child's hair." "Bedding and clothing should be washed in hot water and dried in the dryer." "Children should not share hats, scarves and combs." "The treatment medication may require reapplication in 8 to 10 days."
"Children should not share hats, scarves and combs."
The nurse is providing instructions for a client diagnosed with bacterial pneumonia. What is the most important information to convey to the client? "Complete all of the antibiotics, even if you feel better." "Take your temperature every day." "Take at least two weeks off from work." "You will need another chest x-ray in six weeks."
"Complete all of the antibiotics, even if you feel better."
An unlicensed assistive personnel (UAP), who usually works in pediatrics is reassigned to work on an adult medical-surgical unit. Which of these questions should the charge nurse ask prior to making delegation decisions? "What type of client care did you give in pediatrics?" "How comfortable are you to care for adult clients?" "Do you have your competency checklist that we can review?" "How long have you been a UAP?"
"Do you have your competency checklist that we can review?"
A client is prescribed trimethoprim/sulfamethoxazole for recurrent urinary tract infections. Which information would be important to reinforce during client teaching? "Drink at least eight glasses of water a day." "Stop the medication after five days." "It is safe to take with oral contraceptives." "Be sure to take the medication with food."
"Drink at least eight glasses of water a day."
Which statement by an older adult with chronic obstructive lung disease (COPD) indicates an understanding of the major reason to use pursed-lip breathing for episodes of dyspnea? "My mouth doesn't get as dry when I breathe with pursed lips." "I can breathe better using pursed-lip breathing because less air will be trapped in my chest." "I can breathe better when I pucker up my lips because I can control how fast I breathe in and out." "This position of my lips helps to keep my lungs open."
"I can breathe better using pursed-lip breathing because less air will be trapped in my chest."
Which statement made by a client to an admission nurse suggests that the client is experiencing a manic episode? "I think all children should have their heads shaved." "I have powers to get you whatever you wish, no matter the cost." "I think all of my contacts last week have attempted to poison me." "I have been restricted in thought and harmed."
"I have powers to get you whatever you wish, no matter the cost."
A 6 year-old child diagnosed with acute glomerulonephritis (AGN) presents with anorexia, moderate edema and elevated blood urea nitrogen (BUN) levels. The child requests a peanut butter sandwich for lunch. How should the nurse respond to this request? "I know that is your favorite, but let me help you pick another lunch." "You cannot have the peanut butter until you are feeling better." "I'm sorry, that is not a good choice, but you could have pasta." "That's a good choice, and I know it is your favorite. You can have it today."
"I know that is your favorite, but let me help you pick another lunch."
A 54 year-old female explains to the health care provider that she experiences approximately 10 vasomotor symptoms of menopause ("hot flashes") throughout the day and night. Different treatment options are discussed. Which statement by the client indicates she needs further instruction from the nurse? "I should avoid spicy foods, alcohol, and caffeine." "I may need to take estrogen and progesterone for many years." "I can use a fan at home and in the workplace." "I will take gabapentin ER at bedtime."
"I may need to take estrogen and progesterone for many years."
The nurse is teaching the client about the patient controlled analgesia (PCA) planned for postoperative care. Which statement by the client is incorrect and indicates that further teaching is needed? "I should call the nurse before I take additional doses." "I will call for assistance if my pain is not relieved." "I will receive a continuous dose of medication." "The machine will prevent an overdose of the medication."
"I should call the nurse before I take additional doses."
A client is being discharged with a prescription for an iron supplement. What statement indicates a need for further teaching by the nurse? "I will have greenish-black stools from the medication." "I should not take antacids with my iron supplement." "I should take vitamin C with the iron supplement." "I should take the iron supplement with a full glass of milk."
"I should take the iron supplement with a full glass of milk."
While planning care for a toddler, the nurse teaches the parents about the expected developmental changes for this age. Which statement by the mother shows that she understands the child's developmental needs? "I will set limits on exploring the house." "I intend to keep control over our child's behavior." "I want to protect my child from any falls." "I understand our child's need to use those new skills."
"I understand our child's need to use those new skills."
A staff nurse complains to the nurse manager that an unlicensed assistive personnel (UAP) consistently leaves the work area untidy and does not restock supplies. The initial response by the nurse manager should be which of these statements? "I will add this concern to the agenda for the next unit meeting so we can discuss it." "I can assure you that I will look into the matter in due time." "I would like for you to approach the UAP about the problem the next time it occurs." "I will arrange for a conference with you and the UAP within the next week"
"I would like for you to approach the UAP about the problem the next time it occurs."
The nurse is caring for a client with inflammatory bowel disease who admits to using complementary therapies, including herbal remedies and peppermint tea. Which of the following statements made by the nurse is the most appropriate response? "I would suggest that you discontinue the use of these therapies as they may be dangerous." "It is important to inform your health care provider of the use of these therapies." "These therapies are probably not harmful but may be costing you unnecessary money." "These therapies are known to interfere with prescribed medications so it is important to stop using them."
"It is important to inform your health care provider of the use of these therapies."
During the check-up of a 2 month-old infant at a well-baby clinic, a mother expresses concern to a nurse because a flat pink birthmark on the baby's forehead and eyelid has not gone away. What is an appropriate response by the nurse? "The child is too young for consideration of surgical removal of these at this time." "Port wine stains are often associated with other malformations." "Telangiectatic nevi are normal and will disappear as the baby grows." "Mongolian spots are a normal finding in dark-skinned children."
"Telangiectatic nevi are normal and will disappear as the baby grows."
The nurse assesses a client who has been re-admitted to the psychiatric inpatient unit with a diagnosis of schizophrenia. The client's symptoms have been managed for several months with fluphenazine (Prolixin). Which should be the initial focus of the questioning during the admission assessment? "How much alcohol in the form of beer, wine of hard liquor do you use each day?" "How long have you been outside in the hot weather this prior week?" "What stressors do you have living in your home by yourself?" "Tell me about your medication routine and when do you take it?"
"Tell me about your medication routine and when do you take it?"
An emergency department nurse admits a child who experienced a seizure at school. When the parent comments that this is the first occurrence and denies any family history of epilepsy, what is the best response by the nurse? "Do not worry. Epilepsy can be treated with medications." "This seizure may or may not mean your child has epilepsy. Further evaluation is needed." "Long-term treatment will prevent future seizures." "Since this was the first convulsion, it may not happen again."
"This seizure may or may not mean your child has epilepsy. Further evaluation is needed."
