Foundations and Practice of Mental Health Nursing HESI EXIT 5

As part of the physical assessment, a nurse inspects a newborn for the presence of an umbilical hernia. What infant behavior helps the nurse identify this problem?.

Crying

The nurse is assessing the Apgar scores of four different newborns in a pediatric ward. Which child does the nurse anticipate is experiencing severe distress?

Newborn A.

The nurse instructs a client that, in addition to building bones and teeth, calcium is also important for:

Blood clotting.

A client is seen in the clinic with sickle cell anemia. A brief explanation for this condition is:

Abnormally shaped red blood cells.

Which medication should the nurse anticipate the health care provider will prescribe to relieve the pain experienced by a client with rheumatoid arthritis?.

Acetylsalicylic acid (Aspirin)

A client has been taking lithium carbonate (Eskalith) for 3 days. The nurse has the client's lithium level checked before administering the medication and finds it to be 0.3 mEq/L. The nurse should:

Administer the medication.

A client asks a nurse why captopril (Capoten) was prescribed. What specific drug classification should the nurse include in the explanation to the client?

Antihypertensive

A client is admitted to the hospital with pancytopenia as a result of chemotherapy. What should the nurse plan to teach this client in an effort to minimize the risk of complications as a result of pancytopenia?

Avoid traumatic injuries and exposure to infection

A client admitted for uncontrolled hypertension and chest pain was prescribed a low sodium diet and started on furosemide (Lasix). The nurse should instruct the client to include which foods in the diet?

Bananas

A nurse is performing a neurological assessment of a 7-month-old infant. What reflex should the nurse be able to elicit?

Babinski.

What response should a nurse be particularly alert for when assessing a client for side effects of long-term cortisone therapy?

Behavioral changes

The nurse expects that the most definitive test to confirm a diagnosis of multiple myeloma is:

Bone marrow biopsy

A client with cancer of the pancreas has a pancreaticoduodenectomy (Whipple procedure). The nurse expects that the client will have which tube after surgery?

Nasogastric

What should the nurse include in a teaching plan to help reduce the side effects associated with diltiazem (Cardizem)?

Change positions slowly

A client's arterial blood gas report indicates the pH is 7.52, PCO2 is 32 mm Hg, and HCO3 is 24 mEq/L. What does the nurse identify as a possible cause of these results?

Excessive mechanical ventilation

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

Genital lesion.

While a client with an abdominal aortic aneurysm is being prepared for surgery, the client complains of feeling lightheaded. The client is pale and has a rapid pulse. The nurse concludes that the client is:

Going into shock.

Which screening report will help the nurse determine skeletal growth in a child?

Radiographs of the hand and wrist.

A 14-month-old toddler is able to recognize the shapes of objects and fit smaller boxes into larger boxes. Which type of cognitive development does this action indicate?

Spatial relationship.

What should the nurse suggest when parents ask what to do about their preschooler's stuttering?

Speak clearly and do not complete the child's sentences.

What factors are most important for the nurse to consider when delegating responsibilities?

Staff member's level of education and expertise

A 3-year-old child with eczema of the face and arms has disregarded the nurse's warnings to "stop scratching, or else!" The nurse finds the toddler scratching so intensely that the arms are bleeding. The nurse then ties the toddler's arms to the crib sides, saying, "I'm going to teach you one way or another." How should the nurse's behavior be interpreted?

These actions can be construed as assault and battery.

A client is admitted with the diagnosis of possible myocardial infarction, and a series of diagnostic tests are prescribed. Which blood level should the nurse expect will increase first if this client has had a myocardial infarction?

Troponin T (cTnT),,

What is the nurse's initial action immediately after assisting with a precipitous birth in the triage area of the emergency department?

Warming the newborn.

A nurse is caring for an infant with severe dehydration. Which blood gas report most likely reflects the acid-base balance of this infant?

pH of 7.20 and HCO3- of 20 mm Hg.

Which is the priority intervention for the dependant client with peptic ulcer disease (PUD) who is

vomiting bright red blood? Place the client in a side-lying position.

What are the different patterns of physical development and maturation of neuromuscular functions in a child? Select all that apply:

1/Proximodistal 2/ Cephalocaudal 3/ Differentiation

A nurse is assessing a client and suspects diabetic ketoacidosis (DKA). What clinical findings support this conclusion?

Deep respirations and fruity odor to the breath

A spouse of a client, while visiting at the hospital, slips and falls on a recently washed floor in the hallway leading to the client's room. To meet the criteria of ethical practice, what action should the nurse that witnessed the occurrence take?

Initiate an agency incident report.

A client tells the nurse, "I am so worried about the results of the biopsy they took today." The nurse overhears the nursing assistant reply, "Don't worry. I'm sure everything will come out all right." The nurse concludes that the nursing assistant's answer:

gives false reassurance.

A health care provider prescribes an antibiotic intravenous piggyback (IVPB) twice a day for a client with an infection. The health care provider prescribes peak and trough levels 48 and 72 hours after initiation of the therapy. The client asks the nurse why there is a need for so many blood tests. The nurse's best response is, "These tests will:

Determine adequate dosage levels of the drug."

A client who had injection sclerotherapy for varicose veins is advised to wear compression (support) stockings. What is most important for the nurse to explain to the client about compression stockings?

Don the stockings before getting out of bed in the morning

While caring for a woman who has had a positive contraction stress test (CST), what complication does the nurse suspect?

Uteroplacental insufficiency

A parent of a healthy 8-month-old infant asks a nurse which pureed foods and type of milk is most appropriate at this age. What should the nurse suggest?

pplesauce, carrots, chicken, and formula.

An infant is found to have developmental dysplasia of the hip (DDH) 6 weeks after birth. The parents ask a nurse at the clinic why their infant must be restrained in a harness at such an early age. How should the nurse respond?

Infants' hip joints are cartilaginous, allowing molding of the acetabulum.

An infant is to be discharged 3 days after surgery for hypertrophic pyloric stenosis (HPS). What instructions should the nurse give the parents?

"Give the regular formula slowly while holding the baby, and burp often."

Furosemide (Lasix) has been prescribed as part of the medical regimen for a client with hypertension, and the nurse has provided related teaching. The nurse concludes that the client needs additional teaching when the client states,

"I plan to eat a food high in vitamin K every day."

A female client receiving cortisone therapy for adrenal insufficiency expresses concern about why she is developing facial hair. How should the nurse respond? "

"The drug contains a hormone that causes male characteristics."

A client with rheumatoid arthritis does not want the prescribed cortisone and informs the nurse. Later, the nurse attempts to administer cortisone. When the client asks what the medication is, the nurse gives an evasive answer. The client takes the medication and later discovers that it was cortisone. The client states an intent to sue. What factors in this situation must be considered in a legal action? Select all that apply.

1/Clients have a right to refuse treatment. 2/Nurses are required to answer clients truthfully. 3/The health care provider should have been notified.

-Which aspects of the "self" do children assess while forming an evaluation of their self-esteem? Select all that apply:

1/Moral worth 2/Competence 3/ Sense of control 4/ Worthiness of love.

-A nurse assesses drainage on a surgical dressing and documents the findings. Which documentation is most informative?

A 10-mm-diameter area of drainage at 1900 hours

Which behavior is seen in children at the undifferentiated stage of spiritual development, as propounded by Fowler?

