EAQ for Exam Review 2. NSG 2400
Administering fluid replacement RAT: As a result of osmotic pressures created by an increased serum glucose level, the cells become dehydrated; the client must receive fluid and then insulin. Oxygen therapy is not necessarily indicated. Carbohydrates will increase the blood glucose level, which is already high. Although dietary instruction may be appropriate later, such instruction is inappropriate during the crisis.
Which nursing intervention is appropriate when a client is first admitted with hyperglycemic hyperosmolar nonketotic syndrome (HHNS)? 1 Providing oxygen 2 Encouraging carbohydrates 3 Administering fluid replacement 4 Teaching facts about dietary principles
Pco2: 28, HCO3: 18, pH: 7.28 Decreased pH and bicarbonate values reflect metabolic acidosis; a decreased Pco2 value indicates compensatory hyperventilation. Increased pH and bicarbonate values reflect metabolic alkalosis; an increased Pco2 value indicates compensatory hypoventilation. Increased pH and decreased Pco2 values reflect hyperventilation and respiratory alkalosis. Decreased pH and increased Pco2 values reflect hypoventilation and respiratory acidosis.
Which arterial blood gas report is indicative of diabetic ketoacidosis? 1 Pco2: 49, HCO3: 32, pH: 7.50 2 Pco2: 26, HCO3: 20, pH: 7.52 3 Pco2: 54, HCO3: 28, pH: 7.30 4 Pco2: 28, HCO3: 18, pH: 7.28
-Vomiting -Increased Weight Gain -Decreased Serum Sodium -Decreased Level of Consciousness Water retention and decreased urinary output occur because of excess secretion of antidiuretic hormone (ADH). Early manifestations are related to water retention and may include gastrointestinal (GI) disturbances such as loss of appetite, nausea, and vomiting. Weight gain occurs because of the water retention. Serum sodium levels are decreased because of fluid retention and sodium loss. Central nervous system changes include headaches, lethargy, and decreased level of consciousness, progressing to coma and seizures. Hypothermia also occurs because of central nervous system disturbance. The pulse is full and bounding because of the increased fluid volume.
Which clinical findings would the nurse expect to see when assessing a client with a primary brain tumor who has developed syndrome of inappropriate secretion of antidiuretic hormone (SIADH)? Select all that apply. One, some, or all responses may be correct. 1 Vomiting 2 Hyperthermia 3 Bradycardia 4 Increased weight 5 Decreased serum sodium 6 Decreased level of consciousness
Acetone breath Decreased arterial carbon dioxide level A fruity odor to the breath (acetone breath) occurs when the ketone level is elevated in ketoacidosis. Metabolic acidosis initiates respiratory compensation in the form of Kussmaul respirations to counteract the effects of ketone buildup, resulting in a decreased arterial carbon dioxide level. As the glucose level decreases in hypoglycemia, the sympathetic nervous system is activated, and epinephrine and norepinephrine are secreted, causing diaphoresis. Retinopathy is a long-term complication of diabetes caused by microvascular changes in the retina; it is not a sign of ketoacidosis. With ketoacidosis, the serum bicarbonate level is decreased, not increased, in an effort to neutralize ketones when seeking acid-base balance.
A nurse is caring for a client admitted to the hospital for diabetic ketoacidosis. Which clinical findings related to this event would the nurse document in the client's clinical record? Select all that apply. One, some, or all responses may be correct. 1 Diaphoresis 2 Retinopathy 3 Acetone breath 4 Increased arterial bicarbonate level 5 Decreased arterial carbon dioxide level
1. Excessive thirst 3. Dry mucous Membranes 6. Decreased Urine specific gravity RAT: As excessive fluid is lost through urination, dehydration triggers the thirst response. As excessive fluid is lost through urination, dehydration occurs, resulting in dry mucous membranes and poor skin turgor. Because water is not being reabsorbed, urine is dilute, resulting in a low specific gravity (less than 1.005). Diabetes insipidus is not a disorder of glucose metabolism; blood glucose levels are not affected. Diabetes mellitus affects glucose metabolism. Loss of fluid may decrease the blood pressure because fluid is lost from the intravascular compartment. As fluid is lost from the intravascular compartment, serum osmolarity increases, not decreases.
When assessing a client with diabetes insipidus, which signs would the nurse anticipate finding? Select all that apply. One, some, or all responses may be correct. 1 Excessive thirst 2 Increased blood glucose 3 Dry mucous membranes 4 Increased blood pressure 5 Decreased serum osmolarity 6 Decreased urine specific gravity
Providing tracheostomy care using sterile techniques The licensed practical nurse (LPN) provides tracheostomy care using sterile techniques. Developing a plan to avoid aspiration in a client with tracheostomy is done by the RN. Assessing the client's condition after tracheostomy is done by the RN. Teaching a client and caregiver about home tracheostomy care is done by the RN.
The registered nurse (RN) is delegating care for a client who underwent a tracheostomy. Which task could be delegated to the licensed practical nurse (LPN)? 1 Developing a plan to avoid aspiration 2 Assessing the client's condition after tracheostomy 3 Providing tracheostomy care using sterile techniques 4 Teaching a client and caregiver about home tracheostomy care
"We'll have her massage her gums and floss her teeth frequently." A common side effect of phenytoin is gingival hyperplasia. Meticulous oral hygiene may reduce the risk of this side effect. Phenytoin is strongly alkaline and should be administered with meals to help prevent gastric irritation. Pink urine may be observed during medication excretion; it is expected and does not require treatment. Avoidance of overeating and overhydration may result in better seizure control.
The nurse teaches the parents of a child prescribed long-term phenytoin therapy about care. Which statement indicates the teaching has been effective? 1 "We give the medication between meals." 2 "We'll call the clinic if her urine turns pink." 3 "She's eating high-calorie foods, and we encourage fluids, too." 4 "We'll have her massage her gums and floss her teeth frequently."
Increased Age Ulcerative colitis RAT: A slower fecal transit time, which occurs with aging, may increase the risk for colon cancer. Chronic irritation of the intestinal mucosa, such as occurs in ulcerative colitis, increases the risk for colon cancer. Hemorrhoids are not a risk factor; they are associated with constipation. A high-fiber diet is linked to a decreased risk for colon cancer. Low hemoglobin level is not a risk factor for colon cancer; this may occur as a result of cancer and its therapies.