A client diagnosed with bipolar disorder is reluctant to take lithium (Lithane) as prescribed. What is the most therapeutic response by a nurse to a refusal of the medication? "You need to take your medicine. This is how you will get well." "If you refuse your medicine, we'll just have to give you a shot." "What is it about the medicine that you don't like or that you are afraid of?" "I can see that you are uncomfortable right now. I'll wait until tomorrow to discuss this with you."
"What is it about the medicine that you don't like or that you are afraid of?"
he nurse is assessing an 8 month-old infant diagnosed with atonic cerebral palsy. Which statement from the parent supports this diagnosis? "When I put my finger in her left hand she doesn't respond with a grasp." "When I put her on her back to sleep, she's still in the same position a few hours later." "When it thundered loudly last night she didn't even jump." "My baby doesn't seem to follow when I shake toys in front of her face."
"When I put her on her back to sleep, she's still in the same position a few hours later."
The nurse is reviewing the surgeon's discharge instructions with a client who experienced a myocardial infarction. The client asks the nurse why the waiting period is four to six weeks before having sexual intercourse. Which response best explains this instruction? "When you can climb two flights of stairs without problems, it is generally safe." "Have a glass of wine to relax you, then you can try to have sex." "You need to regain your strength before attempting such exertion." "If you can maintain an active walking program, you will have less risk."
"When you can climb two flights of stairs without problems, it is generally safe."
One hour before the first treatment is scheduled, a client becomes anxious and states, "I do not wish to go through with electroconvulsive therapy." Which response by the nurse is most appropriate? "You'll be asleep and won't remember anything." "I'll go with you and will be there with you during the treatment." "You have the right to change your mind. You seem anxious. Can we talk about it?" "I'll call the health care providers to notify them of your decision."
"You have the right to change your mind. You seem anxious. Can we talk about it?"
A client diagnosed with tuberculosis is started on rifampin and isoniazid. Which statement by the nurse would be most important to include in teaching the client about rifampin? "You may notice an orange-red color to your urine." "You should not skip doses or stop your medicine even if you feel better." "You should avoid drinking alcohol while taking this medication." "You may experience some nausea if you take the medication with food."
"You may notice an orange-red color to your urine."
A client with paranoid delusions stares at a nurse over a period of several days. The client suddenly walks up to the nurse and shouts, "You think you're so perfect and pure and good." Which statement would be the most appropriate response for the nurse to make? "You seem angry right now." "Is that why you've been staring at me?" "Perfect? I don't quite understand." "You seem to be in a really bad mood."
"You seem angry right now."
The nurse is given and order that reads: administer ephedrine 5 mg slow IV push for a systolic blood pressure finding less than 90 mm Hg. The client's vital sign findings: temperature 98.2 F (36.7 C); pulse 120; respirations 20; blood pressure 88/54. Ephedrine comes packaged as 50 mg/mL and must be diluted with normal saline to a total volume of 10 milliliters. ___ml?
1ml
A nurse is reviewing and order that reads: administer conjugated estrogen 1.25 mg daily. The only available tablet strength is 625 mcg. How much medication will the nurse administer? _____Tab
2 tab
The nurse is reviewing the list of new client admissions. For which of these clients should contact precautions be implemented? A 45 year-old diagnosed with pneumonia A 60 year-old diagnosed with herpes simplex A 3 year-old diagnosed with scarlet fever A 6 year-old diagnosed with mononucleosis
A 60 year-old diagnosed with herpes simplex
To which nursing home resident could a nurse safely administer tricyclic antidepressants (TCAs) without questioning the health care provider's order? A 65 year-old Asian-American female with mild hypertension An 85 year-old Caucasian male with narrow-angle glaucoma An Hispanic female with coronary artery disease (CAD) An African-American male with benign prostatic hypertrophy (BPH)
A 65 year-old Asian-American female with mild hypertension
A nurse is assessing a 12 year-old child who has been diagnosed with hemophilia A. Which lab result would the nurse expect? An excess of red blood cells A deficiency of clotting factor VIII A deficiency of clotting factors VIII and IX An excess of white blood cells
A deficiency of clotting factor VIII
Several clients are admitted to an adult medical unit. For which client condition(s) would the nurse institute airborne precautions? A tentative diagnosis of viral pneumonia with productive brown sputum Autoimmune deficiency syndrome (AIDS) with cytomegalovirus (CMV) A positive purified protein derivative (PPD) test with an abnormal chest x-ray Advanced carcinoma of the lung with hemoptysis mixed with a yellow tinge
A positive purified protein derivative (PPD) test with an abnormal chest x-ray
A 60 year-old male client underwent inguinal hernia repair in a day-surgery clinic. He is awake and alert, but has not been able to void since he returned from surgery six hours ago. He has received 1000 mL of IV fluid. Which action would most likely help him to void? Perform Credé's method on the bladder from the bottom to the top Assist the client to stand by the side of the bed to void Have him drink several glasses of water Wait two hours and have the client attempt to void again
Assist the client to stand by the side of the bed to void
The geriatric social worker is working with the nurse to assess the client's ability to perform instrumental activities of daily living (IADL). Which of the following skills are considered instrumental activities of daily living? (Select all that apply.) Ability to write checks Ability to take medications Ability to eat independently/feed self Ability to bathe self Ability to cook meals
Ability to write checks Ability to take medications Ability to cook meals
The nurse is reviewing various group activities with the health care team. When planning a therapeutic milieu, what is the most important factor when selecting a group activity? Build the skills of group participation Match them to the clients' preferences Achieve clients' therapeutic goals Provide consistency with clients' skills
Achieve clients' therapeutic goals
The parents of a 2 year-old child report that the child has been holding the breath during temper tantrums. What is an appropriate approach for the response by a nurse? Teach the parents how to perform cardiopulmonary resuscitation Instruct the parents on how to reason with the child about possible harmful effects Recommend that the parents give in when the child holds the breath to prevent anoxia Advise the parents to ignore breath holding because breathing will begin as a reflex
Advise the parents to ignore breath holding because breathing will begin as a reflex
A nurse is assigned to a newly hospitalized adolescent. What should be the major threat experienced by this hospitalized adolescent? Altered body image Pain management Restricted physical activity Separation from family
Altered body image
The nurse is planning care for a 3 month-old infant in the immediately postoperative period after the placement of a ventriculoperitoneal shunt for hydrocephalus. The nurse should take which action with anticipation of complications of the procedure? Begin formula feedings when infant is alert Pump the shunt at intervals to assess for proper function Assess for abdominal distention or taunt abdominal wall Maintain the infant in an upright position in a car seat
Assess for abdominal distention or taunt abdominal wall
The nurse works in the pediatric emergency department. In which situation would a child be treated by using enemas followed by an antitoxin? A toddler who has eaten an undetermined number of ibuprofen tablets A school-aged child who has swallowed a handful of iron-fortified vitamins An infant who is diagnosed with botulism A preschooler who bit into a laundry detergent pod
An infant who is diagnosed with botulism
Postoperative orders for a client who had a mitral valve replacement include monitoring pulmonary artery pressure together with pulmonary capillary wedge pressure with a pulmonary artery catheter. What is the purpose of these actions by a nurse? Compare the right ventricular pressures Determine the changes in an acid-base balance Establish coronary artery stability Assess the left ventricular end-diastolic pressure
Assess the left ventricular end-diastolic pressure
A nurse is caring for a client in the coronary care unit. The display on the cardiac monitor indicates ventricular fibrillation. What should the nurse do first? Assess the level of consciousness Initiate CPR Assess the pulse Perform defibrillation
Assess the level of consciousness
The client's history documents an aortic regurgitation. Where on the precordium should the nurse place the stethoscope to verify the disorder?
