HESI practice ?s (III) AH III

A male client who is admitted with a bleeding peptic ulcer develops sudden, severe upper abdominal pain. The client becomes diaphoretic and draws his knees over his abdomen. Which finding should the nurse report to the healthcare provider? Rapid, deep respirations. A rigid, boardlike abdomen. Vomiting of undigested food. Bowel sounds increased in frequency and pitch.

A rigid, boardlike abdomen. Rationale Perforation of a peptic ulcer leaks gastric secretions and blood into the abdominal cavity, which causes peritonitis and is manifested by a rigid, board-like abdomen. Shallow, grunting respirations are common behaviors consistent with severe abdominal pain related to perforation. The client with gastrointestinal bleeding is usually NPO. Bowel sounds diminish or become absent.

Which family-centered care concept(s) should the nurse encourage family members to use to promote child growth, development, and independence? Tough love. Therapeutic care. Enabling and empowerment. Teaching and care provision.

Enabling and empowerment. Rationale Family-centered care includes enabling and empowering the child with opportunities that build on identified strengths, enhance self-efficacy, and promote growth within the collaborative family unit.

The nurse is suctioning the tracheostomy for a child who is experiencing rhonchi and unable to expel mucus. Which action should the nurse implement to provide effective pulmonary toileting? Encourage child to cough to raise the secretions before suctioning. Allow child to rest after every five times the suction catheter is passed. Each pass of the suction catheter should take no longer than five seconds. Select a catheter 3/4 the size of the diameter of the tracheostomy tube.

Each pass of the suction catheter should take no longer than five seconds. Rationale To ensure the child's O2 saturation returns to normal, suctioning of the tracheostomy should last no more than five seconds per aspiration and rest periods provided after each aspiration.

Which therapeutic response should the nurse identify that best evaluates the use of reminiscence strategies with an older adult? Improve mood towards a more positive affect. Reduce the client's anxiety. Stimulate memory chains through associations. Broaden the client's judgment and general knowledge.

stimulate memory chains through associations. Rationale Reminiscence strategies stimulate memory chains by attempting to recall patterns of association that improve the client's memory. Reminiscence strategies primarily stimulate memory retrieval and recall

The nurse is explaining dietary management to a client with pregestational diabetes during a prenatal visit. Which client statement indicates that the teaching has been effective? "Diet and insulin needs will change significantly throughout my pregnancy." "Dietary selections should be based on my urine glucose testing results." "I should eat an additional 600 calories/day throughout my pregnancy." "I can continue the same well-balanced diet as I did before pregnancy"

"Diet and insulin needs will change significantly throughout my pregnancy." Rationale Diet and insulin requirements change significantly throughout pregnancy and are directly related to hormonal changes, energy needs, and fetal growth, especially in the third trimester. The client's statement about an increase in these needs reflects the client's understanding. Dietary management during diabetic pregnancy should be based on blood, not urine glucose results. Energy needs are calculated on the basis of 30 to 35 calories per kilogram of ideal body weight. Although prepregnancy weight and dietary habits effect a client's overall health, a gravid client with diabetes should expect individualized changes in nutrition and insulin that meet increased fetal and metabolic requirements.

An older client who is admitted with terminal cancer of the liver begins to talk with the nurse about spiritual life after death. Which response by the nurse best assesses the client's spiritual needs? "What do you believe happens to your spirit when you die?" "Has your terminal condition made you lose your faith or beliefs?" "Members of your church are allowed to visit you whenever you desire." "I notice you have a Bible. Is that a source of spiritual strength for you?"

"I notice you have a Bible. Is that a source of spiritual strength for you?" Rationale Assessing a client's source of strength and faith can direct interaction and treatment plans, so making an observation about the client's Bible identifies the client's spiritual basis and opens communication regarding the client's source of strength. Questioning the client's beliefs does not provide information that assists in meeting the client's spiritual needs.

Which entry in the client's medical record provides the best documentation of client care? 1230 - Client's vital signs taken. 0700 - Client drank adequate amount of fluids. 0900 - Meperidine (Demerol) given for lower abdominal pain. 0830 - IV fluid rate increased to 100 ml/hour according to protocol.

0830 - IV fluid rate increased to 100 ml/hour according to protocol. Rationale A recorded entry in the medical record should include client-centered interventions that include thorough, yet succinct, specific information. provides the most specific data and includes time, action, and rationale for implementation.