What information from a client's history would the nurse identify as risk factors for the development of colon cancer? Select all that apply. One, some, or all responses may be correct. 1 Hemorrhoids 2 Increased age 3 High-fiber diet 4 Ulcerative colitis 5 Low hemoglobin level
1. Avoid intramuscular injections. 5. Examine the skin for ecchymotic areas. RAT: Intramuscular injections should be avoided because of the increased risk of bleeding and possible hematoma formation. Decreased platelets increase the risk of bleeding, which leads to ecchymoses. Neutropenic precautions are for clients with decreased WBCs, not platelets. Platelet count, rather than WBC count, will be monitored. Anticoagulants are contraindicated because of the increased bleeding risk.
When a client is admitted with thrombocytopenia, which nursing actions would be included in the plan of care? Select all that apply. One, some, or all responses may be correct. 1 Avoid intramuscular injections. 2 Institute neutropenic precautions. 3 Monitor the white blood cell (WBC) count. 4 Administer prescribed anticoagulants. 5 Examine the skin for ecchymotic areas.
Ensuring patent airway Ensuring a patent airway is the priority of the nurse because a client may lose consciousness during a seizure. IV fluids should be administered when the condition of the client is stable. Level of consciousness should be monitored during ongoing treatment. Continuous muscle contractions are observed in a client with tonic-clonic seizures, which may cause injury. The client should be protected from injury during seizures.
Which action would the nurse perform immediately according to priority of care for a client with tonic-clonic seizures? 1 Ensuring patent airway 2 Administering intravenous (IV) fluids 3 Monitoring level of consciousness 4 Protecting the client from injury during seizures
Supine, with the head elevated about 45 degrees The head should be elevated, allowing gravity to minimize intracranial pressure. The Trendelenburg position is contraindicated because it can increase intracranial pressure. The infant should be positioned on the back or side to allow routine changes in head position; prone positioning is unsafe for infants and increases the risk of sudden infant death syndrome.
Which position would the nurse select for an infant with hydrocephalus? 1 On either side and supine 2 Supine and Trendelenburg 3 Prone, with the legs elevated about 30 degrees 4 Supine, with the head elevated about 45 degrees
Inadequate antidiuretic hormone (ADH) secretion Deficient ADH from the posterior pituitary results in diabetes insipidus. This can be caused by head trauma; water is not conserved by the body, and excess amounts of urine are produced. Although increased serum glucose may cause polyuria, it is associated with diabetes mellitus, not diabetes insipidus. Ineffective renal perfusion will cause decreased urine production. Although excess amounts of IV fluids may cause dilute urine, it is unlikely that a client with head trauma will be receiving excess fluid because of the danger of increased intracranial pressure.
A client is admitted with a head injury and has large amounts of clear, colorless urine draining from the urinary catheter. Which physiological response is possibly causing the increased urine output? 1 Increased serum glucose 2 Deficient renal perfusion 3 Inadequate antidiuretic hormone (ADH) secretion 4 Excess amounts of intravenous (IV) fluid
Negative pressure in the pleural space Removal of air and fluid from the pleural space reestablishes negative pressure, resulting in lung expansion. Neutral pressure in the pleural space will cause collapse of the lung. Atmospheric pressure in the thoracic cavity will cause collapse of the lung. Intrapulmonic pressure refers to pressure within the lung itself, not the pressure within the thoracic cavity.
A nurse is caring for a client with a pneumothorax who has a chest tube attached to a closed chest drainage system. If the chest tube and closed chest drainage system are effective, which type of pressure will be reestablished? 1 Neutral pressure in the pleural space 2 Negative pressure in the pleural space 3 Atmospheric pressure in the thoracic cavity 4 Intrapulmonic pressure in the thoracic cavity
2. Help the client adjust to the temporary prosthesis. RAT: A temporary prosthesis attached to a cast with a metal extension can be applied immediately after surgery. This will allow the adolescent to walk within several hours and helps start the adjustment process. The first dressing change is usually done by a member of the surgical team; also, this is too early to expect the adolescent to be ready to look at the surgical site. Assigning the adolescent to a particular room is usually done out of necessity rather than to promote psychologic adjustment. It is too early to have another cancer survivor visit, but this may be done later in the recovery process.
A teenager with a diagnosis of osteosarcoma is to have the affected leg amputated. Which should promote psychological adjustment and early function immediately after surgery? 1 Allow the client to change the first dressing. 2. Help the client adjust to the temporary prosthesis. 3 Assign the client to a room with another adolescent. 4. Have the client meet with a member of a cancer survivor organization.
Constant bubbling in the water-seal chamber Constant bubbling in the water-seal chamber is indicative of an air leak. The nurse would assess the entire length of the system from the container to the client's chest wall tube insertion site to find the source of the air leak. If the source of the air leak is not found in the system and bubbling continues, the leak is most likely within the client's chest or at the insertion site. This could cause the lung to collapse because of a buildup of air pressure within the plural cavity, and the health care provider should be notified. In this type of surgical procedure, 75 mL of blood in the chest tube collection chamber is an expected finding in the early postoperative period. A column of water 20 cm high in the suction control chamber and an intact occlusive dressing at the chest tube insertion site are also expected assessment findings.Test-Taking Tip: Read every word of each question and option before responding to the item. Glossing over the questions just to get through the examination quickly can cause you to misread or misinterpret the real intent of the question.
The client has a closed chest tube drainage system connected to suction. Which assessment finding requires additional evaluation by the nurse? 1 A column of water 20 cm high in the suction control chamber 2 75 mL of bright red blood in the drainage collection chamber 3 An intact occlusive dressing at the insertion site 4 Constant bubbling in the water-seal chamber
"I will stop taking my insulin when I am ill because I am not eating." The diabetic client's metabolic needs will require the same amount of insulin and sometimes more when in a stressed state, including illness. The client checking the urine for ketones when blood sugar is more than 250, alternating water and Gatorade intake, and continuing insulin indicate that the client has an understanding of the basic sick day rules. Alternating the intake of water and Gatorade throughout the day provides noncarbohydrate water and fluids containing glucose and electrolytes while reducing the risk of consuming too much sugar.
The nurse is assessing a client admitted with diabetic ketoacidosis. Which statement made by the client indicates a need for further education on sick day management? 1 "I will stop taking my insulin when I am ill because I am not eating." 2 "I will check my urine for ketones when my blood sugar is over 250." 3 "I will alternate drinking Gatorade and water throughout the day while ill." 4 "I will continue all my insulin including my glargine when I am sick."