Aortic regurgitation occurs when the aortic valve leaflets do not close properly during diastole. The classic finding is a high-pitched, blowing, decrescendo diastolic murmur ("lub-whoosh"). Closure of the aortic and pulmonic valves are heard best at the base of the heart. Aortic regurgitation can best be heard at the 2nd right intercostal space, lateral to the sternum.
A charge nurse is planning assignments on a medical unit. A client with which need could be assigned to an unlicensed assistive person (UAP)? Review dietary needs with client prior to transfer to long-term care facility Change post-op hip dressing after removal of a drainage tube Assist with meals and monitor ability to swallow following a mild stroke Apply compression stockings and ambulate in hall three times a day
Apply compression stockings and ambulate in hall three times a day
A nurse is suctioning a tracheostomy tube in a client. The nurse should take what action in order to prevent unnecessary hypoxia during this procedure? Lubricate three to four inches of the catheter tip Withdraw catheter in a circular motion with intermittent suction Apply suction for no more than 10 seconds Maintain sterile technique throughout the procedure
Apply suction for no more than 10 seconds
A 35-year-old client of Puerto Rican-American descent is diagnosed with ovarian cancer. The client states, "I refuse both radiation and chemotherapy because they are 'hot.'" Which action should the nurse take next? Ask the client to talk about concerns regarding "hot" treatments Talk with the client's family about the situation Report the situation to the health care provider Document the situation and client response in the notes
Ask the client to talk about concerns regarding "hot" treatments
The charge nurse is making assignments on the day shift for a registered nurse (RN), a licensed practical nurse (LPN) and a certified nursing assistant (CNA). Which assignments are most appropriate for the client who fell during the night and now has a skin tear on the arm and a hematoma on the hip and is scheduled for an x-ray of the hip? (Select all that apply.) Assign medication administration to the LPN Assign the CNA to assist with personal hygiene tasks Delegate wound care to the RN Assign complete care to the LPN Assign the LPN to report confusion or headache
Assign medication administration to the LPN Assign the CNA to assist with personal hygiene tasks Delegate wound care to the RN Assign the LPN to report confusion or headache
A nurse is teaching a client with Raynaud's phenomenon about lifestyle and behavioral changes that will improve the quality of life. Besides smoking cessation, what would be the next most important thing this client should do? Keep feet dry Avoid cold temperatures Avoid spicy foods Reduce stress
Avoid cold temperatures
The nurse is working to improve relationships with clients. To establish the feeling of trust in a nurse-client relationship, the nurse should exhibit which of the following qualities? Flexibility and kindness Honesty and consistency Sympathy and understanding Confidence and optimism
Honesty and consistency
The client is seen in the emergency one day after falling in his bathroom at home. The client reports having "a few drinks" prior to the fall. Which finding requires the nurse's immediate attention? Nausea and vomiting Headache Blurred vision Bruise behind one ear
Bruise behind one ear
The nurse is assessing a client who has been treated long-term with glucocorticoid therapy. Which finding might the nurse expect? Peripheral edema Increased muscle mass Jaundice Buffalo hump
Buffalo hump
A 36 year-old female client has a hemoglobin level of 14 g/dL and a hematocrit of 42%, 24 hours after a dilation and curettage (D&C). Which of the following findings should the nurse expect when assessing the client? Complaints of fatigue with ambulation Capillary refill of less than three seconds Pale mucous membranes Respirations 36 breaths per minute
Capillary refill of less than three seconds
The health care provider orders the antidepressant trazodone ER 150 mg at bedtime. Which common side effect of this drug should the client understand? Reduces arthritic pain Causes drowsiness Relieves nasal stuffiness Decreases acne breakouts
Causes drowsiness
Upon entering an adult client's room, the client is found to be unresponsive. After calling for help, what is the next action that should be taken by the nurse? Check for a carotid pulse Give two rescue breaths Deliver five abdominal thrusts Maintain an open airway
Check for a carotid pulse
The registered nurse (RN) needs to delegate some tasks to the unlicensed assistive personnel (UAP). Which activity should the RN ask the UAP to perform? Check the blood pressure of a two-hour postoperative client Ask a client receiving chemotherapy about pain Adjust the rate of a gastric tube feeding Record a history on a newly admitted client
Check the blood pressure of a two-hour postoperative client
A client is scheduled for a CT scan with contrast. What interventions should be taken by the nurse prior to sending the client to the imaging department? (Select all that apply.) Confirm that a signed consent is in the chart Administer prescribed medication to sedate the client Reassess the client's allergies Ensure the client is well-hydrated Ask the client to remove all metal jewelry
Confirm that a signed consent is in the chart Reassess the client's allergies Ask the client to remove all metal jewelry
Decentralized scheduling is used on a nursing unit. What is the advantage of this management strategy? Conserves time spent on planning Frees the nurse manager to handle other priorities Allows requests for special privileges Considers client and staff needs
Considers client and staff needs
A nurse is reviewing with a client how to collect a clean catch urine specimen. What is the appropriate sequence to teach the client? Clean the meatus, then urinate into the container Void a little, clean the meatus, then collect specimen Clean the meatus, begin voiding, then catch urine stream Void continuously and catch some of the urine midstream
Clean the meatus, begin voiding, then catch urine stream
The nurse is caring for a client who had a closed reduction of a fractured right wrist followed by the application of a fiberglass cast 12 hours ago. Which finding requires the nurse's immediate attention? Capillary refill of fingers on right hand is about three seconds Client reports burning and tingling in the right hand and arm Slight swelling of fingers of right hand Skin warm to touch and normally colored
Client reports burning and tingling in the right hand and arm
Due to a recent outbreak in the community, the nurse is speaking to a group of parents and elementary school teachers about rheumatic fever. Which information is most important for the nurse to emphasize? Children may remain strep carriers for years Most play activities will be restricted indefinitely Clumsiness and behavior changes should be reported Home schooling is preferred to classroom instruction
Clumsiness and behavior changes should be reported
The school nurse suspects that a third-grade child might have attention deficit hyperactivity disorder (ADHD). Prior to referring the child for further evaluation, what should the nurse do? Compare the child's behavior with classic signs and symptoms of ADHD Compile a history of behavior patterns and developmental accomplishments Consult with the teacher about how to assist with impulse control Observe the child's behavior on at least two occasions
Compile a history of behavior patterns and developmental accomplishments
During the admission process, the staff nurse realizes that the information on the identification (ID) bracelet does not match the information on the client's admission face sheet. What action should the nurse take? Communicate with staff that the two-identifiers requirement must be verified using the admission face sheet Contact the admission department to create a new ID bracelet Use a permanent marker to change the incorrect information on the ID bracelet Write the corrected information on the whiteboard in the client's room