Children have no concept of right or wrong to guide their behaviors.

Which statement by the student nurse indicates an understanding about children who engage in associative play?

Children play together and are engaged in a similar activity.

What is the nurse's priority concern when caring for an infant born with exstrophy of the bladder?

Development of an infection.

What should a nurse emphasize when teaching lifelong management of type 1 diabetes to an adolescent?

Inspecting both feet frequently for signs of trauma.

A health care provider prescribes a tap water enema for a 6-month-old infant with suspected Hirschsprung disease. What rationale causes the nurse to question this prescription?

It could cause a fluid and electrolyte imbalance.

An infant who underwent open repair of a fractured sternum now has a chest tube. What should the nurse explain to the parents concerning the chest tube?

It is inserted to drain the chest cavity of air.

A health care provider prescribes a vitamin tablet that contains vitamin B complex. What should the nurse teach the client?

It may turn the urine bright yellow.

At 12 weeks' gestation a client with a history of frequent spontaneous abortions says to the nurse, "Every day I wonder whether I'll be able to have this baby." How should the nurse respond?

It's understandable for you to be worried that you won't be able to carry this pregnancy to term. You've had a difficult time."

The nurse is reassessing a newborn who had an axillary temperature of 97° F (36° C) and was placed skin to skin with the mother. The newborn's axillary temperature is still 97° F (36° C) after 1 hour of skin-to-skin contact. Which intervention should the nurse implement next?

Placing the newborn under a radiant warmer in the nursery

A nurse manager works on a unit where the nursing staff members are uncomfortable taking care of clients from cultures that are different from their own. How should the nurse manager address this situation?

Plan a workshop that offers opportunities to learn about the cultures they might encounter while at work.

What is an appropriate nursing intervention for a neonate with respiratory distress syndrome (RDS)?

Position the infant to promote respiratory efforts.

A nurse reviews a list of medications that have been prescribed for a client. The nurse is aware that it is unsafe to administer which medication as an IV bolus?

Potassium chloride

A nurse on the adolescent unit is planning to discuss smoking prevention. What is the most effective approach for the nurse to use?

Presenting information on how smoking affects appearance and odor of the breath.

A nurse weighs a neonate who is born at 29 weeks' gestation. The weight is 1619 g (3 lb 9 oz). In light of this weight and gestational age, how should this infant be classified?

Preterm

What should the nurse tell a new mother will be delayed until her newborn is 36 to 48 hours old?

Screening for phenylketonuria

An adolescent girl with a seizure disorder refuses to wear a medical alert bracelet. What should the nurse tell the girl that may help her wear the bracelet consistently?

Select a bracelet similar to bracelets worn by her peers.

The nursing instructor determines that the student nurse understands the type(s) of hepatitis that most commonly are spread by consuming contaminated food and water or by fecal contamination if the student identifies which of the following?

Select all that apply.. Hepatitis A, E.

A client is admitted to the hospital for a thyroidectomy. In which position should the nurse maintain the client after this surgery?

Semi-Fowler

The mother of a newborn with exstrophy of the bladder tells the nurse that the primary health care provider said that her child may develop an unusual gait when learning to walk. What does the nurse tell the mother is the cause of waddling gait?

Separation of the pubic bones

A nurse is caring for a child with chordee. The parents ask why corrective surgery is necessary. Before responding, the nurse considers that in adulthood, if the chordee is not surgically corrected, the child will be at increased risk for:

Sexual dysfunction.

The nurse recognizes that the mental process most sensitive to deterioration with aging is:

Short-term memory

A nurse in the pediatric clinic receives a call from the mother of an infant who has been prescribed digoxin (Lanoxin). The mother reports that she forgot whether she gave the morning dose of digoxin. How should the nurse respond?

Skip this dose and give it at the next prescribed time."

When assessing a client's fluid and electrolyte status, the nurse recalls that the regulator of extracellular osmolarity is:

Sodium

The parents of a 6-month-old infant ask the nurse about the best toy to buy for their baby. What type of toy should the nurse suggest?

Soft stuffed animals.

A client with esophageal varices is admitted with hematemesis, and two units of packed red blood cells are prescribed. The client complains of flank pain halfway through the first unit of blood. The nurse's first action is to:

Stop the transfusion

During a blood transfusion a client develops chills and a headache. What is the priority nursing action?

Stop the transfusion at once.

A primary health care provider prescribes a heart-healthy diet for a client with angina. The client's spouse says to the nurse, "I guess I'm going to have to cook two meals, one for my spouse and one for myself." Which is the most appropriate response by the nurse?

The diet prescribed for your spouse is a healthy diet. It contains guidelines that many of us should follow.

A client has a cesarean birth. The nurse monitors the newborn's respiration because infants subjected to cesarean birth are more prone to atelectasis. Why does this occur?

The ribcage is not compressed, then released during birth.

Knee-length elastic support stockings are prescribed for a client with varicose veins. What should the nurse teach the client about the elastic stockings?

The stockings should be applied before getting out of bed.

An infant who was in a motor vehicle collision has undergone open repair of a fractured sternum and now has a chest tube. What should the nurse explain to the infant's parents about the chest tube?

The tube has been placed to drain the air that entered the chest cavity during surgery."

A nurse instructs the parents of an adolescent with asthma how to reduce the allergens in the child's bedroom. The mother tells the nurse what she plans to do to make the room hypoallergenic. Which idea indicates that further teaching is needed?

Using flat outdoor carpeting to cover hardwood floors.

A child has been diagnosed with hemophilia type A after experiencing excessive bleeding from a minor trauma. The mother shares that she is four weeks pregnant and questions as to whether this pregnancy will result in a child with hemophilia. The best response is:

With each pregnancy, there is a 50% chance of a carrier transmitting the condition or being a carrier, depending on the sex of the child.

The mother of a 2-year-old girl expresses concern that her daughter's growth rate has slowed. What should the nurse explain to the mother about the growth of toddlers?

"This growth pattern is typical at this age

While a 3-month-old infant is at the well-baby clinic for a checkup, the parents express concern that their baby still has a soft spot on the top of the head. The nurse informs the parents that their infant's anterior fontanel will close around:

13 to 18 months of age.

While assessing a newborn suspected of having Down syndrome, what does the nurse expect to note?

A single line across each palm

A client who has peripheral arterial disease of the lower extremities tells the nurse, "I walk so slowly that no one wants to walk with me." What is the best response by the nurse? "

A vascular rehabilitation program may help you."

A nurse is caring for an infant with developmental dysplasia of the hip. What is the priority intervention for this child?

Abduction of the hip.

An emergency department nurse is admitting a client after an automobile collision. The health care provider estimates that the client has lost about 15% to 20% of blood volume. Which assessment finding should the nurse expect this client to exhibit?

Apical heart rate of 142 beats/min

An infant has developmental dysplasia of the hip. What clinical finding should the nurse expect to note during an assessment?

Apparent shortening of one leg.

A newborn with a myelomeningocele is being transferred immediately from the birthing room to the neonatal intensive care unit (NICU). What is the first nursing intervention?

Apply a sterile saline dressing.

A 14-month-old child is admitted to the pediatric hospital with a fractured right femur. The child is placed in Bryant traction. When the parents see the child for the first time in traction, they are surprised to see both legs in traction and ask why. What information should the nurse share about Bryant traction?