Teach isometric exercises The prescription for isometric exercises should be questioned; isometric exercises increase the basal metabolic rate and intracranial pressure. Anticonvulsants may be administered prophylactically after traumatic brain injury to limit the risk for seizures, which will further increase intracranial pressure. Osmotic diuretics may be used to draw fluid from the cerebral tissue into the vascular space to decrease cerebral edema and intracranial pressure. Elevation of the head of the bed helps reduce cerebral edema as the result of gravitational force on the fluid.
The nurse is caring for a client who has a traumatic brain injury with increased intracranial pressure. Which health care provider prescription would the nurse question? 1 Continue anticonvulsants 2 Teach isometric exercises 3 Continue osmotic diuretics 4 Keep head of bed at 30 degrees
1. Auscultate the lungs and check the heart rate. 2. Prepare by turning suction on to between 80 and 120 mm Hg pressure. 3. Hyperoxygenate using 100% oxygen. 4. Don sterile gloves. 5. Guide the catheter into the tracheostomy tube using a sterile-gloved hand. The status of the client should be ascertained as a baseline before starting the procedure. The suction should be turned on to check its adequacy before beginning. Because oxygen will be lost during suctioning, the client should be oxygenated using 100% oxygen before initiating the procedure. Then the nurse should don sterile gloves to protect the client from infection and guide the catheter into the tracheostomy tube without using negative pressure.
The nurse is suctioning a client's tracheostomy. What is the correct order of nursing actions when performing this procedure? 1. Don sterile gloves. 2. Auscultate the lungs and check the heart rate. 3. Prepare by turning suction on to between 80 and 120 mm Hg pressure. 4. Guide the catheter into the tracheostomy tube using a sterile-gloved hand. 5. Hyperoxygenate using 100% oxygen.
"Supplements that contain folic acid interfere with the effectiveness of chemotherapy." Vitamins are contraindicated because methotrexate is a folic acid antagonist, and folic acid will counteract the effectiveness of methotrexate. Telling the parent that vitamins won't help his or her child feel better doesn't answer the question; the parent is asking about improving her child's strength, not well-being.
The parent of a toddler taking methotrexate asks the nurse whether the child should be started on vitamin supplements. Which statement by the nurse is appropriate? 1 "That's a fine suggestion, and I'll ask for a prescription." 2 "Vitamin supplements won't help him feel any better right now." 3 "He'll benefit from a vitamin supplement and will be getting it soon." 4 "Supplements that contain folic acid interfere with the effectiveness of chemotherapy."
"You have been thinking about your diagnosis." The correct response acknowledges the client's statements, encourages further expression of feelings, and provides an opportunity for further discussion. The statement indicating that the client feels guilty about smoking focuses on only one of the client's statements and discourages communication about the other client concerns. Although the nurse will obtain information about smoking history during the admission assessment, asking about how many years the client has smoked discourages further communication about the client's concerns. Asking about the client's father indicates that the nurse is not open to discussion of the client's concerns and cuts off communication.
When a newly admitted client tells the nurse, "The doctor told me I have lung cancer. My father died from cancer. I wish I had never smoked," which response by the nurse is best? 1 "What type of cancer did your father have?" 2 "You are feeling guilty about your smoking." 3 "You have been thinking about your diagnosis." 4 "How many years have you smoked cigarettes?"
Apply suction only as the catheter is being withdrawn. Use of suction on withdrawal of a suction catheter reduces unnecessary removal of oxygen. In addition, suction should be applied intermittently during the withdrawal procedure to prevent hypoxia. A sterile catheter is used to prevent infection and the catheter should be inserted only approximately 1 to 2 cm past the end of the tracheostomy tube to prevent tissue trauma. Hyperventilating a client before suctioning should always be with oxygen, not room air. Inserting the catheter until the cough reflex is stimulated frequently occurs and does help mobilize secretions, but is not a safety measure. Removal of the inner cannula before inserting the suction catheter is not necessary.
When suctioning a client with a tracheostomy, which nursing intervention is correct? 1 Hyperventilate the client with room air before suctioning. 2 Apply suction only as the catheter is being withdrawn. 3 Insert the catheter until the cough reflex is stimulated. 4 Remove the inner cannula before inserting the suction catheter.
1. Change the ostomy pouch on a routine basis. 2. Replace the ostomy wafer weekly or sooner as needed. 5. Empty the ostomy pouch before exercise and at bedtime. RAT: Tips for limiting stool leakage are important for the comfort and dignity of a client with an ostomy. Changing the ostomy pouch on a routine basis will decrease the risk of leakage. Twice-weekly changes are typical. Recommendations include changing the skin barrier (wafer) at least once weekly or more often as needed to protect the integrity of the skin beneath and around the ostomy. Emptying the pouch before activities and before bedtime will also help prevent leakage and overfill. Recommendations include showering or bathing with the pouch on, not off. Keeping the pouch on helps maintain the integrity of the wafer and prevents any stool from leaking onto the skin or into the shower while bathing. Instruct clients to have a new pouch at the ready to be exchanged with the old pouch after showering. If clients wait to empty the pouch until it is more than 1/2 full, the likelihood of leakage increases. Emptying the pouch sooner prevents overfill and leakage.
When teaching a client with a new colostomy about appliance care and maintenance, which information would the nurse include? Select all that apply. One, some, or all responses may be correct. 1 Change the ostomy pouch on a routine basis. 2 Replace the ostomy wafer weekly or sooner as needed. 3 Remove the ostomy pouch when showering. 4 Empty the ostomy pouch when 3/4 full of stool or gas. 5 Empty the ostomy pouch before exercise and at bedtime.
Use sterile technique when cleaning the inner cannula. Don sterile gloves before removing the inner cannula. Sterile technique is used when cleaning the inner cannula to avoid transmitting microorganisms to the lungs. Sterile gloves are worn when removing the inner cannula. There is no need to suction the client before starting tracheostomy care, although the client may be preoxygenated before removing the inner cannula. A brush is used to clean the inner cannula. Hydrogen peroxide is used to clean secretions from the inner cannula, the cannula is rinsed with normal saline. Because hydrogen peroxide can be irritating to tissue, normal saline is used to clean the skin around the tracheostomy stoma.