Contact the admission department to create a new ID bracelet
A client with a history of asthma and kidney stones is admitted with a diagnosis of recurrent renal calculi. The client experiences shortness of breath following a lithotripsy. The nurse auscultates the client's lungs and finds decreased air movement but no wheezing. The arterial blood gas (ABG) results are pH 7.31, PaO2 53 mm Hg, PaCO2 50 mm Hg, and O2 sat 82%. Which of the following actions are appropriate for the nurse to take? (Select all that apply.) Contact the health care provider Start high flow oxygen via face mask Increase IV fluids Start oxygen via nasal cannula Administer a short-acting bronchodilator via nebulizer Prepare for possible intubation Call respiratory therapy
Contact the health care provider Start high flow oxygen via face mask Administer a short-acting bronchodilator via nebulizer Prepare for possible intubation Call respiratory therapy
Lactulose has been prescribed for a client with advanced liver disease. Which finding should the nurse use to evaluate the effectiveness of this treatment? Decreased lethargy Less edema Less jaundice Increased appetite
Decreased lethargy
The nurse is applying silver sulfadiazine topical to severe burns on the arms and legs of an adult. Which side effect should the nurse monitor for? Increased neutrophils Decreased neutrophils Hardened eschar Skin discoloration
Decreased neutrophils
A nurse is assigned to provide care in the pediatric unit. What must be the priority consideration for nurses when communicating with children? Developmental level Present environment Physical condition Nonverbal cues
Developmental level
A client with heart failure is newly referred to a home health care team. The nurse discovers that the client has not been following the prescribed diet. What should be the appropriate nursing action? Discuss diet with the client to learn the reasons for not following the diet Discharge the client from home health care because of noncompliance Notify the provider of the client's failure to follow prescribed diet Make a referral to Meals-on-Wheels for a weekly delivery of a proper meal
Discuss diet with the client to learn the reasons for not following the diet
The nurse is assessing the newborn of a mother with diabetes. The nurse should understand that hypoglycemia is related to what pathophysiological process? Pancreatic insufficiency Disruption of fetal glucose supply Reduced glycogen reserves Maternal insulin dependency
Disruption of fetal glucose supply
During an initial home visit, a nurse is discussing with family members the care of their 86 year-old mother who is newly diagnosed with Alzheimer's disease. Which of these interventions would be most helpful at this time? Discuss communication strategies to try using with the client List actions to improve the client's daily nutritional intake Leave a book about relaxation techniques Write out a daily exercise routine for them to assist the client to do
Discuss communication strategies to try using with the client
The nurse is assessing a client who sustained multiple fractures, contusions, and lacerations in a motor vehicle accident three days ago. The client suddenly becomes confused. Which of the following findings would support the nurse's suspicion that the client has developed a fat embolism? (Select all that apply.) Dyspnea Elevated temperature Hypertension Low oxygen saturation Petechiae on the upper anterior chest
Dyspnea Elevated temperature Low oxygen saturation Petechiae on the upper anterior chest
A nurse is providing discharge teaching to a client who has a new diagnosis of renal calculi. Which point should be included as a dietary recommendation to prevent recurrence of this condition? Increase dietary vitamin C Eat calcium-rich foods several times per day Consume foods high in vitamin E Increase foods rich in animal proteins
Eat calcium-rich foods several times per day
A client continually repeats phrases that others have just said. The nurse should document this behavior as which term? Echolalia Catatonia Autistic Echopraxis
Echolalia
A nurse is caring for a 13 year-old after a spinal fusion to treat scoliosis. Which nursing intervention is appropriate in the immediate postoperative period? (Select all that apply.) Perform neurovascular checks every 8 hours Encourage passive leg and ankle exercises Position the client flat in bed and logroll every 2 to 4 hours Assist the client to stand and walk to the bathroom as needed Maintain bedrest with the head of the bed elevated at least 30 degrees Encourage use of patient-controlled analgesia
Encourage passive leg and ankle exercises Position the client flat in bed and logroll every 2 to 4 hours Encourage use of patient-controlled analgesia
A client diagnosed with schizophrenia, talks animatedly and the nursing staff are unable to understand what the client is attempting to communicate. The client is observed mumbling to self and speaking to the radio. A desirable outcome for this client's care should be which of these behaviors? Demonstrates improved social relationships within the unit Engages in meaningful and understandable verbal communication Expresses feelings appropriately through verbal interactions Interprets accurately the events and behaviors of others
Engages in meaningful and understandable verbal communication
The nurse is preparing a client diagnosed with deep vein thrombosis (DVT) for a venous doppler evaluation. Which of these actions should be necessary to prepare the client for this test? Ensure the client is wearing a hospital gown prior to the test Determine if the client has any allergies to the contrast material Ask client not to eat or drink anything after midnight Administer a sedating medication prior to the test
Ensure the client is wearing a hospital gown prior to the test
A client initially experiences a large local reaction with swelling of the entire leg after being stung by a bee. A concerned family member drives the client to the emergency department. The client is now having difficulty breathing and has swelling of the tongue. Which of the following medications should be administered first? Diphenhydramine (Benadryl) subQ Methylprednisolone (Solu-Medrol) IV Epinephrine (Adrenaline) IV Albuterol (Proventil) inhaler
Epinephrine (Adrenaline) IV
The nurse is assessing a client diagnosed with chronic obstructive pulmonary disease (COPD). The client is on oxygen for low PaO2 levels. Which assessment is a nursing priority to evaluate the outcome of the therapy? Evaluate oxygen saturation (SaO2) levels frequently Assess lung sounds Observe for skin color changes Assess coughing frequency and sputum characteristics
Evaluate oxygen saturation (SaO2) levels frequently
The nurse is caring for a 14 year-old child in the postanesthesia care unit (PACU) following corrective surgery for scoliosis. Which action should receive priority in the plan? Evaluate the movement and sensation of extremities Assist to stand up at bedside within the first few hours Teach client isometric exercises for the legs Initiate the antibiotic therapy prescribed for 10 days
Evaluate the movement and sensation of extremities
During examination of the mouth of a 3 year-old child, the nurse discovers that the teeth have chalky white-to-yellowish staining with pitting of the enamel. Which of these conditions would most likely explain these findings? Oral iron therapy Ingestion of tetracycline Poor dental hygiene Excessive fluoride intake
Excessive fluoride intake The described findings are indicative of fluorosis, a condition characterized by an increase in the extent and degree of the enamel's porosity. This problem can be associated with repeated swallowing of toothpaste with fluoride or the drinking water with high levels of fluoride.