As a means of ensuring countertraction, both legs are placed in traction and the buttocks are suspended off the bed.

In the diagram, which letter identifies the patent ductus arteriosus?

B.

How can a nurse best accomplish therapeutic communication with an adolescent?

By establishing a relationship over time.

A Foley catheter was placed with an urimeter for an 85-year-old client with a history of congestive heart failure. The output is 45 mL/hour, cloudy, and has sediment. These findings indicate:

Cloudy urine may be indicative of infection.

A nurse is caring for an infant with tetralogy of Fallot. What clinical finding should the nurse expect when assessing this child?

Clubbing of the fingers.

What should the nurse include in the teaching plan for parents of an infant with phenylketonuria (PKU)?

Cognitive impairment occurs if PKU is untreated.

A child is being treated with oral ampicillin (Omnipen) for otitis media. What should be included in the discharge instructions that the nurse provides to the parents of the client?

Complete the entire course of antibiotic therapy.

A nurse who is monitoring the blood glucose level of the term infant of a diabetic mother (IDM) identifies a blood glucose level of 48 mg/dL. What should the nurse do?.

Continue to monitor the blood glucose level per policy.

A nurse is assessing a postpartum client for signs of an impending hemorrhage resulting from laceration of the cervix. Besides monitoring the client for a firm uterus, what other assessment is important?

Continuous trickling of blood

A client with an abdominal wound infected with methicillin-resistant Staphylococcus aureus (MRSA) is scheduled for a computed tomography (CT) scan of the abdomen. To ensure client and visitor safety during transport, the nurse should implement which precaution?

Cover the infected site with a dressing.

The nurse is caring for a client that is admitted with the diagnosis of mild chronic heart failure. The nurse expects to hear what lung sounds?

Crackles

A nurse's co-worker approaches the nurse to inquire about the test results of a friend that is being cared for by the nurse. How should the nurse respond?

Decline to discuss the friend's medical condition.

When performing a postoperative assessment, which parameter would alert the nurse to a common side effect of epidural anesthesia?

Decreased blood pressure

A nurse is caring for a newborn with a diaphragmatic hernia and impaired gas exchange. What does the nurse identify as the cause of the infant's decreased gas exchange?

Decreased oxygen intake.

A nurse is caring for a 9-month-old infant who has been admitted to the pediatric unit with a tentative diagnosis of meningitis. A lumbar puncture is performed. The nurse explains to the parents that the primary reason this procedure is performed is to:

Determine the causative agent.

What clinical finding does a nurse anticipate when admitting a client with an extracellular fluid volume excess?

Distended jugular veins

A nurse identifies signs of electrolyte depletion in a client with heart failure who is receiving bumetanide (Bumex) and digoxin (Lanoxin). What does the nurse determine is the cause of the depletion?

Diuretic therapy

Which nursing behavior is an intentional tort?

Divulging private information about a client's health status to the media

An adolescent girl is concerned about her body image after amputation of a leg for bone cancer. After the nurse has obtained the girl's consent, what nursing action is most therapeutic?

Encouraging her peers to visit.

The nurse develops a teaching plan for a client with diabetes who has been diagnosed with lower extremity arterial disease (LEAD). The nurse includes measures to increase arterial blood flow to the extremities, including:

Exercises that promote muscular activity

A nurse is caring for an infant with a cleft lip and palate. What information should the nurse include when teaching the parents about this diagnosis?

Expectation that these children will have no other defect and otherwise will be healthy.

The nurse is discussing discharge plans with a client who had a myocardial infarction. The client states, "I'm worried about going home." The nurse responds, "Tell me more about this." What interviewing technique did the nurse use?

Exploring

A client's intravenous (IV) infusion infiltrates. The nurse concludes that what is most likely the cause of the infiltration?

Failure to secure the catheter adequately

For which classic clinical finding should the nurse assess the stool of clients with malabsorption syndrome?

Fat globules

A nurse is caring for a 1-month-old infant who has undergone surgery to repair a cleft lip. What should the nurse use to facilitate feeding during the immediate postoperative period?

Feeding syringe.

A nurse is caring for a pregnant client with type 1 diabetes having amniocentesis. She is in the 37th week of gestation and has been experiencing signs of preeclampsia. The purpose of the amniocentesis is to determine:

Fetal lung maturity

What nursing intervention best meets a major developmental need of a newborn in the immediate postoperative period?

Giving a pacifier to the infant.

The parents of a sick infant talk with a nurse about their baby. One says, "I'm so upset; I didn't realize that our baby was ill." What major indication of illness in an infant should the nurse explain to the parent?

Grunting respirations.

A nurse is teaching Unlicensed Assistive Personnel (UAP) about ways to prevent the spread of infection. It would be appropriate for the nurse to emphasize that the cycle of the infectious process must be broken, which is accomplished primarily through:

Handwashing before and after providing client care.

A client is receiving total parenteral nutrition (TPN) through a central venous access device. The nurse discovers that the TPN bag is empty and the next bag has not been received from the pharmacy. What is the most appropriate action for the nurse to take?

Hang a bag of 10% dextrose at the ordered TPN rate and place an urgent request for the next TPN bag.

A nurse is assessing the growth and development of a 6-month-old infant. What behavior indicates that the infant has reached the expected level of development?`

Holds a bottle without help.

A client is admitted to the hospital for an elective surgical procedure. The client tells a nurse about the emotional stress of recently disclosing being a homosexual to family and friends. What is the nurse's first consideration when planning care?

Identifying personal feelings toward this client

When should the nurse begin discharge planning for a client who will be transferred to a nursing home after discharge?

Immediately upon admission

The mother of a 3-month-old infant tells the nurse that her baby has occasional bouts of diarrhea. What is the best response by the nurse

Immunological properties of the intestinal lining are immature in young infants."

A client newly diagnosed with type 1 diabetes receives information about insulin. The client states, "I hate shots. Why can't I take the insulin in pill form?" What is the nurse's best response?

Insulin is poorly absorbed and its action is erratic when taken by mouth."

A client is admitted to the emergency department with burns to the anterior trunk, entire right arm, and anterior right leg. The practitioner prescribes morphine sulfate (Duramorph) for pain. What route of administration should the nurse expect to administer this medication?

Intravenously.

A mother tells the nurse that she is concerned about her 8-month-old baby's diet because the infant will eat only mashed potatoes and drink only milk. The nurse anticipates that this diet will result in a deficiency of:

Iron.

A nurse administers an intramuscular injection of vitamin K to a newborn. What is the purpose of the injection?

It provides protection until the intestinal flora has been established.

A nurse is assessing a newborn for signs of hyperbilirubinemia (pathologic jaundice). What clinical finding confirms this complication?

Jaundice that develops in the first 12 to 24 hours

A client with a suspected dysrhythmia is to wear a Holter monitor for 24 hours at home. What should the nurse instruct the client to do?

Keep a record of the day's activities

Which action by a home care nurse would be considered an act of euthanasia?

Knowing that a dying client is overmedicating and not acting on this information.

An infant who has been found to have developmental dysplasia of the hip (DDH) is being examined in the pediatric clinic. What clinical finding does the nurse expect to identify during the physical assessment?