Which actions will the nurse include when doing tracheostomy care? Select all that apply. One, some, or all responses may be correct. 1 Suction the client before starting tracheostomy care. 2 Use sterile technique when cleaning the inner cannula. 3 Use sterile cotton-tipped swabs to clean the inner cannula. 4 Don sterile gloves before removing the inner cannula. 5 Use hydrogen peroxide to clean the skin around the stoma.
1. Feeling Tired 2. Rectal Bleeding 4. Change in the shape of stools 5. Feeling abdominal bloating RAT: Anemia may manifest as fatigue, feeling tired, and/or generalized weakness. Anemia is common with rectosigmoid colon cancer from the loss of blood rectally. Passage of red blood (hematochezia) is 1 of the cardinal signs of rectosigmoid colon cancer; ulceration of the tumor and straining to pass stool precipitate this clinical finding. A cancerous mass can grow into the lumen of the sigmoid colon, altering the shape of stool; stools may be ribbonlike or pencil thin. Tumors in the rectosigmoid colon cause partial and eventually complete obstruction of the intestinal lumen. Because there is less fluid in the stool of the descending and sigmoid colon, a formed mass develops; thus, the client strains to pass stools, and gas pains (causing a feeling of abdominal bloating), cramping, and incomplete evacuation commonly occur. An inability to digest fat is not specific to rectosigmoid colon cancer; therefore, stools will not float and will contain bile, which colors the stool brown.
Which clinical manifestations does the nurse expect the client to report when admitted for surgical resection of a rectosigmoid colon cancer? Select all that apply. One, some, or all responses may be correct. 1 Feeling tired 2 Rectal bleeding 3 Inability to digest fat 4 Change in the shape of stools 5 Feeling of abdominal bloating 6 Stools float and are clay-colored
"You will be given medication to relax you before the test and you won't remember anything afterward." A sedative-hypnotic such as midazolam or propofol is used to produce conscious sedation. The child will feel relaxed and will not remember the procedure. A bone marrow specimen is obtained through a puncture wound; sutures are not necessary. A local anesthetic is not used; the child is given sedation or anesthesia. The child may ambulate freely after the procedure.
Which education would the nurse provide to a 9-year-old child who will undergo bone marrow aspiration? 1 "The provider will put in a few stitches after the test, but you won't feel them after the test." 2 "You will be given numbing medicine before the test, but you might feel some pressure during the test." 3 "You will be given medication to relax you before the test and you won't remember anything afterward." 4 "You will have to stay in bed for several hours after the test, but you may still turn from side to side."
Crepitus at the chest tube site Crepitus at the chest tube site may indicate ongoing pneumothorax and the nurse would take actions such as listening to breath sounds, checking oxygen saturation, checking results of the postremoval chest x-ray, and notifying the health care provider. A poor cough effort may indicate the need for action such as pain management, but is not likely to be caused by removal of the chest tube. Pain at the chest tube site may occur because of inflammation and indicates the need for pain management, but would not indicate any complications associated with chest tube removal. A small amount of serosanguinous drainage is common after removal of chest tubes.
Which finding in a client who has had a chest tube removed would be of most concern to the nurse? 1 Poor cough effort 2 Pain at chest tube site 3 Crepitus at the chest tube site 4 Two centimeters of pink drainage on dressing
Keep calm because this is not an immediate emergency. Clients' concerns decrease if they understand the stoma will stay open long enough for easy insertion of another tube. A permanent opening into the trachea formed after 2 or 3 weeks and does not require prompt reinsertion of a tube. The client is in no immediate danger, and imperative notification of the health care provider is unnecessary.
Which instruction would the nurse teach the client concerned about dislodging a laryngectomy tube at a 3-week postoperative follow-up visit? 1 Reinsert another tube immediately. 2 Notify the health care provider at once. 3 Keep calm because this is not an immediate emergency. 4 Quickly take action to prevent the tracheal stoma from closing.
Monitoring blood pressure Blood pressure monitoring is important because the tumor is of renal origin and the renin-angiotensin mechanism may be involved. Palpating the liver should be avoided; it puts pressure on the involved area, increasing the risk of rupture of the tumor and seeding of cancer cells. There are no data to indicate that the child has a urinary tract infection. Lying in the prone position puts pressure on the involved area, increasing the risk of rupture of the tumor and seeding of cancer cells.
Which intervention would the nurse include in the care of a child with Wilms tumor? 1 Palpating for liver size 2 Monitoring blood pressure 3 Obtaining urine for a culture 4 Maintaining the prone position
1. Place the head and neck in neutral alignment. RAT: The nurse would first attempt nursing interventions such as placing the head and neck in alignment (neutral position) to facilitate venous return and thereby decrease ICP. If nursing measures prove ineffective, notify the health care provider, who may prescribe mannitol. The nurse would notify the health care provider for hyperventilation therapy or for pentobarbital. Hyperventilation is used only when all other interventions have been ineffective in decreasing ICP.
Which intervention would the nurse perform first for the client admitted with a closed head injury and increased intracranial pressure (ICP)? 1 Place the head and neck in neutral alignment. 2 Obtain a prescription for 100 mg of pentobarbital IV. 3 Administer 1 g mannitol intravenously (IV) as prescribed. 4 Increase the ventilator's respiratory rate to 20 breaths/minute.
Placing the child in a private room, restricting ill visitors, and using strict hand-washing techniques Children with leukemia most often die of infection; a low neutrophil count is associated with myelosuppressant therapy. Placing the child in a private room, restricting ill visitors, and using strict hand-washing techniques are the best ways to minimize complications. Encouraging a well-balanced diet, including iron-rich foods, and helping the child avoid overexertion are not appropriate measures to prevent infection resulting from neutropenia; they are appropriate for treating the anemia. Avoiding taking rectal temperatures, limiting injections, and applying direct pressure for 5 minutes after venipuncture are not appropriate measures to prevent infection resulting from neutropenia; they are more appropriate for preventing bleeding. Offering a moist, bland, soft diet; using toothettes rather than a toothbrush; and providing frequent saline mouthwashes are not appropriate measures to prevent infection resulting from neutropenia; they are used to ease and treat stomatitis.