The nurse has performed the initial assessments of four clients admitted with an acute episode of asthma. Which assessment finding would cause the nurse to call the health care provider immediately? Appearance of the use of abdominal muscles for breathing Expectoration of large amounts of purulent mucous Expiratory wheezes that are suddenly absent in one lobe Prolonged inspiration with each breath
Expiratory wheezes that are suddenly absent in one lobe
During a nursing staff meeting, there is discussion of perceived inequities in weekend staff assignments. As a follow-up, the nurse manager should initially take which action? Clarify reasons for current assignments Facilitate creative thinking about staffing Help staff see the complexity of issues Allow the staff to change assignments
Facilitate creative thinking about staffing
A parent has numerous questions regarding normal growth and development of a 10 month-old infant. Which growth or development parameter should be of the most concern to a nurse? Head circumference is about the same as chest size Able to stand up briefly in play pen Cries when the parents leave the room Fifty percent increase in birth weight
Fifty percent increase in birth weight
A client, who had his entire stomach surgically removed six months ago, is now readmitted. Which of the following assessment findings would indicate that the client is experiencing complications associated with this surgery? Poor wound healing Tendency to bruise easily Decreased night vision Findings consistent with fatigue
Findings consistent with fatigue
A client says, "It's raining outside and it's raining in my heart. Did you know that St. Patrick drove the snakes out of Ireland? I've never been to Ireland." What should the nurse document this behavior as? Circumstantiality Perseveration Flight of ideas Neologisms
Flight of ideas
A nurse documents "effective use of guided imagery to change pain from a 4 to a 1 (on a 10-point scale)." Which definition best describes this technique? Focus on pleasant, relaxed mental pictures The repetition of a word to self with the eyes closed Inhalation to a count of four and exhalation to a count of four Closure of the eyes to focus on the back of the eyelids or blank screen
Focus on pleasant, relaxed mental pictures
A nurse is teaching a child and family members about the medication phenytoin prescribed for seizure control. Which side effect is most likely to occur? Drowsiness Vomiting Vertigo Gingival hyperplasia
Gingival hyperplasia
A nurse is teaching a parent how to administer oral iron supplements to a 2 year-old child. Which intervention should be included in the teaching? Stop the medication if the stools become tarry green Administer the iron with your child's meals Give the medicine with orange juice and through a straw Add the medicine to a bottle of formula
Give the medicine with orange juice and through a straw
A mother, who has been exclusively breastfeeding her 6 month-old, requests more information about meeting the nutritional needs of her infant. What information will the nurse provide? Cut back on the number of times a day the infant receives breastmilk Offer finger foods to encourage self-feeding during family meals Begin a regular schedule of meals and snacks, offering a variety of foods Gradually begin adding pureed iron-rich meat and/or cereal as the first foods
Gradually begin adding pureed iron-rich meat and/or cereal as the first foods
A nurse is caring for a client several days after a cerebral vascular accident (CVA). Warfarin has been prescribed. Today's prothrombin level is 40 seconds (normal range 10 to 14 seconds). Which finding requires priority follow-up? Homan's sign Lung sounds Gum bleeding Generalized weakness
Gum bleeding
he nurse is preparing a client and her healthy newborn for discharge. The nurse provides information about hormonal effects in newborns and tells the client to expect which of the following conditions in her baby? Edema of the scrotum Lanugo Mongolian spots Gynecomastia
Gynecomastia
A newly admitted adult client has a diagnosis of hepatitis A. The charge nurse should reinforce to the staff members that the priority routine in infection control strategy, in addition to handwashing, is which of these approaches? Use a mask with a shield if there is a risk of fluid splash Wear a gown to change linens soiled from incontinence Place appropriate precaution signs outside and inside the room Have gloves on while handling bedpans with feces
Have gloves on while handling bedpans with feces
A nurse is assessing a healthy child at the two-year check up. Which finding should the nurse report immediately to the health care provider? Height and weight percentiles vary widely Growth pattern appears to have slowed Recumbent and standing height are different Short-term weight changes are uneven
Height and weight percentiles vary widely
Which of these client's behaviors would indicate that the nurse-client relationship has passed from the orientation phase to the working phase? Expresses a desire to be cared for and pampered Recognizes regressive behaviors as a defense mechanism Identifies feelings about situations and expresses them appropriately Revitalizes a relationship with the family to help cope with the death of a child
Identifies feelings about situations and expresses them appropriately
The client is diagnosed with heart failure and oral digoxin is prescribed. What is the priority nursing assessment for this medication? Measure apical pulse prior to administration Monitor serum electrolytes and creatinine Maintain accurate intake and output ratios Monitor blood pressure every 4 hours
Measure apical pulse prior to administration
A nurse is caring for a client admitted to the hospital with a diagnosis of right lower lobe (RLL) pneumonia. On assessment, the nurse notes rhonchi and a loose but weak cough. The client has significant pleuritic pain and is unable to take a deep breath to cough effectively. Which nursing diagnosis would be most appropriate for this client based on this assessment data? Ineffective airway clearance related to sputum production and ineffective cough Impaired gas exchange related to acute infection and sputum production Ineffective breathing pattern related to acute infection Anxiety related to hospitalization and role conflict
Ineffective airway clearance related to sputum production and ineffective cough
The nurse is performing pulmonary assessment on a client. Indicate the correct sequence of pulmonary assessment by dragging and dropping the steps below into the correct order. Inspection Auscultation Palpation Percussion
Inspection is first, observing for pattern of breathing, symmetry, anteroposterior and transverse chest diameters, as well as skin color, sounds and odors. The nurse will then palpate the posterior and anterior chest, noting any tenderness, crepitus, or tactile fremitus. The next step is percussion, which is performed in a systematic manner, usually from side to side from apex (top) of lungs to base (bottom), listening to changes in tone from one area to another. Lastly, the lungs are auscultated, listening over the anterior, posterior, and lateral chest for expected or adventitious sounds.