The nurse is instructing a client about the use of podofilox (Condylox) for the treatment of genital warts. Which information should the nurse provide? "Genital warts are not contagious during treatment." "Use your fingers to spread the drug on the affected areas." "Take this drug with meals to prevent gastrointestinal upset." "Redness, peeling, and itching may occur at the site of application."

"Redness, peeling, and itching may occur at the site of application." Rationale The client should be informed that Podofilox may cause redness, peeling, itching, or swelling at the site of application. Genital warts are highly contagious and gloves should be worn during application to avoid spreading to unaffected tissues or to the eyes. Podofilox is applied topically in the treatment of genital warts.

When conducting an assessment interview with a new client, which question should the nurse use to elicit the most information? "Where is your family?" "Do you have a family?" "Tell me about your family." "Would you like to talk about your family?"

"Tell me about your family." Rationale Open-ended questions require the client to disclose information beyond "yes, no" or short answers and typically stimulate the client into discussion that reveals details. "Tell me about your family" is an open-ended statement that invites a broader response in whatever direction the client chooses.

The nurse places a heating pad on the lower leg of a client with peripheral vascular disease (PVD). When the heating pad is removed, the client's skin is blistered and a full-thickness burn is evident. What consequence can occur based on the nurse's action? All elements are present to find the nurse liable for damages. The injury was not foreseeable therefore the nurse is not liable. Client harm occurred which is enough evidence to prove liability. The standard of care was not breached so the nurse is not liable.

All elements are present to find the nurse liable for damages. Rationale The nurse has a duty to deliver safe care. If that duty is breached, the injury foreseeable, and the client suffers harm, then the elements for establishing liability are present. In caring for a client with PVD, the nurse should anticipate that heat injury is possible and provide the standard of care to prevent harm. Client harm represents only one element and should not be the lone criteria for determining liability.

A client with advanced cirrhosis and hepatic encephalopathy is manifesting mounting ascites and 4+ pitting edema of the feet and legs. The nurse identifies fluid leaking from his skin when he is turned. Which intervention is most important for the nurse to include in the client's plan of care? Turn the client every 4 hours. Restrict dietary protein intake. Perform passive range of motion 4 times per day. Apply a pressure-relieving mattress under the client.

Apply a pressure-relieving mattress under the client. Rationale The client's risk for impaired skin integrity requires meticulous skin care because the edematous tissues are showing indications of breakdown. A pressure-relieving mattress should be used to reduce the risk of skin tearing with manual turning.

To avoid a false positive result for fecal occult blood in a stool specimen, the nurse should instruct the client to avoid ingestion of which substances prior to collecting a sample? (Select all that apply.) Select all that apply Fish. Beef. Vitamin C tablets. Turkey. Ibuprofen (Advil). Coffee.

Beef. Ibuprofen (Advil). Fish. Vitamin C tablets. Rationale The fecal occult blood test, or guaiac test, measures microscopic amounts of blood in the feces. False positive results can occur from food products such as fish, beef and other red meats, green vegetables, vitamin C supplements, aspirin, and nonsteroidal antiinflammatory medications, including ibuprofen.

Which action should the nurse implement when providing nasogastric (NG) feeding to an unresponsive client? Check residual volume every four hours. Stimulate the gag reflex every eight hours. Administer small amounts of the formula. Give the feeding while the client is supine.

Check residual volume every four hours Rationale The gastric residual volume should be assessed every four hours to evaluate absorption of the feeding and to determine delayed gastric emptying.

A female client who is diagnosed with an eating disorder has difficulty translating her pain into words. Which approach should the nurse implement to allow this client greater self-disclosure? Letter writing. Dance and movement therapy. Personality inventory testing. Cooking and meal planning classes.

Dance and movement therapy. Rationale Clients with eating disorders often have difficulty with "talk" therapy. To allow for greater self-disclosure and exploration of fundamental issues, dance and movement therapy, an expressive therapy and non-verbal form of communication, allows the client to express inner feelings that cannot otherwise be vocalized.

The healthcare provider prescribes digital evacuation of a fecal impaction for an older client who is admitted with a closed head injury after falling out of bed. As a part of the procedure policy, the nurse applies a topical anesthetic gel to the rectum. Which rationale best supports the use of the anesthetic gel? Decrease risk for bradycardia. Prevent rectal mucosal tearing. Minimize hemorrhoidal trauma. Dislodge the fecal mass.

Decrease risk for bradycardia. Rationale Conditions in which bradycardia occurs include vagal stimulation and increased intracranial pressure. Manipulation or stretching of the anus causes vagal stimulation, so a topical anesthetic gel reduces sensory input that stimulates a client who is at risk for increased intracranial pressure and decreases the risk for bradycardia.