Which interventions would the nurse implement to prevent infection in a preschool child with acute nonlymphoid leukemia who is admitted with a fever and neutropenia? 1 Placing the child in a private room, restricting ill visitors, and using strict hand-washing techniques 2 Encouraging a well-balanced diet, including iron-rich foods, and helping the child avoid overexertion 3 Avoiding taking rectal temperatures, limiting injections, and applying direct pressure for 5 minutes after venipuncture 4 Offering a moist, bland, soft diet; using toothettes rather than a toothbrush; and providing frequent saline mouthwashes
Apply a petroleum gauze dressing over the site. A petroleum gauze dressing will prevent air from being sucked into the pleural space, causing a pneumothorax. The petroleum gauze dressing should be taped only on three sides to allow for excessive air to escape, preventing a tension pneumothorax. The health care provider should be notified immediately and the client assessed for signs of respiratory distress. Positioning the client on the left side will not make a difference in outcome. There is no indication that the client is experiencing respiratory distress. Preparing to insert a new chest tube is not a priority of the nurse at this moment.
Which nursing action is of highest priority when a client's chest tube has accidentally dislodged? 1 Place the client in a left side-lying position. 2 Apply oxygen via nonrebreather mask. 3 Apply a petroleum gauze dressing over the site. 4 Prepare to insert a new chest tube.
4. Monitoring for increasing intracranial pressure RAT: The shunt may become obstructed, leading to an accumulation of cerebrospinal fluid in the head; the accumulated fluid causes an increase in intracranial pressure, which in turn leads to brain stem hypoxia. Positioning the infant flat helps prevent complications resulting from too-rapid reduction of intracranial fluid. Although pain management is essential to minimize an increase in intracranial pressure, sedation is contraindicated because it will mask the infant's level of consciousness. The infant is positioned on the side opposite the shunt to prevent pressure on the valve and incision area.
Which nursing intervention would the nurse implement for an infant during the first 24 hours after surgery to place a ventriculoperitoneal shunt for hydrocephalus? 1 Placing in the high Fowler position 2 Administering the prescribed sedative 3 Positioning on the same side as the shunt 4 Monitoring for increasing intracranial pressure
Supine on the unaffected side Placing the infant supine will prevent complications from too-rapid reduction of intracranial fluid; placing the infant on the unaffected side will prevent pressure on the shunt valve. Placing the infant on the affected side will put pressure on the shunt valve, which may cause it to become obstructed, interfering with the outflow of cerebrospinal fluid. Raising the head of the bed will allow a too-rapid reduction in cerebrospinal fluid, which may cause the cerebral cortex to pull away from the dura, resulting in a subdural hematoma. Placing the infant on the affected side will put pressure on the shunt valve. Elevating the head to 90 degrees will permit too rapid a reduction in cerebrospinal fluid.
Which position would the nurse use for an infant after the insertion of a ventriculoperitoneal shunt for hydrocephalus? 1 Supine on the unaffected side 2 Side-lying on the affected side 3 Head elevated at 45 degrees on the affected side 4 Head elevated at 90 degrees on the unaffected side
"Wash with soap and water." Soap and water remove fecal debris and microorganisms; this promotes skin integrity and prevents infection. Hydrogen peroxide is too irritating and should be avoided. Applying ointment to this extent is contraindicated because it will interfere with adherence of the appliance. Vigorous rubbing may be irritating and may promote conditions that contribute to infection.
Which teaching point would the nurse include when teaching a client about how to care for the skin around a colostomy stoma? 1 "Wash with soap and water." 2 "Rinse the area with peroxide." 3 "Apply a thick coat of an emollient." 4 "Rub vigorously to remove hardened feces."
150 mg/dose Convert the child's weight of 44 lb to kilograms (44 ÷ 2.2 = 20); 20 kg × 15 mg/kg = 300 mg for the entire day. Divide 300 mg into two doses (300 mg ÷ 2 = 150 mg/dose). Use ratio and proportion to calculate the dose.
A 6-year-old child is prescribed carbamazepine 15 mg/kg/day divided equally into two doses for clonic seizures. The child weighs 44 lb (20 kg). The medication available is carbamazepine suspension 100 mg/5 mL. How many milliliters would the nurse administer in one dose? Record your answer using one decimal place. ___ mL
1 "It decreases inflammation." RAT: Prednisone is a synthetic glucocorticoid that exerts an active anti-inflammatory effect by stabilizing lysosomal membranes, thereby inhibiting proteolytic enzyme release. Prednisone does not affect the lymphocytes. Although prednisone increases the appetite and creates a sense of well-being, these are not the reasons it is administered. There is no indication the child is receiving radiation.
The nurse is caring for a child undergoing chemotherapy for acute lymphoid leukemia. The parents ask why the child needs prednisone. Which response by the nurse would be correct? 1 "It decreases inflammation." 2 "It suppresses the production of lymphocytes." 3 "It increases appetite and a sense of well-being." 4 "It may decrease skin irritation and edema."
Observe for fluctuations of the fluid in the water-seal chamber. Fluctuations of the fluid in the water-seal chamber indicate effective communication between the pleural cavity and the drainage system. Milking the chest tube toward the drainage unit should be avoided because it raises pressure in the pleural space, which can result in a tension pneumothorax. Bubbling in the suction control chamber occurs whenever the chest drainage system is connected to suction and is not a sign that the chest drainage system is patent. Extent of chest expansion in relation to breath sounds does not directly reflect the patency of the chest tube.
There is still a pathway from the mouth to the stomach; eating patterns are not lost when a laryngectomy is performed. Air passes through a tracheal stoma that bypasses the nose and olfactory organs. There is no passage of air from the lungs to the nose; air is expelled through a tracheal stoma. Use of a straw could lead to aspiration.
Lethargy is an early sign of a changing level of consciousness; a changing level of consciousness is one of the first signs of increased ICP. Nausea is a subjective symptom, not a sign, potentially present with increased ICP. Sunset eyes is a late sign of increased ICP that occurs in children with hydrocephalus. Hyperthermia is a late sign of increased ICP that occurs as compression of the brainstem increases.
Which early sign of increased intracranial pressure (ICP) would the nurse monitor in a client who sustained a head injury while playing soccer? 1 Nausea 2 Lethargy 3 Sunset eyes 4 Hyperthermia
Recognize the signs of urinary tract infection (UTI). Because the child now has one kidney, the parents must watch carefully for signs and symptoms of UTI on an ongoing basis. A UTI can compromise kidney function; therefore, it should be identified in the early stage and treated immediately. A kidney transplant is not necessary because the child has a functioning kidney. Sodium is usually not restricted. Fluids are not restricted; adequate fluid intake is encouraged to prevent UTI.