A client is admitted with a tentative diagnosis of congestive heart failure (CHF). Which assessment finding, consistent with this diagnosis, would the nurse expect? Cyanosis Chest pain Heart murmur Inspiratory crackles
Inspiratory crackles
A client is admitted with a diagnosis of myocardial infarction (MI) and reports having chest pain. The nurse provides care based on the knowledge that pain associated with an MI is related to which of the following findings? Insufficient oxygenation of the cardiac muscle An electrolyte imbalance Fluid volume excess Arrhythmia
Insufficient oxygenation of the cardiac muscle
The nurse provides regular mouth care to the hospice client who is actively dying at home. The family wants to know why the doctor doesn't order an IV since the client's mouth seems so dry. What information can the nurse provide to the family that best answers their question. The client will need to be hospitalized if an IV is started Intravenous hydration will increase episodes of delirium The client will need to have a indwelling catheter inserted if an IV is started Intravenous hydration can delay death
Intravenous hydration can delay death
A client who is being treated for paranoid schizophrenia becomes loud and boisterous. The nurse immediately places the client in seclusion, and the client willingly complies. How might the nurse's action be interpreted by the case manager? It was appropriate in view of the client's behaviors of violence It was necessary to maintain the therapeutic milieu of the unit It may result in charges of unlawful seclusion and restraint It leaves the nurse vulnerable for charges of assault and battery
It may result in charges of unlawful seclusion and restraint
A 78 year-old client has just returned from having an intravenous pyelography. Which information is a priority for the nurse to reinforce? Eat a light diet for the rest of the day Rest for the next 24 hours because the preparation and the test are tiring Measure the urine output for the next day and immediately notify the health care provider if it is less than usual Drink at least one 8-ounce glass of fluid every hour while awake for the next two days
Measure the urine output for the next day and immediately notify the health care provider if it is less than usual
A nurse is caring for a client with sickle cell disease who is scheduled to receive a unit of packed red blood cells. Which is an appropriate action for the nurse during the administration of the infusion? Store the packed red cells in the refrigerator while starting IV line Limit the infusion time to a maximum of four hours Slow the rate of infusion if the client develops a fever or chills Assess vital signs every 15 minutes throughout the entire infusion
Limit the infusion time to a maximum of four hours
A nurse admits a premature infant who has been diagnosed with respiratory distress syndrome (RDS). In planning care for the infant, the nurse understands that the pathophysiology of this disorder affects the infant's ability to do what? Regulate intrapulmonary airway pressures Maintain alveolar surface tension Adequately clear thick, sticky mucus from the lungs Stabilize thermoregulation
Maintain alveolar surface tension
A client reports to the nurse that she is experiencing a sudden, deep and throbbing pain in one leg. What is the most appropriate first action to be taken by the nurse? Apply ice to the extremity Ambulate for several minutes Suggest isometric exercises Maintain the client on bed rest
Maintain the client on bed rest
A client in acute respiratory distress is admitted with arterial blood gas results of: PH 7.30; PO2 58, PCO2 34; and HCO3 19. The nurse should make which conclusion about these results? Metabolic acidosis Respiratory acidosis Respiratory alkalosis Metabolic alkalosis
Metabolic acidosis
An infant has just had a pyloromyotomy. Initial postoperative nursing care would include which of these approaches? Intravenous fluids for three to four days Formula or breast milk as tolerated Bland diet appropriate for age NPO then glucose and electrolyte solutions
NPO then glucose and electrolyte solutions
A client treated for depression tells the nurse at the mental health clinic, "I recently purchased a handgun because I am thinking about suicide." Which of these should be the FIRST action taken by the nurse? Notify the primary care provider immediately Suggest inpatient psychiatric care Phone the family to warn them of the risk Respect the client's confidential disclosure
Notify the primary care provider immediately
The nurse is assessing a child with suspected lead poisoning. Which assessment should a nurse expect to find? Auditory wheezes with expiration Numbness and tingling in feet Excessive perspiration A history of difficulty sleeping
Numbness and tingling in feet
A nurse is talking to parents about nutrition for their school-aged children. What is the most common nutritional disorder found in this age group? Malnutrition Anorexia Obesity Bulimia
Obesity
The client is using nonsteroidal anti-inflammatory drugs (NSAIDs), such as ibuprofen, to manage arthritis pain. The nurse should caution the client about which common side effect? Urinary incontinence Constipation Occult bleeding Nystagmus
Occult bleeding
A client with schizophrenia receives haloperidol 5 mg three times a day. The client's family is alarmed and calls the clinic nurse when "his eyes rolled upward." The nurse should recognize this finding as what type of side effect? Nystagmus Tardive dyskinesia Dysphagia Oculogyric crisis
Oculogyric crisis
A nurse is caring for a client with extracellular fluid volume deficit. Which assessment would the nurse anticipate finding? Oliguria Rapid respirations Bounding pulse Distended neck veins
Oliguria
A newborn presents with a pronounced cephalohematoma after a birth in the posterior position. Which nursing diagnosis should guide the plan of care? Pain related to periosteal injury Injury related to intracranial hemorrhage Parental anxiety related to knowledge deficit Impaired mobility related to bleeding
Parental anxiety related to knowledge deficit
The nurse is caring for a client who has a wound on the leg from a motorcycle accident. During a home visit, the nurse should use which assessment parameter as an indication that this client is experiencing normal wound healing? White patches on the outside edges Green drainage from the center Eschar over the surface Pebbled red tissue in the wound base
Pebbled red tissue in the wound base
The nurse enters a client's room just as the client begins to experience a generalized tonic clonic seizure. What action should the nurse take? Place the client on one side Insert a padded tongue blade in client's mouth Hold the client's arms at the side Elevate the head of the bed
Place the client on one side
The mother of a child diagnosed with poison ivy tells the nurse that she does not know how her child contracted the rash because the child had not been playing in wooded areas. As the nurse asks questions about possible contact, which of these situations should the nurse recognize as the highest risk for exposure to poison ivy? Playing with cars on the pavement near burning leaves Eating small amounts of grass while playing "farm" Playing with toys in a backyard flower garden Throwing a ball to a neighborhood child who has poison ivy