A client is using an otic solution, hydrocortisone and polymyxin B (Otobiotic otic), for external otitis media. Which therapeutic response should the nurse tell the client to expect? Decreases inflammation and pain. Reduces the existing colony count. Slows the rate of organism growth. Prevents hearing loss as a possible complication.

Decreases inflammation and pain. Rationale The otic preparation of polymyxin B and hydrocortisone is a combination antibiotic and corticosteroid used to reduces inflammation and control pain.

The nurse identifies the nursing diagnosis of, "Visual sensory/perceptual alterations related to increased intraocular pressure (IOP)" for a client with glaucoma. Which nursing intervention should the nurse include in the plan of care? Encourage compliance with drug therapy to prevent loss of vision. Develop pain management strategies associated with ocular nerve atrophy. Identify coping mechanisms related to the eventual loss of peripheral vision. Recognize that damage to the eye can be reversed until late stages of the disease.

Encourage compliance with drug therapy to prevent loss of vision. Rationale Glaucoma is characterized by a silent increase in IOP, optic nerve atrophy, and visual field loss that is managed with eyedrop instillation of beta-blocker, alpha-adrenergic, or carbonic anhydrase inhibitors. The retinal damage caused by the increased IOP is irreversible and can lead to blindness, so the client's drug therapy compliance addresses the nursing diagnosis.

Which intervention(s) should the nurse use when interacting with a client with Alzheimer's disease? (Select all that apply). Select all that apply Adhere to strict time limits for activities. Give all instructions at the start of the activity. Encourage verbal and nonverbal communication. Speak to the client in a loud and clear voice. Maintain a calm demeanor during all interactions.

Encourage verbal and nonverbal communication. Maintain a calm demeanor during all interactions. Rationale Alzheimer's causes the client to experience cognitive deficits and memory impairment, so frequent communication and a calm affect should be maintained with the client.

An adolescent client is admitted to the mental health unit for impulsivity and acting-out behavior at school. What intervention should the nurse implement that is most beneficial for this client? Administer an antianxiety agent PRN. Implement close observation precautions. Separate the adolescent from adult clients on the unit. Explain the consequences for breaking the unit rules.

Explain the consequences for breaking the unit rules. Rationale Therapeutic interventions, such as limit-setting and consequences for breaches of rules provide consistent expectations of behavior and are most beneficial in establishing trust and reinforcing acceptable behaviors for interacting with others.

The nurse reviews a client's laboratory results and identifies an elevated serum ammonia level. Which pathophysiological process contributes to this finding? A decreased bile flow into the small intestine due to a bile duct obstruction. Bowel flora act on bowel protein to deaminate amino acids and form ammonia. Failure of the liver to convert ammonia absorbed from the bowel to urea. An increased reabsorption of urobilinogen from the bowel into the blood.

Failure of the liver to convert ammonia absorbed from the bowel to urea. Rationale As a result of hepatocellular damage, the pathogenesis of hyperammonemia occurs when the liver fails to convert ammonia absorbed from the bowel to form urea for eventual excretion by the kidneys. The normal metabolism of ingested proteins are transformed into ammonia by the action of bowel flora, where ammonia is absorbed and detoxified by conversion into urea by the hepatocytes.

After attending an inservice for bioterrorism preparedness and staff education, the nurse should identify which findings consistent with a possible anthrax exposure? Fever, cough, chest pain, and hemoptysis. Vesicular skin lesions on the face and extremities. Flu-like symptoms, gastrointestinal distress, and papular lesions. Abdominal cramping, diarrhea, drooping eyelids, and jaw clench.

Flu-like symptoms, gastrointestinal distress, and papular lesions. Rationale Clinical features of anthrax include flu-like symptoms, gastrointestinal distress, and papular lesions. Fever, cough, chest pain, and hemoptysis are characteristic of plague. Vesicular skin lesions on the face and extremities are seen with smallpox. Abdominal cramping, diarrhea, drooping eyelids, jaw clench, and difficulty swallowing are clinical features of botulism.

Which action by the nurse-manager demonstrates an effective leadership style? Directs a staff nurse to modify communication skills. Implements behavior changes through the annual evaluation process. Uses the group process to determine behaviors that distress the staff. Fosters positive behavior changes in staff members.

Fosters positive behavior changes in staff members. Rationale Democratic leadership styles allow group members to participate in change, and to effectively lead members in the change process, positive behavior changes in staff members should be fostered and supported.