Which essential education would the nurse provide the parents of a 4-year-old child after a nephrectomy for a Wilms tumor? 1 Prepare for a kidney transplant. 2 Restrict the child's intake of sodium. 3 Maintain the child's fluid restrictions. 4 Recognize the signs of urinary tract infection (UTI).
3. brick red stoma RAT: indicates adequate vascular perfusion. A blue, gray, or dark purple color indicates inadequate perfusion of the stoma.
A client had a colon resection and formation of a colostomy 2 days ago. Which color indicates to the nurse that the stoma is viable? 1 Blue 2 Gray 3 Brick red 4 Dark purple
Before each dose of chemotherapy The purpose of an antiemetic before chemotherapy is to prevent the child from experiencing nausea during and after the administration of the medication. Waiting until nausea has occurred is too late; the medication should be given before nausea occurs. The meals are not causing the nausea; the nausea is caused by the chemotherapy, and if nausea is not prevented, the child will not eat.
An adolescent with leukemia is to be given a chemotherapeutic agent. Which time is best for the nurse to administer the prescribed antiemetic? 1 As nausea occurs 2 An hour before meals 3 Just before each meal is eaten 4 Before each dose of chemotherapy
Keep the trachea free of secretions A patent airway is the priority; therefore removal of secretions is necessary. Providing emotional support is important but not the priority immediately after surgery. Observing for signs of infection is an important postoperative concern but does not occur immediately. Although important, promoting a means of communication is not as important as a patent airway.
During a client's immediate postoperative period after a laryngectomy, which is a nursing priority? 1 Provide emotional support 2 Observe for signs of infection 3 Keep the trachea free of secretions 4 Promote a means of communication
Presence of Infection Infection increases the body's metabolic rate, and insulin is not available for increased demands. Although emotional stress will affect glucose levels, diabetic ketoacidosis will rarely result. Increased insulin dose will lead to insulin coma (hypoglycemia) if diet is not increased as well. Inadequate food intake will result in insulin coma.
Which common cause of diabetic ketoacidosis would the nurse consider when caring for a postoperative client with diabetes? 1 Emotional stress 2 Presence of infection 3 Increased insulin dose 4 Inadequate food intake
Defect in hypothalamus A defect in the hypothalamus (thirst center) could be the most probable cause of primary DI. Meningitis or a brain tumor could interfere with the synthesis, transport, or release of antidiuretic hormone (ADH) and cause central DI. Lithium therapy affects the renal response to ADH and results in nephrogenic DI or medication-related DI.
Which medical condition could most probably result in clients developing primary diabetes insipidus (DI)? 1 Meningitis 2 Brain tumor 3 Lithium therapy 4 Defect in hypothalamus
Renal biopsy RAT: A renal biopsy is an invasive procedure. In the early stages, Wilms tumor is encapsulated. Any disruption of the tumor capsule may precipitate metastasis. Magnetic resonance imaging, computed tomography, and abdominal ultrasound are all helpful in making the diagnosis.
Which provider prescription would the nurse question for a young child with a tentative diagnosis of Wilms tumor? 1 Renal biopsy 2 Abdominal ultrasound 3 Computed tomography scan 4 Magnetic resonance imaging
1. Water sports RAT: Water sports pose a severe threat; should water enter the stoma, the client will drown. Strenuous exercises are not harmful; as long as there is no obstruction, adequate oxygen will be available because the respiratory rate will increase. Pillows are not contraindicated, although care should be taken not to occlude the airway by any bedding while asleep. Humidity is desirable and helpful in keeping secretions liquefied.
A client has a laryngectomy. The avoidance of which activity identified by the client indicates that the nurse's teaching about activities and the stoma is understood? 1 Water sports 2 Strenuous exercises 3 Sleeping with pillows 4 High-humidity environment
"After surgery, I will be able to chew and swallow food." There is still a pathway from the mouth to the stomach; eating patterns are not lost when a laryngectomy is performed. Air passes through a tracheal stoma that bypasses the nose and olfactory organs. There is no passage of air from the lungs to the nose; air is expelled through a tracheal stoma. Use of a straw could lead to aspiration.
A client is scheduled for a total laryngectomy and radical neck dissection. The nurse provides education about postoperative activity. The nurse concludes that the teaching is effective when the client makes which statement? 1 "After surgery, I will be allowed to blow my nose." 2 "After surgery, I will be allowed to sip through a straw." 3 "After surgery, I will be able to chew and swallow food." 4 "After surgery, I will be able to smell and differentiate odors."
Suction the tracheostomy Noisy, increased respirations and increased pulse are signs that the client needs immediate suctioning to clear the airway of secretions. After suctioning, a complete respiratory assessment should be performed. After suctioning, then performing a respiratory assessment, further problem-solving may require readjustment of the tracheostomy tube and ties or a health care provider changing the tracheostomy tube.
A postoperative client with a tracheostomy tube in place suddenly develops noisy, increased respirations and an elevated heart rate. The nurse would take which action immediately? 1 Suction the tracheostomy. 2 Change the tracheostomy tube. 3 Readjust the tracheostomy tube and tighten the ties. 4 Perform a complete respiratory assessment.
Assessing the respirations Respiratory therapy is needed in clients who undergo surgery for lung cancer. Assessing respiration can be safely delegated to the respiratory therapist. Placing a Foley catheter, an IV catheter, or administering patient-controlled analgesia is within the scope of an RN's practice.
The health care team is caring for a client who has undergone surgery for lung cancer. The client needs respiratory therapy. Which task can be safely delegated to a respiratory therapist paired with a registered nurse (RN)? 1 Placing a Foley catheter 2 Assessing the respirations 3 Placing an intravenous (IV) catheter 4 Administering patient-controlled analgesia
Intake and output DDAVP replaces antidiuretic hormone, facilitating the reabsorption of water and the consequent return of balanced fluid intake and urinary output. The mechanisms that regulate pH are not affected. DDAVP does not alter serum glucose levels; diabetes mellitus, not diabetes insipidus, results in hyperglycemia. Although the correction of tachycardia is consistent with the correction of dehydration, the client is not dehydrated if the fluid intake is adequate; respirations are unaffected.