Playing with cars on the pavement near burning leaves
The nurse is working with an adolescent diagnosed with morbid obesity. The nurse should recognize that obesity in adolescence is most often associated with what other finding? Sexual promiscuity Drug experimentation Dropping out of school Poor body image
Poor body image
A client is treated in the emergency department for diabetic ketoacidosis and a glucose level of 650 mg/dL. The nurse would expect which serum lab value to be altered as a result of therapy associated with the client's condition? Calcium Potassium Magnesium Creatinine
Potassium
The nurse is using the image below to explain and clarify information in teaching the client about a new colostomy. Based on this image, which of the following statements about the consistency of the drainage is correct? The feces have a normal, formed consistency The feces are mushy (liquid to semiformed) The feces are semiformed to formed The feces are liquid to semiliquid and the discharge is often irritating to the skin around the stoma
The feces are semiformed to formed
The nurse manager is reviewing the provisions of the Americans with Disabilities Act (ADA) regarding hiring a person with disabilities. Which approach should the nurse manager take? Provide reasonable accommodations for individuals with a disability Consider both mental and physical disabilities during interviews Make all necessary accommodations for individuals with a disability Maintain an environment free from associated hazards
Provide reasonable accommodations for individuals with a disability
After a successful alcohol detoxification, a client remarked to a friend, "I've tried to stop drinking but I just can't. I can't even work without having a drink." The client's belief that he needs alcohol indicates the dependence is primarily of which type? Psychological Biological Physical Socialcultural
Psychological
A client was admitted to the psychiatric unit diagnosed with major depressive disorder (MDD) after a suicide attempt. Which of the following findings of MDD would the nurse expect the client to exhibit? Meticulous attention to grooming and hygiene Anxiety from unconscious anger with hostility Guilt coupled with indecisiveness from a poor self-concept Psychomotor retardation or agitation
Psychomotor retardation or agitation
A nurse is administering lidocaine to a client with a myocardial infarction. Which assessment finding requires the nurse's immediate action? Central venous pressure reading of 11 Blood pressure of 144/92 Pulse rate of 48 beats per minute Respiratory rate of 22
Pulse rate of 48 beats per minute
A nurse is caring for a client with a new order for bupropion hydrochloride for treatment of depression. The order reads "Wellbutrin 175 mg twice a day for four days." What is the appropriate action? Observe the client for mood swings Question this medication dose Give the medication as ordered Monitor neurologic signs frequently
Question this medication dose
The nurse recognizes that cultural practices affect health outcomes. Which statement best reflects what nurses can do to improve health outcomes in clients from different cultures? Recommend a plan that meets client goals as well as professional nursing standards Incorporate high personal standards and values for all interactions Use conventional wisdom to gain a deeper understanding about the client's health practices Reinforce the correct Western medical perspective
Recommend a plan that meets client goals as well as professional nursing standards
A nurse is examining an infant in a clinic. Which nursing assessment for the infant is most valuable in the identification of serious visual defects? Pupil response to light Cover test Visual acuity Red reflex test
Red reflex test
A client who is diagnosed with cirrhosis of the liver is started on lactulose. What should the nurse understand about the main action of the drug? Control portal hypertension Reduce ammonia levels Add dietary fiber Stimulate peristalsis
Reduce ammonia levels
A nurse is teaching a client about the healthy use of ego defense mechanisms. An appropriate goal for this client should be which of these? Reduce fear and protect self-esteem Increase independence and communicate more often Avoid conflict and leave unpleasant situations Minimize anxiety and delay apprehension
Reduce fear and protect self-esteem
A client is being discharged with a prescription for warfarin. Which information is critical to be included in the nurse's discharge teaching? Take Tylenol for minor pains Report any nose or gum bleeds Use a soft toothbrush Don't increase your intake of green leafy vegetables
Report any nose or gum bleeds
A nurse is teaching about nonsteroidal anti-inflammatory agents (NSAIDs) to a group of clients diagnosed with arthritis. The nurse should emphasize which of these actions to minimize a side effect of these drugs? Use alcohol in moderation when driving or operating heavy machinery Take the medication after meals or with food Correct response Continue to take aspirin for short-term pain relief Report joint stiffness in the morning
Report joint stiffness in the morning
A nurse has asked the second staff nurse to sign for a wasted narcotic, which was not witnessed by another person. What should be an appropriate initial action? Confront the nurse about the suspected drug use Report this immediately to the nurse manager Counsel the colleague about the risky behaviors Sign the narcotic sheet and document the event in an incident report
Report this immediately to the nurse manager
A client with an IV antibiotic infusing is scheduled to have blood drawn at 1:00 pm for a peak antibiotic level measurement. The nurse notes that the IV infusion is running behind schedule and won't be infused until 1:30 pm. What action should the nurse take? Increase the infusion rate to finish it by 1:00 pm Notify the client's health care provider Reschedule the laboratory test for 2:00 pm Stop the infusion at 1:00 pm and get the blood drawn
Reschedule the laboratory test for 2:00 pm
A client with chronic obstructive pulmonary disease (COPD) and a history of coronary artery disease is receiving aminophylline 25 mg/hour. Which finding would be associated with side effects of this medication? Decreased blood pressure and respirations Flushing and headache Increased heart rate and blood pressure Restlessness and palpitations
Restlessness and palpitations
A client reports bilateral knee pain from osteoarthritis and is taking the prescribed nonsteroidal anti-inflammatory drug (NSAID). The nurse should instruct the client to make which lifestyle change to manage this condition? Start a regular exercise program Avoid foods high in citric acid Keep the legs elevated when sitting Rest the knees as much as possible
Start a regular exercise program
The home health nurse makes a scheduled visit to provide wound care and finds the client lethargic and confused. The client's partner states the client fell down the stairs two hours ago. What action should the nurse take next? Place a call to the client's health care provider for instructions Send the client via ambulance to the emergency department for evaluation Instruct the client's partner to call the health care provider if symptoms return Reassure the client's partner that the symptoms are transient