The nurse is providing tracheostomy care for a client who has encrusted secretions inside the inner cannula. Which solution should the nurse use to remove the debris? Iodine. Azelaic acid. Isopropyl alcohol. Hydrogen peroxide.

Hydrogen peroxide. Rationale An oxidizing antiseptic, such as hydrogen peroxide is used as a cleansing agent to loosen dried secretions that collect on the inner cannula and around the tracheostomy stoma.

The nurse is evaluating a client's response to diuretic therapy. Which assessment provides the best measure of the client's fluid volume status? Blood pressure and pulse. Intake, output, and daily weight. Serum potassium and sodium levels. Measurements of abdominal girth and calf circumference.

Intake, output, and daily weight. Rationale Intake, output, and daily weight provide the best quantitative data about a client's fluid volume status based on weight changes in 24 hours, using the equivalent of 1 gm = 1 ml. Blood pressure and pulse are influenced by fluid volume, but some clients compensate more effectively cardiovascularly than others. Although serum potassium and sodium levels may change based on the amount of diuresis, body weight changes in a 24 hour time frame provide the best measure of routine diuresis.

During admission to the mental health unit, a female client with bipolar disorder, manic phase, is loud, hyperverbal, hyperactive, and is garishly dressed. Which intervention should the nurse include when planning care for this client? Encourage others to use peer pressure to modify the client's behaviors. Plan group activities that focus on the client as the center of attention. Maintain an environment that reduces stimulation of the client. Include activities that require attention to detail to limit inappropriate behavior.

Maintain an environment that reduces stimulation of the client. Rationale A client in the manic phase of bipolar disorder demonstrates flight of ideas, feelings of grandiosity, and has an inflated self-esteem, so the plan of care should include interventions that minimize client stimulation.

Which assessment finding should the nurse identify in an adult client with sleep deprivation? Mood swings and irritability. Persistent elevated blood pressure. Decreased temperature. Inappropriate and acting out behaviors.

Mood swings and irritability. Rationale Sleep deprivation is often manifested in a client with multiple stressors and causes nightmares, nocturia, frequent awakening and feeling "exhausted" with early rising, all of which contribute to mood swings and irritability. Although sleep deprivation stimulates neuro-endocrine responses, confusion, altered reasoning ability, lethargy, and withdrawn behavior is more likely.

Which action should the nurse implement to assess for jugular vein distention (JVD) in a client with heart failure (HF)? Ask the client to perform the Valsalva maneuver while lying in a supine position. Palpate the jugular veins, comparing the volume and pressure of one with those of the other. Measure in centimeters the distance that the jugular veins are distended outward from the neck. Observe the vertical distention of the veins as the client is gradually elevated to an upright position.

Observe the vertical distention of the veins as the client is gradually elevated to an upright position. Rationale An indicator of elevated right atrial pressure in HF is jugular distention of greater than 3 cm vertical distance between the intersection of the angle of Louis and the level of the jugular distention, which occurs when the client is gradually elevated to an upright position.

The nurse manager is explaining to a new nurse that the nursing units at the hospital are managed by the nursing staff who control self-scheduling of shift work, implement unit quality improvement program, and participate in unit recruitment-retention programs. What type of management model is the nurse manager describing? Operational shared governance. Nursing staff unions. Clinical career ladder program. Centralized nursing division.

Operational shared governance. Rationale Shared governance is a model of organizational management where decision making is decentralized in which staff nurses are empowered through autonomy and accountability about the delivery of client care on the nursing unit. Unions in nursing represent a group of employees in collective bargaining processes to negotiate decisions with an employing organization's management. Clinical career ladder programs are partnerships between heath care agencies, nursing staff, and nursing schools for advancement in education and promotion. A centralized organizational decision-making model in nursing is characterized by a nurse executive who retains decision-making authority.

On the second day after admission, a client with a fractured pelvis develops chest pain, tachypnea, and tachycardia. Which additional finding should the nurse identify that is most likely related to a fat embolism? Hypotension. Restlessness and confusion. Warm, reddened areas in the legs. Petechiae of the anterior chest wall.

Petechiae of the anterior chest wall. Rationale The pathophysiologic process of fat embolism syndrome (FES) after fracture is related to the release of bone marrow fat globules into the venous circulation followed with platelet aggregation. Fat emboli lodge in the pulmonary vasculature, result in tissue hypoxia, and manifest as petechiae on the neck, anterior chest wall, axilla, buccal membrane, and conjunctiva of the eye.