The nurse administers desmopressin acetate (DDAVP) to a client with diabetes insipidus. Which would the nurse monitor to evaluate the effectiveness of the medication? 1 Arterial blood pH 2 Intake and output 3 Fasting serum glucose 4 Pulse and respiratory rates
4. Do not palpate the abdomen. RAT: Palpation increases the risk of tumor rupture and is contraindicated. There are no data to indicate that surgery is scheduled; therefore, there is no reason to maintain NPO status. There is no contraindication to IV medication. Recording of intake and output may or may not be instituted; it is not specific to children with Wilms tumor.
Which sign would the nurse place at the bedside of a child admitted with a diagnosis of Wilms tumor? 1 Keep NPO (nothing by mouth). 2 No intravenous (IV) medications 3 Record intake and output. 4 Do not palpate the abdomen.
4. White blood cells (WBCs) Antineoplastic medications depress bone marrow, which causes leukopenia; the client must be protected from infection, which can be life-threatening. RBCs diminish slowly and can be replaced with a transfusion of packed RBCs. Platelets decrease as rapidly as WBCs, but complications can be limited with infusions of platelets.
A complete blood count is prescribed before each round of a client's cancer chemotherapy. Which component of the complete blood count is of greatest concern to the nurse? 1 Platelets 2 Hematocrit 3 Red blood cells (RBCs) 4 White blood cells (WBCs)
Anorexia Limb Pain Splenomegaly RAT: Hypermetabolism associated with the leukemic process results in loss of appetite. Bone marrow dysfunction and invasion of the periosteum result in bone pain. Infiltration, enlargement, and fibrosis of the spleen occur early in the disease process as the excess white blood cells are trapped. Flushing is not expected. Bone marrow dysfunction results in anemia, and pallor accompanies the decreased erythrocyte count. Mouth lesions (stomatitis) occur later during the disease process or as a result of chemotherapy.
A child is admitted to the pediatric unit with a tentative diagnosis of acute lymphocytic leukemia (ALL). Which early signs and symptoms of leukemia would the nurse expect to identify? Select all that apply. One, some, or all responses may be correct. 1 Flushing 2 Anorexia 3 Limb pain 4 Splenomegaly 5 Mouth lesions
Serum potassium levels will decrease as potassium ions shift from the extracellular fluid to the intracellular fluid compartment. RAT Insulin stimulates cellular uptake of glucose and stimulates the sodium/potassium pump, leading to the influx of potassium into cells. The resulting hypokalemia is offset by parenteral administration of potassium. Potassium is not lost from the body by profuse diaphoresis. Potassium moves from the extracellular to the intracellular compartment rather than being excreted in the urine. Anabolic reactions are stimulated by insulin and glucose administration; potassium is drawn into the intracellular compartment, necessitating a replenishment of extracellular potassium.
Which rationale explain why intravenous (IV) potassium is prescribed in addition to regular insulin for clients in diabetic ketosis? 1 Potassium loss occurs rapidly from diaphoresis present during coma. 2 Potassium is carried with glucose to the kidneys to be excreted in the urine in increased amounts. 3 Potassium is quickly used up during the rapid series of catabolic reactions stimulated by insulin and glucose. 4 Serum potassium levels will decrease as potassium ions shift from the extracellular fluid to the intracellular fluid compartment.
Oliguria Seizures vomiting Cancerous cells of small cell lung cancer can produce antidiuretic hormone, which causes fluid retention, resulting in increased blood volume and decreased urine volume. Fluid retention associated with SIADH can cause cerebral edema, resulting in confusion and seizures. Fluid retention resulting in hyponatremia causes nausea and vomiting. The client will have nausea and vomiting, resulting in a decreased oral fluid and food intake.
Which signs would the nurse expect to observe in a client with small cell carcinoma of the lung who develops syndrome of inappropriate antidiuretic hormone (SIADH)? Select all that apply. One, some, or all responses may be correct. 1 Oliguria 2 Seizures 3 Vomiting 4 Polydipsia 5 Polyphagia
Decrease in the level of consciousness Decreasing level of consciousness occurs because of the brain's acute sensitivity to hypoxia. The respirations usually are depressed because of brainstem compression. The systolic pressure increases and the diastolic pressure decreases, resulting in a widening, not narrowing, pulse pressure. The peripheral vascular resistance is decreased when hypoxia occurs, thereby decreasing, not increasing, the diastolic blood pressure.
A client is admitted to the hospital after sustaining a head injury. Which assessment finding indicates increased intracranial pressure? 1 Rise in respiratory rate 2 Narrowing of pulse pressure 3 Decrease in the level of consciousness 4 Increase in the diastolic blood pressure
Depresses the central nervous system (CNS) Lorazepam is used to treat status epilepticus because it depresses the CNS. It also functions as an anxiolytic and sedative and can cause anterograde amnesia; however, these are not the reasons it is prescribed for status epilepticus.
A client is treated with lorazepam for status epilepticus. Which effect of lorazepam is the reason it is given? 1 Decreases anxiety associated with seizures 2 Promotes rest after the seizure episode 3 Depresses the central nervous system (CNS) 4 Provides amnesia for the convulsive episode
Fever accompanied by decreased responsiveness Fever accompanied by decreased responsiveness is associated with infection. This is the greatest postoperative hazard for children with shunts for hydrocephalus. Eyes with sclerae visible above the irises occur with progressively increasing intracranial pressure, usually before shunt insertion. Violent involuntary muscle contractions may occur as the result of an infected shunt; however, it is not the most common sign of an infectious process. The peritoneum absorbs cerebrospinal fluid adequately; ascites (excessive fluid accumulation in the abdomen) is not a problem.
An infant born with hydrocephalus will be discharged after insertion of a ventriculoperitoneal shunt. Which common complication would the nurse instruct the parents to report if it occurs at home? 1 Visibility of the sclerae above the irises 2 Violent involuntary muscle contractions 3 Excessive fluid accumulation in the abdomen 4 Fever accompanied by decreased responsiveness
Registered Nurse (RN) The team leader assigns the professional, technical, and ancillary personnel to the type of client care they are prepared to deliver and must be knowledgeable about the legal and organizational limits of each role. The RN is qualified to meet all of the client's needs. The charge nurse does not receive a client assignment in team nursing. The client assignment is beyond the scope of UAP. The LPN/LVN may be qualified to address the client's tracheostomy and chest tube but is not able to support the blood transfusion.