Limited abduction of the affected hip.

A client is diagnosed with hypertension that is related to atherosclerosis. The nurse recalls that with atherosclerosis:

Lipid plaque formation occurs within the arterial vessels

A nurse is caring for preterm infants with respiratory distress in the neonatal intensive care unit. What is the priority nursing action?

Maintaining a high-humidity environment to promote gas exchange

What is the priority of preoperative nursing care for an infant with a cleft lip?

Modifying feeding.

An 85-year-old client has a serum potassium level of 6.7 mEq/L. Which nursing action is a priority at this time?

Monitor for cardiovascular irregularities

A child with a congenital heart defect has a cardiac catheterization. What is an essential element of nursing care after this procedure?

Monitoring the extremity distal to the insertion site

A neonate born at 32 weeks' gestation and weighing 3 lb (1360 g) is admitted to the neonatal intensive care unit. The nurse should take the neonate's mother to visit the infant when the:

Mother is well enough to be taken to the intensive care unit

Refusing to follow the prescribed treatment regimen, a client plans to leave the hospital against medical advice. The nurse recognizes that it is important to inform the client that the client:

Must accept full responsibility for possible undesirable outcomes.

During a newborn assessment a nurse identifies the absence of the red reflex in the eyes. The nurse should:

Notify the primary health care provider.

After several episodes of intermittent abdominal pain and vomiting, a 5-month-old infant is admitted to the pediatric unit. A diagnosis of intussusception is made. What is the priority nursing assessment that will help confirm the diagnosis?

Observing characteristics of stools.

A client with a history of seizures is admitted with a partial occlusion of the left common carotid artery. The client has been taking phenytoin (Dilantin) for 10 years. When planning care for this client, what should the nurse do first

Obtain a history of seizure type and incidence

A nurse is caring for a client who is admitted to the hospital with a diagnosis of unstable angina. Sublingual nitroglycerin has been prescribed. What client response indicates that nitroglycerin is effective?

Pain subsides as a result of arteriole and venous dilation

A sonogram performed on a client in the third trimester demonstrates a low-lying placenta. The nurse should teach the client that she is at risk for:

Painless vaginal bleeding

A nurse is assessing an infant with a tentative diagnosis of hypertrophic pyloric stenosis (HPS). For what clinical finding associated with this disorder should the nurse assess the infant?

Palpable mass in the epigastric area to the right of the umbilicus.

A nurse caring for a client with a myocardial infarction is concerned that the client may develop left ventricular failure. For which clinical manifestation should the nurse assess the client?

Paroxysmal nocturnal dyspnea

A client develops heart failure. Which response should the nurse expect when assessing the client?

Peripheral edema

After changing a dressing that was used to cover a draining wound on a client with Vancomycin Resistant Enterococcus (VRE), the nurse should take which step to ensure proper disposal of soiled dressing?

Place the dressing in a red bag/hazardous materials bag.

What should a nurse do to decrease or control the sensory and cognitive disturbances that can occur after a client has open heart surgery?

Plan for maximum periods of rest.

A client is admitted with metabolic acidosis. The nurse considers that two body systems interact with the bicarbonate buffer system to preserve healthy body fluid pH. What two body systems should the nurse assess for compensatory changes?

Respiratory and urinary

A client sustains a crushing injury of the spinal cord above the level of origin of the phrenic nerve. As a result of this injury, the nurse expects what client response?

Respiratory paralysis and cessation of diaphragmatic contractions

A client undergoes a bowel resection. When assessing the client 4 hours postoperatively, the nurse identifies which finding as an early sign of shock?

Restlessness

A client arrives at the emergency room complaining of chest pain and dizziness. The client has a history of angina. The health care provider prescribes an electrocardiogram (ECG) and lab tests. A change in which component of the ECG tracing should the nurse recognize as the client actively having a myocardial infarction (MI)?

S-T segment

A client is admitted to the hospital with a diagnosis of a fractured hip after a fall. What clinical finding does the nurse expect to identify when assessing the client?.

Shortening of the affected extremity

A client who has been battling cancer of the ovary for seven years is admitted to the hospital in a debilitated state. The health care provider tells the client that she is too frail for surgery or further chemotherapy. When making rounds during the night, the nurse enters the client's room and finds her crying. Which is the most appropriate intervention by the nurse?

Sit down quietly next to the bed and allow her to cry.

The client is diagnosed with peripheral arterial disease (PAD) and the nurse is discussing lifestyle modifications. Which of these is the most beneficial lifestyle modification the nurse should teach this client?

Stop smoking

A nurse is caring for a preterm infant who is receiving oxygen therapy. What should the nurse do in an attempt to prevent retinopathy of prematurity (ROP)?

Support the neonate's saturation while providing minimal FiO2.

The mother of an infant with hypertrophic pyloric stenosis (HPS) asks the nurse many questions about the problem. What information should the nurse convey when answering these questions?

Surgery is usually necessary.

The nurse has taken a client's blood pressure twice, 10 minutes apart, in the same arm while the client is seated. The nurse records the two blood pressures of 172/104 and 164/98. What is the appropriate nursing action in response to these readings?

Take the client's blood pressure in the other arm and then schedule a health care practitioner's appointment for as soon as possible.

Which principle should the nurse consider when assisting a client with crutches to learn the four-point gait?

The client must be able to bear weight on both legs.

The parents of an infant with tetralogy of Fallot ask a nurse about the problems involved with this disorder. When answering, what must the nurse consider?

The disorder consists of right ventricular hypertrophy, ventricular septal defect, pulmonic stenosis, and overriding aorta.

The parents of an infant who just underwent insertion of a ventriculoperitoneal shunt for hydrocephalus are concerned about the prognosis. What information should the nurse give the parents?

The shunt may need to be replaced as the child grows older.

A nurse is preparing for a teaching session with the parents of an infant with phenylketonuria (PKU). The parents are upset and want an explanation of why the child has this disease that they have never heard of. What should the nurse consider before responding?

This autosomal recessive disorder was inherited from parents who are carriers.

A client who had several episodes of chest pain is scheduled for an exercise electrocardiogram. Which explanation should the nurse include when teaching the client about this procedure?

This is a noninvasive test to check your heart's response to physical activity."

The nurse anticipates that a child born with a missing chromosome is most likely to have:

Turner syndrome.

A client has corrective surgery for a bladder laceration. What nursing intervention takes priority during this client's postoperative period?

Turning frequently

A nurse is assessing growth and development in a 6-month-old infant. What behaviors does the nurse expect the infant to demonstrate?

Turning over completely, sitting momentarily without support, and reaching to be picked up.

A client develops severe bone marrow suppression related to cancer treatment. What is important for the nurse to include in the client's teaching?

Use a soft toothbrush for oral hygiene.

A client is admitted to the hospital for a total hip replacement. Included in the health care provider's prescriptions is a prescription for digoxin (Lanoxin) 2.5 mg by mouth daily. The nurse knows that digoxin is supplied in 0.125 mg tablets. What should the nurse do?

Verify the prescription with the health care provider.

The primary health care provider instructs the nurse to administer a high dose of acyclovir (Zovirax) 60 mg/kg/day to a neonate with a body weight of 4.4 lbs. What dose does the nurse administer to the neonate each day? Record your answer in milligrams using a whole number. _______ mg:

120.