Send the client via ambulance to the emergency department for evaluation
The nurse is planning care for a 2 year-old hospitalized child. Which situation would the nurse expect to most likely affect the child's behavior? Presence of other toddlers Unfamiliar toys and games Strange bed and surroundings Separation from parents
Separation from parents
A hospitalized 8 month-old infant is receiving gentamicin. While monitoring the infant for drug toxicity, the nurse should focus on which laboratory result? Growth hormone levels Platelet counts Serum creatinine Thyroxin levels
Serum creatinine
A nurse is assessing a young child at a clinic visit for a mild respiratory infection. Koplik spots are noted on the oral mucous membranes. What should the nurse assess next? Lungs Urine Skin Sputum
Skin
At the day treatment center, a client diagnosed with schizophrenia-paranoid type sits alone alertly watching the activities of clients and staff. The client is hostile when approached and asserts that the health care provider prescribes medication to control the client's mind. The client's behavior most likely indicates what associated nursing diagnosis? Social isolation related to altered thought processes Sensory perceptual alteration related to withdrawal from environment Impaired verbal communication related to impaired judgment Feelings of increased anxiety related to paranoia
Social isolation related to altered thought processes
The nurse is preparing a handout on infant feeding to be distributed to families visiting the clinic. Which notation should be included in the teaching materials? A variety of ground meat should be started early to provide iron Solid foods should be mixed with formula in a bottle Solid foods are to be introduced one at a time beginning with cereal Egg white is added early to increase protein intake
Solid foods are to be introduced one at a time beginning with cereal
The nurse is using the Glasgow Coma Scale to assess a client diagnosed with a traumatic brain injury. When the client does not obey verbal commands to move, which technique should the nurse use to evaluate motor function? Squeeze the trapezius muscle firmly Rub the sternum with the knuckles Lift the client's arm and observe for pronation and drift Apply finger tip pressure for 10 seconds
Squeeze the trapezius muscle firmly
There's an order to check the pH of aspirate every four hours for a client who has a continuous tube feeding. The nurse checks the aspirate at the designated time and the pH is 8. What action should the nurse take? Irrigate the tube with water and reassess pH Stop the tube feeding for about an hour and then reassess aspirate Continue the tube feeding as scheduled Hold the tube feeding and notify the health care provider
Stop the tube feeding for about an hour and then reassess aspirate
The nurse is caring for a child diagnosed with nephrotic syndrome. What finding should the nurse expect when assessing the child? Swelling around the eyes Increased appetite Increased activity levels Weight loss
Swelling around the eyes
The nurse is teaching a client about the difference between tardive dyskinesia (TD) and neuroleptic malignant syndrome (NMS). Which statement is true about tardive dyskinesia? TD can occur in clients taking antipsychotic drugs longer than two years TD can easily be treated with anticholinergic drugs TD more commonly develops in children and young adults diagnosed with Tourette syndrome TD occurs within minutes of the first dose of any antipsychotic drug but it is reversible
TD can occur in clients taking antipsychotic drugs longer than two years
The nurse is teaching a client about an oral hypoglycemic medication. The nurse should place primary emphasis on which of the following points? Distinguishing hypoglycemia from hyperglycemia Increasing the dosage based on blood glucose Taking the medication at specified times Recognizing the findings of toxicity
Taking the medication at specified times
The charge nurse delegates the task of taking vital signs to an unlicensed assistive personnel (UAP). Despite written and verbal instructions not to take the blood pressure on the left arm of a client who is 48 hours postmastectomy, the charge nurse later observes a blood pressure cuff on that client's left arm. Which of these statements is accurate about this situation? The UAP is responsible for following instructions given by the charge nurse The UAP is covered by the charge nurse's license The charge nurse did not delegate appropriately The charge nurse has no accountability for this situation
The UAP is responsible for following instructions given by the charge nurse
The nurse is having a discussion with the parents of a newborn who was diagnosed with hypospadias. The nurse should communicate which point? The initial repair is delayed until six to eight years of age The postoperative appearance of the penis will be normal The surgery may be performed in stages over a period of time Circumcision can be performed at any time
The surgery may be performed in stages over a period of time
A client is about to undergo a plaster cast application. Prior to the cast application, the nurse should be sure to include what teaching point in the discussion? The cast should be covered with cotton material until it fully dries The cast material will be dipped several times into the tepid water The casted extremity will be placed on a cloth-covered surface The wet cast should be handled with the palms of hands until fully dry
The wet cast should be handled with the palms of hands until fully dry
The nurse is talking with the family of an 18 month-old toddler who is newly diagnosed with retinoblastoma. Which point is a priority when discussing this diagnosis with the parents? There is a need for genetic counseling Prepare them for their child's permanent disfigurement Suggest that total blindness may follow surgery Inform them that even aggressive treatment is usually ineffective
There is a need for genetic counseling
After a myocardial infarction, a client is placed on a sodium-restricted diet. When the nurse is teaching the client about the diet, which meal plan would be the most appropriate to suggest? Turkey 3 oz., a fresh sweet potato, 1/2 cup fresh green beans, milk, and an orange Broiled fish 3 oz., a baked potato, ½ cup canned beets, an orange, and milk A bologna sandwich, fresh eggplant, 2 ounces of fresh fruit, tea, and apple juice Canned salmon 3 oz., fresh broccoli, a biscuit, tea, and an apple
Turkey 3 oz., a fresh sweet potato, 1/2 cup fresh green beans, milk, and an orange
A client is scheduled for an intravenous pyelogram (IVP). Which information from the client's history indicates the greatest potential hazard for this test? Type 2 diabetic taking metformin (Glucophage) Constipation Urge incontinence Hypertension
Type 2 diabetic taking metformin (Glucophage)
A nurse is caring for a 10 year-old child who will be started on heparin therapy. Which assessment is critical for the nurse to make before initiating this therapy? Skin turgor Vital signs Lung sounds Weight
Weight
During the admission process, the client reports heavy alcohol use for at least one year. What effect does the nurse anticipate the hospitalized client will experience when alcohol consumption stops? Withdrawal Bradycardia Somnolence Craving
Withdrawal