In the team nursing model, which team member would be assigned a client with a tracheostomy, chest tube, and blood transfusion? 1 Charge nurse 2 Registered nurse (RN) 3 Unlicensed assistive personnel (UAP) 4 Licensed practical nurse/licensed vocational nurse (LPN/LVN)
2. Unequal pupil size RAT: Increased ICP causes unequal pupils as a result of pressure on the third cranial nerve. It causes an increase in the systolic pressure, which reflects the additional pressure needed to perfuse the brain. ICP increases the pressure on the vagus nerve, which produces bradycardia, and it causes an increase in body temperature from hypothalamic damage.
Which assessment finding reflects increased intracranial pressure (ICP)? 1 Tachycardia 2 Unequal pupil size 3 Decreasing body temperature 4 Decreasing systolic blood pressure
Wash the area with soap and water and then apply a protective ointment. Using soap and water and ointment helps maintain skin integrity and prevent infection. Applying an ointment to the extent of 3 inches (7.6 cm) is contraindicated because it will interfere with adherence of the appliance. Rubbing may be irritating and may promote conditions that contribute to infection. Soap and water are adequate unless peroxide is specifically prescribed by the health care provider; gauze bandages generally are not applied around or over a stoma.
The nurse provides postoperative teaching about colostomy care to a client who underwent surgery for cancer of the colon. The education would include which instruction related to skin care around the stoma? 1 Apply liberal amounts of Vaseline for 3 inches (7.6 cm) around the stoma. 2 Wash the area with soap and water and then apply a protective ointment. 3 Pour saline over the stoma, and rub the area to remove hard fecal matter. 4 Rinse the area with peroxide before applying fresh gauze bandages.
Phenytoin inhibits absorption of folate from foods. Phenytoin inhibits folic acid absorption and potentiates the effects of folic acid antagonists. Folic acid diminishes, not potentiates, the effects of phenytoin. Absorption of iron from foods and prevention of neuropathy caused by phenytoin are not effects of folic acid.
A client who is receiving phenytoin asks why folic acid was prescribed. Which explanation would the nurse provide? 1 Phenytoin inhibits absorption of folate from foods. 2 Folic acid potentiates the action of phenytoin. 3 Absorption of iron from foods is improved. 4 Neuropathy caused by phenytoin is prevented.
Contact the primary health care provider. The observation may be indicative of bleeding, and the health care provider should be notified. Overlooking the first signs of hemorrhage may permit the client to go into shock. Continuing to only monitor the client is unsafe. Documenting the amount of sputum is an action to be taken, but not until after contacting the primary health care provider. Vital signs should be monitored, but the priority is to take action to identify and treat bleeding. Increasing the coughing and deep-breathing regimen can precipitate bleeding because of an increase in intrathoracic pressure.
A client with a history of hemoptysis and cough for the past 6 months is suspected of having lung cancer. A bronchoscopy is performed. Two hours after the procedure the nurse identifies an increase in the amount of bloody sputum. Which is the nurse's priority? 1 Contact the primary health care provider. 2 Document the amount of sputum. 3 Monitor vital signs every hour. 4 Increase the frequency of cough and deep-breathing exercises.
Administer the next dose of the medication as prescribed. Administering the next dose of the medication as prescribed is within the therapeutic range of 10 to 20 mcg/L (40-80 mcmol/L); the nurse would administer the medication as prescribed. Holding the next dose and then resuming administration as prescribed is unsafe and will reduce the therapeutic blood level of the medication. Calling the health care provider to obtain a prescription with an increased dose is inappropriate because the blood level is within the therapeutic range.
A client's phenytoin level is 16 mcg/L. Which action will the nurse take? 1 Hold the medication and notify the health care provider. 2 Administer the next dose of the medication as prescribed. 3 Hold the next dose and then resume administration as prescribed. 4 Call the health care provider to obtain a prescription with an increased dose.
Drawing fluid from brain cells into the bloodstream Mannitol, an osmotic diuretic, pulls fluid from the brain to relieve cerebral edema. Mannitol's diuretic action does not decrease the production of cerebrospinal fluid. Mannitol does not affect brain metabolism; rest and lowered body temperature reduce brain metabolism. Preventing uncontrolled electrical discharges in the brain is the action of phenytoin sodium, not mannitol.
A health care provider prescribes mannitol for a client with a head injury. Which mechanism of action is responsible for therapeutic effects of this medication? 1 Decreasing the production of cerebrospinal fluid 2 Limiting the metabolic requirements of the brain 3 Drawing fluid from brain cells into the bloodstream 4 Preventing uncontrolled electrical discharges in the brain
-Monitoring urine output -Administering Oral rehydration medication. -The LPN scope of practice includes monitoring urine output. Administration of any type of oral medication can also be performed by the LPN. Activities related to a client's hygiene, such as emptying the drainage, are usually performed by unlicensed assistive personnel (UAP). Feeding the client is usually performed by a UAP. Administration of intravenous fluids is the responsibility of the registered nurse.
A health care team is caring for a client with diabetes insipidus. Which task is most suitable to be delegated to a licensed practical nurse (LPN) to provide effective client care? Select all that apply. One, some, or all responses may be correct. 1 Emptying the urinary drainage bag 2 Monitoring urine output 3 Assisting the client with eating 4 Administration of intravenous fluids 5 Administering oral rehydration medication
Abdominal swelling Wilms tumor is a nephroblastoma that is first observed as a firm, painless intra-abdominal mass located on one side of the abdomen. Periorbital edema is a sign of glomerulonephritis, not Wilms tumor. Projectile vomiting is indicative of central nervous system problems or a gastrointestinal obstruction, not Wilms tumor. A low-grade fever is a nonspecific sign of many illnesses, not necessarily Wilms tumor.
Which clinical manifestation would the nurse expect in a 3-year-old child newly diagnosed with a Wilms tumor? 1 Periorbital edema 2 Projectile vomiting 3 Abdominal swelling 4 Low-grade temperature
Marked irritability may be a sign of malfunction of the shunt or infection and should be reported immediately. Complaints of pain are expected after surgery. A pulse rate of 100 beats per minute is within the expected range (70-110 beats per minute) for children between the ages of 2 and 10 years. A low-grade fever is expected after the stress of surgery.
Which finding during the assessment of a child after a shunt procedure to correct increased intercranial pressure is of most concern? 1 Marked irritability 2 Complaints of pain 3 Pulse of 100 beats per minute 4 Temperature of 99.4(F (37.4(C)