The nurse is preparing to administer a subcutaneous dose of 15 units of lispro insulin (Humalog) to a client. Choose the proper syringe for this injection.

15 unit 100 unit syringe

A client is to receive an intravenous (IV) antibiotic in 50 mL of 0.9% sodium chloride to be administered over 20 minutes. At what rate should the nurse set the infusion pump? Record your answer using a whole number. ___ mL/hr

150.

A nurse has just administered an immunization injection to a 2-month-old infant. What instructions should the nurse give the parent if the infant has a reaction?

Give acetaminophen for fever; call the health care provider if the child exhibits marked drowsiness or seizures.

Several individuals who sustained urgent but nonemergent injuries are seated in the emergency department when an ambulance arrives with a client suspected of having a myocardial infarction. The nurse must explain to the waiting clients that they will have to wait longer for care. Which is the best explanation for the nurse to give?

I know you have been waiting, but a client's life depends on immediate treatment. You will receive the same attention when you are seen."

-A 12-month-old infant has become immunosuppressed during a course of chemotherapy. What information regarding the measles, mumps, and rubella (MMR) vaccine should the nurse, preparing for the infant's discharge, give the parents

Infants who are receiving chemotherapy should not be given these vaccines.

A client with a diagnosis of uncontrolled diabetes began receiving Lasix (Furosemide) two days ago. The nurse reviews the morning lab results and discovers that the client's potassium level is 2.8 mEq/L. What is the most appropriate action for the nurse to take?

Notify the primary healthcare provider of the result that is critically low.

A nurse plans an evening snack of milk, crackers, and cheese for a client who is receiving NPH insulin (Novolin N). What does this snack provide?

Nourishment to counteract late insulin activity

A mother reports feeding her infant immediately before arriving in the emergency department. After completing the assessment, the nurse reports which finding immediately to the health care provider because it likely indicates pyloric stenosis?

Peristaltic waves that traverse the epigastrium.

A nurse in the emergency department is assessing a 10-month-old infant who was injured in an automobile collision. The infant, who is quiet but does not appear lethargic, has a large hematoma on the left temporal area. What sign of neurological involvement is the most critical to identify?

Persistent vomiting.

A client receives a prescription for morphine via patient-controlled analgesia (PCA). Before beginning administration of this medication, what should the nurse assess first?

Respirations,

When two nurses are getting an older adult out of bed, the client reports feeling light headed. The nurse identifies that the client's pulse is stable and the client's color has not changed. What should the nurses assist the client to do?

Sit on the edge of the bed while they hold the client upright.

Supplemental oxygen is ordered for a preterm neonate with respiratory distress syndrome (RDS). What action does the nurse take to reduce the possibility of retinopathy of prematurity?

Verifying oxygen saturation frequently to adjust flow on the basis of need

A nurse reviews the prescribed treatment with the parents of an infant born with bilateral clubfeet. Which parental statement indicates to the nurse that further education is required?.

We'll have to have the baby fitted with prosthetic devices before he'll be able to walk."

An adolescent child is in the terminal stage of cancer. The parents ask how they will know when death is imminent. The nurse discusses the physical manifestations with the parents. What are the signs and symptoms of approaching death? Select all that apply.

Weak pulse/Difficulty swallowing/ Loss of bladder control.

A client is fitted for and receives a prosthesis after an above-the-knee amputation. A week later the client states, "I feel so much better." What is the reason why most clients report an improved self-image after using a prosthesis?

eir improved functional abilities

A nurse plans to set up emergency equipment at the bedside of a client in the immediate postoperative period after a thyroidectomy. What should the nurse include in the bedside setup?

Tracheostomy set and oxygen

A 9-month-old infant who appears well nourished, alert, and happy is brought to the well-baby clinic for a routine physical examination. Using Erikson's theory of development, the nurse determines that the infant is in the process of achieving the task of:

Trust.

A nurse is planning to provide self-care health information to several clients. Which client should the nurse anticipate will be most motivated to learn?

A 56-year-old male who had a heart attack last week and is requesting information about exercise

A male client receiving hemodialysis undergoes surgery to create an arteriovenous fistula. Before discharge, the nurse discusses care at home with the client and his wife. Which statement by the client's wife indicates that further teaching is required?

"I have to take his blood pressure every day in the arm with the fistula."

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

"I should obtain a pneumococcal vaccination each year."

The nurse provides nutritional counseling to the parents of a 6-month-old formula-fed infant who will begin eating solid foods. Which statement by a parent indicates understanding of the nurse's advice?

"I'll keep giving him formula instead of regular cow's milk.

Neomycin, 1 gram, is prescribed preoperatively for a client with cancer of the colon. The client asks why this is necessary. How should the nurse respond?

"It will kill the bacteria in your bowel and decrease the risk for infection after surgery."

A client is scheduled for a transurethral resection of the prostate (TURP). Which statement made by the client most indicates the need for further preoperative teaching?

"My incision will probably be painful."

A physician orders heparin 6,000 units subcutaneously daily. The pharmacy dispenses a vial containing 10,000 units per milliliter. To ensure the patient's safety, how many milliliters of heparin should the nurse administer? Include a leading zero if applicable. Record your answer using one decimal place.

0.6

The health care provider prescribes 375 mg of intravenous ampicillin IV every 6 hours for a 5-month-old with a recurrent respiratory infection. The drug is supplied as 500 mg of powder in a vial. The directions state that the powder should be mixed with 1.8 mL of diluent, which yields 250 mg/mL. How many milliliters should the nurse administer? Take your answer to one decimal place. ___ mL:

1.5

A nurse is obtaining a health history from the newly admitted client who has chronic pain in the knee. What should the nurse include in the pain assessment? Select all that apply.

1/Pain history, including location, intensity, and quality of pain 2/Pain pattern, including precipitating and alleviating factors

An infant is to receive an intravenous antibiotic as a piggyback. The prescription is 10 mg/kg body weight/24 hr, to be administered in equal doses every 12 hours. The infant weighs 22 lb. How many milligrams of the antibiotic should the infant receive per dose? Record your answer using a whole number. ___ mg

50.

The nurse has initiated an intravenous antibiotic on a client with hyperpyrexia and diminished urine output. The nurse concludes that the probable cause of the diminished urine output is:

A compensatory response to fever

The nurse is caring for a group of postpartum clients. Which one should the nurse monitor most closely?

A grand multipara who just had her sixth child.

Which prescribed medication should the nurse expect to administer to a female client who exhibits the genital lesions presented in the illustration at

Acyclovir sodium (Zovirax)

A client's cardiac monitor indicates multiple premature ventricular complexes (PVCs). The nurse expects that the treatment plan will include a prescription for which medication?.

Amiodarone (Cordarone)

Elbow restraints have been prescribed for a confused client to keep the client from pulling out a nasogastric tube and indwelling urinary retention catheter. What is most important for the nurse to do?

Assess the client's condition every hour.

A health care provider prescribes epoetin (Epogen) subcutaneously three times a week for an older adult with chronic lymphocytic leukemia (CLL) who lives alone. The nurse plans to teach the client about the medication. What should the nurse do first?

Assess the client's readiness to learn.

A nurse anticipates that a hospitalized client will be transferred to a nursing home. When should the nurse begin preparing the client for the transfer?

At the time of admission

A nurse is caring for a postoperative client that has a nasogastric tube set to low intermittent suction. The nurse recalls that the primary reason that an IV of 5% dextrose with 0.45% sodium chloride and 20 mEq of potassium has been prescribed is to prevent:

Electrolyte imbalance

Heart failure develops in a 4-month-old infant with a congenital heart defect, and the infant exhibits marked dyspnea at rest. The nurse should immediately assess the infant for:

Bilateral crackles.

A client returns from a cardiac catheterization procedure and is to remain in the supine position for four hours with the affected leg straight. The nurse explains that these measures are to prevent:.

Bleeding at the arterial puncture site

Which nutrient-related problem is common to a newborn infant, a client after a cholecystectomy, and a client receiving anticoagulant therapy after a myocardial infarction?

Blood-clotting function of vitamin K

A nurse addresses the needs of a client who is hyperventilating to prevent what complication?

Carbonic acid deficit

A nurse administers a parenteral preparation of potassium slowly and cautiously to avoid which complication?

Cardiac arrest

A nurse understands that after the administration of alprazolam (Xanax) it is important to assess the client for side effects. Initially the nurse should:.

Check the blood pressure.

A client had an open reduction and internal fixation of the head of the femur. In the postanesthesia care unit the client's vital signs remained stable for one hour, with a blood pressure (BP) 130/78 mm Hg, pulse (P) 68, and respiration (R) 16. One hour after returning to the postsurgical unit, the client's vital signs are BP 100/60 mm Hg, P 74, and R 22, and the client is restless. What should the nurse do first?

Check the dressing on the incision

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

Demonstrate correct use of the insulin pump."

A client who is receiving multiple medications for a myocardial infarction complains of severe nausea, and the client's heartbeat is irregular and slow. The nurse determines that these signs and symptoms are toxic effects of:

Digoxin (Lanoxin)

The nurse is preparing discharge instructions for a client who was prescribed enalapril maleate (Vasotec) for treatment of hypertension. Which is appropriate for the nurse to include in the client's teaching?

Do not change positions suddenly

A client is admitted to the hospital with a tentative diagnosis of infectious pulmonary tuberculosis. What infection control measures should the nurse take?

Don an N95 respirator mask before entering the room.

A client has a history of hypothyroidism. Which skin condition should the nurse expect when performing a physical assessment?.

Dry

What effect of povidone-iodine (Betadine) does a nurse consider when using it on the client's skin before obtaining a specimen for a blood culture?

Eliminates surface bacteria that may contaminate the culture

To prevent thrombophlebitis in the immediate postoperative period, which action is most important for a nurse to include in the client's plan of care?

Encourage early mobility.

A client becomes anxious after being scheduled for a colostomy. What is the most effective way for the nurse to help the client?

Encourage the client to express feelings

A nurse who is observing a sleeping newborn identifies periods of irregular breathing and occasional twitching movements of the arms and legs. The neonate's heart rate is 150 beats/min; the respiratory rate is 50 breaths/min; and the glucose strip reading is 60 mg/dL. The nurse concludes that these findings are indicative of:

Expected adaptations

While changing her baby girl's diaper, a client expresses concern about a small spot of red vaginal discharge on the diaper. How should the nurse respond to this concern?

Explaining that this is an expected finding.

What should the nurse include in the plan of care for a newborn with hypospadias before corrective surgery is performed?

Explaining to the parents why a circumcision is not done.

A client is admitted to the emergency department with a contaminated wound. The client is a poor historian, and the nurse realizes that it is impossible to determine whether the client is immunized against tetanus. Because it will produce passive immunity for several weeks with minimal danger of an allergic reaction, the nurse expects that what medication will be prescribed?

Human tetanus antitoxin

A neonate born at 39 weeks' gestation is small for gestational age. What commonly occurring problem should the nurse anticipate when planning care for this infant?

Hypoglycemia

The client receives a prescription for tap water enemas until clear. The nurse is aware that no more than two enemas should be given at one time to prevent the occurrence of:

Hypokalemia

A client has been admitted with a diagnosis of intractable vomiting and can only tolerate sips of water. The initial blood work shows a sodium level of 122 mEq/L and a potassium level of 3.6 mEq/L. Based on the lab results and symptoms, what is the client experiencing?

Hyponatremia

The nurse provides discharge teaching to a client who has received prescriptions for digoxin (Lanoxin), furosemide (Lasix), and a 2-gram sodium diet. The nurse evaluates that further teaching is needed when the client states:

I can use a little table salt on my food as long as I do not use it when cooking."

A nurse teaches an adolescent undergoing chemotherapy for cancer about the need for special mouth care because of the potential for oral lesions. What statement indicates to the nurse that the instructions have been understood?

I can use foam-tipped applicators to wipe my teeth and gums.

A nurse is developing a teaching plan for a client with a history of a myocardial infarction (MI). The client requests information on how to prevent a future MI. The nurse determines that additional teaching or clarification is needed when the client states,

I will: Restrict my physical activity."

The practitioner diagnoses placenta previa. What does this indicate to the nurse about the condition of the placenta?

Low-lying

A 1-month-old infant with hydrocephalus is scheduled to have surgery for the insertion of a ventriculoperitoneal shunt. What is the primary focus of nursing interventions for this infant?

Maintaining a satisfactory comfort level to limit crying.

What is the priority nursing action in the care of a young child with severe diarrhea?

Maintaining fluid and electrolyte balance.

A nurse confirms that a 9-month-old infant's immunization schedule is up to date. Which immunization will the infant receive at 15 months of age?

Measles, mumps, and rubella (MMR).

A nurse who is caring for a 2-day-old neonate suspects that the infant has cystic fibrosis. What early sign of this disorder did the nurse identify?

Meconium ileus.

A pain scale of 1 to 10 is used by a nurse to assess a client's degree of pain. The client rates the pain as an 8 before receiving an analgesic and a 7 after being medicated. What conclusion should the nurse make regarding the client's response to pain medication?

Medication is not adequately effective.

A client with arthritis increases the dose of ibuprofen (Motrin, Advil) to abate joint discomfort. After several weeks the client becomes increasingly weak. The client is admitted to the hospital and is diagnosed with severe anemia. What clinical indicators does the nurse expect to identify when performing an admission assessment? Select all that apply.

Melena Tachycardia

A client with a cardiac dysrhythmia is receiving digoxin (Lanoxin) and verapamil (Calan). Because of the combined effect of these two medications, the nurse assesses the client for:

Myocardial depression

A client with angina pectoris is scheduled for a stress echocardiogram. The nurse explains that the echocardiogram is a:

Noninvasive approach to assess cardiovascular status

A client who had surgery 24 hours ago reports pain in the calf. Assessment reveals redness and swelling at the site of discomfort. What should the nurse do?

Notify the health care provider.

A client who has a hemoglobin of 6 gm/dL is refusing blood because of religious reasons. What is the most appropriate action by the nurse?

Notify the primary health care provider of the client's refusal of blood products.

A nurse plans to discuss childhood nutrition with a group of parents whose children have Down syndrome in an attempt to minimize a common nutritional problem. What problem should be addressed?

Obesity.

An adolescent who was admitted to the hospital with ketoacidosis is stable and receiving Novolin R subcutaneously. One hour after its administration the nurse enters the room and notes that the adolescent is diaphoretic and irritable. What is the nurse's priority intervention?

Obtaining a blood glucose reading.

A dehydrated 2-month-old infant with a history of diarrhea is admitted to the pediatric unit. Oral rehydration therapy is instituted. What is the most accurate method of monitoring the infant's hydration status

Obtaining daily weights.

An expectant couple asks the nurse about the cause of low back pain in labor. The nurse replies that this pain occurs most often when the position of the fetus is:

Occiput posterior

The left foot of a client with a history of intermittent claudication becomes increasingly cyanotic and numb. Gangrene of the left foot is diagnosed, and because of the high level of arterial insufficiency, an above-the-knee amputation (AKA) is scheduled. The response that demonstrates emotional readiness for the surgery is when the client:

Participates in learning perioperative care

A client who has a history of several myocardial infarctions is admitted to the hospital for an unrelated medical condition. Because of the client's history, the nurse is concerned about the possibility of the client experiencing right ventricular failure. For what early common indication of right ventricular failure should the nurse monitor the client?

Peripheral edema

A nurse performs an assessment of a 3-day-old infant. What finding should the nurse report to the health care provider?

Petechiae covering the chest

A complete blood count is ordered for a 5-month-old infant with tetralogy of Fallot. What does the nurse expect to see when reviewing the laboratory results?

Polycythemia.

A client diagnosed with multiple myeloma has been given a poor prognosis. After discharge, the client plans to travel on an airplane and attend sporting events with friends and family. The nurse prepares a discharge teaching plan for this client and includes:

Preventing infection; the client is at risk for leukopenia

An infant is found to have hydrocephalus. Which assessment finding alerts the nurse to suspect increasing intracranial pressure?

Projectile vomiting.

A preterm newborn in the neonatal intensive care unit experiences periods of apnea, and apnea monitoring is instituted. What is the nurse's initial action if the apnea alarm sounds?

Provide tactile stimulation.

The nurse is reviewing the plan of care to prevent contractures of the joints of the lower extremities in a client with paraplegia. The nurse should question which item that is listed on the plan?

Provide the client with active lower extremity exercise instructions.

A client at 36 weeks' gestation is admitted to the high-risk unit because she gained 5 lb in the previous week and there is a pronounced increase in blood pressure. What is the initial intervention in the client's plan of care?

Providing a dark, quiet room with minimal stimuli

A toddler wearing a diaper is impatient with the wet diaper and shows a desire to have it changed. Which toilet training readiness does this behavior indicate?

Psychological readiness.

After surgery for repair of a myelomeningocele, the nurse places the infant in a side-lying position with the head slightly elevated. The main reason the nurse places the infant in this position after this particular surgery is that it:

Reduces intracranial pressure.

A client is admitted to the coronary care unit complaining of "viselike" chest pain radiating to the neck. Assessment reveals a blood pressure of 124/64, an irregular apical pulse of 64 beats per minute, and diaphoresis. Cardiac monitoring is instituted and morphine sulfate 4 mg intravenous (IV) push stat is prescribed. The priority nursing care for this client is directed toward:

Relief of pain

A nurse who is caring for a client experiencing anginal pain expects that the pain will be:

Relieved by sublingual nitroglycerin

A client with a fractured tibia and fibula is to be discharged from the emergency department with a right leg cast and crutches. In addition to the technical aspects of crutch walking, the nurse should teach the client to

Remove loose rugs from the environment.

The nurse is caring for a client newly diagnosed with diabetes. When preparing the teaching plan about the importance of yearly eye examinations, the nurse should plan to instruct the client on which eye problem most associated with diabetes?,

Retinopathy

Before administering a nasogastric feeding to a preterm infant the nurse aspirates a small amount of residual fluid from the stomach. What is the nurse's next action?

Returning the aspirate and subtracting the amount of the aspirate from the feeding.

The parents of an infant with tetralogy of Fallot ask the nurse to explain what is wrong with their baby's heart. Before explaining the problem in a way that they will understand, the nurse remembers that tetralogy of Fallot includes:

Right ventricular hypertrophy, ventricular septal defect, pulmonic stenosis, and overriding of the aorta

A client is admitted to the hospital with complaints of frequent loose, watery stools, anorexia, malaise, and weight loss during the past week. Laboratory findings indicate leukocytosis and an elevated sedimentation rate. The nurse concludes that the probable cause of the client's presenting adaptations is:

Systemic responses of the body to a localized inflammatory process

Which statement by the unlicensed assistive personnel (UAP) indicates a correct understanding of the UAP's role? "I will:

Take clients' vital signs after their procedures are over."

A client's serum potassium level has increased to 5.8 mEq/L. What action should the nurse implement first?

Take vital signs and notify the health care provider.

Which task is most appropriate for a nurse to delegate to unlicensed assistive personnel?

Taking the blood pressure of a client before physical therapy

A 17-year-old mother is to sign the consent for her son's myringotomy. What should the nurse say to the mother about this procedure?

Tell me what you know about this procedure.

A client is hospitalized because of severe depression. The client refuses to eat, stays in bed most of the time, does not talk with family members, and will not leave the room. The nurse attempts to initiate a conversation by asking questions but receives no answers. Finally the nurse tells the client that if there is no response, the nurse will leave and the client will remain alone. How should the nurse's behavior be interpreted?

This threat is considered assault, and the nurse should not have reacted in this manner

A nurse notes that a healthy newborn is lying in the supine position with the head turned to the side with the legs and arms extended on the same side and flexed on the opposite side. Which reflex does the nurse identify?

Tonic neck

The nurse performs a respiratory assessment and auscultates breath sounds that are high-pitched, creaking, and accentuated on expiration. Which term best describes the findings?

Wheezes

A woman who is admitted to the labor suite has herpes simplex virus type 2 (HSV-2) with active lesions in the perineal area. What should the nurse's plan of care include?

Withholding oral fluid intake

A client has a right above-the-knee amputation after trauma sustained in a work-related accident. Upon awakening from surgery, the client states, "What happened to me? I don't remember a thing." What is the nurse's best response?

You were in a work-related accident this morning."

An adolescent child with a seizure disorder is to be discharged with a prescription for phenytoin (Dilantin) 140 mg/day, to be divided into two doses. The hospital pharmacy prepares an oral suspension in a concentration of 125 mg/5 mL. What amount of solution should the nurse teach the parents to give for each dose? Record your answer to one decimal place. ___

mL 2.8.

A client is receiving patient-controlled analgesia (PCA) after surgery. The nurse determines that with this type of therapy the:

Client is able to self-administer pain-relieving drugs as necessary

During a blood transfusion a client develops chills and a headache. What should be the nurse's first response?

Stop the transfusion

A client is receiving a unit of packed red blood cells (PRBC). The client experiences tingling in the fingers and headache. What is the nurse's priority action?

Stop the transfusion.

The health care provider prescribes a progressive exercise program that includes walking for a client with a history of diminished arterial perfusion to the lower extremities. The nurse explains to the client that if leg cramps occur while walking, the client should:

Stop to rest until the pain resolves

A complete blood count (CBC), urinalysis, and x-ray examination of the chest are prescribed for a client before surgery. The client asks why these tests are done. Which is the best reply by the nurse?

"They are done to identify other health risks."

A 14-year-old teenager with type 1 diabetes wants to go out to eat with friends after a volleyball game. The teenager asks the school nurse whether this is permissible on the insulin/diet/exercise regimen that has prescribed. How should the nurse respond?

'll teach you how to determine the amount of carbohydrates in different fast foods.

A client is scheduled to receive an IV infusion of potassium chloride (KCl) 40 mEq in 100 mL of 5% dextrose and water to be infused over 2 hours. Before administering this IV medication, it is a priority for the nurse to assess which of the following? (Select all that apply.)

1/Urinary output 2/Last serum potassium level 3/Patency of the intravenous access

*An intravenous infusion of 30 mg of an antibiotic in 50 mL of D5W every 6 hours is prescribed for an adolescent. It is to run over 30 minutes. At what hourly rate should the nurse set the infusion device? Record your answer as a whole number. ___ mL/hr:

100

A nurse is teaching a mother about the immunization schedule for her baby. Between which months of age should the measles vaccine be given?

12 and 15.

A client presents with a severe stiff neck, shuffling gate, and other extrapyramidal symptoms. Benztropine 2.5 mg by mouth is prescribed. The medication is available in 1 mg scored tablets. How many tablets should the nurse administer? Record the numeric answer, using one decimal place. _____ tablet(s)

2.5

At the start of the nursing shift, there were 200 mL in a client's intravenous (IV) bag. The nurse took the bag down when there were 50 mL still in the bag and hung a new 1000 mL IV bag. The client received two intravenous piggybacks (IVPBs) during the shift; each contained 100 mL. When calculating the intake and output at the end of the shift, the nurse looks at the IV bag. Refer to the illustration. How many mL of IV fluid did the client receive during the shift? Record the answer as a whole number. ___ mL

950

A 13-year-old female adolescent comes to the pediatric clinic, and her body mass index (BMI) is found to be 21. Compare the adolescent's BMI to the body mass index-for-age percentiles for girls ages 2 to 20 years and determine what percentile this adolescent falls under. Record your answer using a whole number:

: 75

The health care provider prescribes nitroglycerin ointment to be applied topically every eight hours for a client who was admitted for chest pain and a myocardial infarction (MI). Which statement, if made by the client, would indicate understanding of the side effects of nitroglycerin ointment? "I may experience:

A headache."

A hospitalized client experiences a fall after climbing over the bed's side rails. Upon reviewing the client's medical record, the nurse discovers that restraints had been prescribed but were not in place at the time of the fall. What information should the nurse include in the follow-up incident report?

A listing of facts related to the incident as witnessed by the nurse.

A client has been diagnosed with type 1 diabetes mellitus. When providing instructions on sharps disposal, the nurse should instruct the client to place the syringes in:

A plastic liquid detergent bottle with a screw-top lid

An electrocardiogram (ECG) is performed before a client is to have a cardiac catheterization, and hypokalemia is suspected. To confirm the presence of hypokalemia, the nurse expects the primary health care provider to prescribe:

A serum electrolyte level

An adolescent boy comes to the school nurse complaining of a 2-day history of low-grade fever, exhaustion, and lack of energy and appetite. He has been tardy to school twice in the past week. Which assessment should the nurse use to identify the possible origin of the problem?

Checking for lymphadenopathy.

A 3-week-old infant has surgery for esophageal atresia. What is the immediate postoperative nursing care priority for this infant?

Checking the patency of the nasogastric tube.

A client's cardiac monitor indicates ventricular tachycardia. The nurse assesses the client and identifies an increase in apical pulse rate from 100 to 150 beats per minute. An appropriate treatment plan includes:

Amiodarone bolus.

A nurse counsels the parents of an 8-month-old infant to remove small objects from the floor when their child is crawling on it. What is the best rationale for this instruction?

An 8-month-old infant can pick up small objects easily.

An infant with hypertrophic pyloric stenosis is admitted to the pediatric unit. What does the nurse expect to find when palpating the infant's abdomen?

An olive-sized mass in the right upper quadrant.

A client being treated for hypertension reports having a persistent hacking cough. What class of antihypertensive should the nurse identify as a possible cause of this response when reviewing a list of this client's medications?

Angiotensin-converting enzyme (ACE) inhibitors

An infant with a cleft lip is fed with a special nipple. What should the nurse teach the parents about feeding their infant to minimize regurgitation?

Burp frequently during a feeding.

An infant with talipes equinovarus has a plaster cast applied to the involved foot. How should the nurse move the infant while the cast is wet?

By handling the cast with just the palms.

A nurse is caring for an infant with hydrocephalus after the insertion of a shunt. How should the nurse evaluate the effectiveness of the shunt?

By palpating the anterior fontanel.

At the age of 3 weeks an infant undergoes surgery to repair a cleft lip. Postoperative nursing care should include:

Cleansing the suture line to prevent infection.

On reporting to the labor and delivery area a primipara indicates to the nurse that her contractions are occurring every 5 minutes. Upon further inquiry the nurse learns that the client has not attended any childbirth classes, and a cervical assessment reveals that she is in labor. When is the best time for the nurse to include education on simple breathing and relaxation techniques?

During the latent phase of the first stage of labor

For which common complication of myocardial infarction (MI) should the nurse monitor the client that has been admitted to the coronary care unit for two days?

Dysrhythmia

The nurse administers 2 units of salt-poor albumin to a client with portal hypertension and ascites. The nurse explains to the client that the purpose of the albumin is to:

Elevate the circulating blood volume.

A client takes isosorbide dinitrate (Isordil) daily. The client states, "I would like to start taking sildenafil (Viagra) for erectile dysfunction. I was told I can't take sildenafil and isosorbide dinitrate at the same time." The nurse explains that taking both of these medications concurrently may result in severe:

Hypotension

A client just had a total hip replacement and is experiencing restlessness and changes in mentation. Which complication does the nurse consider the client may be experiencing based on these responses?

Hypovolemic shock

Which medication is prescribed to an infant with congenital syphilis?

IV penicillin (Pfizerpen).

A client is admitted with a higher than expected red blood cell (RBC) count. What physiological alteration does the nurse expect will result from this clinical finding?

Increased blood viscosity

A nurse is caring for a client with a diagnosis of polycythemia vera. The client asks, "Why do I have an increased tendency to develop blood clots?" Which effect of the polycythemia vera should the nurse explain increases the risk of these thromboses?

Increased blood viscosity

An infant is admitted to the intensive care unit with multiple injuries. When the adolescent mother sees her infant for the first time, she cries out, "I didn't mean to hurt her!" What should the nurse do first?

Offer support by saying, "This must be difficult for you."

A nurse provides crutch-walking instructions to a client that has a left-leg cast. The nurse should explain that weight must be placed:

On the hands

A 4-day-old infant is admitted to the pediatric unit with a cleft lip and palate. Surgery to repair the lip is scheduled for later in the week. Which assessment finding requires notification of the surgeon and will probably result in cancellation of the surgery?

Oral candidiasis.

A 2-month-old girl is admitted to the pediatric unit in heart failure. The practitioner prescribes nothing-by-mouth status and the semi-Fowler position. How should the nurse obtain the infant's weight?

Placing the infant in an infant seat, recording the weight, and then subtracting the weight of the seat.