In which order should the nurse implement these actions when withdrawing a solution from an ampule? (Arrange from first on top to last on the bottom.) 1. Flick the stem several times with a finger. 2. Wrap the neck with a protective device. 3. Break the neck by pressing thumbs outward. 4. Stabilize ampule on a firm surface. 5. Withdraw the solution using a filter needle.

Rationale Flicking the stem ensures all medication is in the bottom of the ampule. Wrapping the neck with a protective device (such as a small gauze pad or alcohol prep pad) protects fingers from trauma as the glass tip is broken off. Snapping the neck of the ampule quickly and outwards minimizes the nurse's risk of injury from shattering glass. Stabilizing the ampule assists in maintaining sterility as the needle is placed to withdraw the solution. Withdrawing the solution with a filter needle protects against aspirating microscopic glass into the syringe.

A client is receiving an opioid analgesic every 2 hours for intractable pain. Which pathophysiological consequence should the nurse identify if the client receives the medication at regular intervals? Metabolic acidosis. Metabolic alkalosis. Respiratory acidosis. Respiratory alkalosis.

Respiratory acidosis. Rationale Respiratory acidosis results from retention of CO2 secondary to hypoventilation due to respiratory depression, which is an adverse effect of opiates.

Pulse oximetry is being used to monitor a client's oxygen saturation. Which client risk factor(s) should the nurse consider as variable(s) that affect this measurement? select all that apply Smoking. Jaundice. Hypotension. Ambient oxygen. Antibiotic therapy. Type 1 diabetes mellitus.

Smoking. Jaundice. Hypotension. Type 1 diabetes mellitus. Rationale The measurement of oxygen saturation using a pulse oximeter is influenced by a variety of client risk factors, such as smoking, which causes vasoconstriction and reduces peripheral blood flow; jaundice, which interferes with the oximeter's ability to process reflected light; hypotension, which decreases peripheral blood flow and arterial pulsations necessary to calculate oxygen saturation; and Type 1 diabetes mellitus, which causes peripheral vascular disease that can reduce pulse volume

A mother brings her 4-week-old infant for the first well-child visit and tells the nurse that the baby is not smiling. Which information should the nurse provide? Social smiling begins at approximately 2 months of age. Smiling during feeding should occur around 1 month of age. An infant should smile and coo when a parent enters the room at approximately 3 months of age. Baby babbling begins at approximately 4 months of age in response to a parent talking to the infant.

Social smiling begins at approximately 2 months of age. Rationale An infant begins social smiling at approximately 2 months of age. The infant may make comfort sounds during feeding at 1 month of age, but a smile is often a response to gas. Although cooing and babbling usually begins at approximately 3 months of age, smiling is often the first sign of social recognition at 2 months.

An 11-year-old boy with oppositional defiant disorder becomes angry and defiant over the rules of the day treatment mental health program. Which response by the nurse is the most effective way to defuse the situation? Approach and secure the child in a basket hold. Administer a PRN anxiolytic medication. Call additional staff to restrain and seclude the child. Tell the child to go to the gym to play basketball.

Tell the child to go to the gym to play basketball. Rationale Redirecting the expression of feelings into nondestructive, age-appropriate behaviors, such as a physical activity helps a child learn how to moderate the expression of feelings and exert self-control. The least restrictive alternative should be implemented before resorting to more restrictive measures.

What description encompasses the role in client care management played by nursing informatics? The input and retrieval of electronic data about a client's medical history. The specialty of hospital nursing management of computerized client care. A computer system design to analysis client health data during hospitalization. The processing of electronic nursing data that is used to support nursing practice and knowledge.

The input and retrieval of electronic data about a client's medical history. Rationale Nursing informatics encompass activities that involve identifying, naming, organizing, grouping, collecting, processing, analyzing, storing, retrieving or managing data and information about a client's medical history and care.

The nurse is developing the plan of care for an older client who is immobile and at risk for pressure ulcers. Which contributing factor should the nurse include in the nursing diagnosis, " Risk for altered skin integrity?" Poor nutrition. Tissue ischemia. Prolonged illness or disease. Nitrogen buildup in the underlying tissues.

Tissue ischemia. Rationale Prolonged, intense pressure affects cellular metabolism by impeding capillary blood flow to tissue over weight-bearing bony prominences, resulting in tissue ischemia, skin breakdown, and tissue death. Although key factors contributing to pressure ulcers include poor nutrition, prolonged illness or disease, and build-up of metabolic nitrogen in underlying tissues, tissue ischemia is the primary factor in pressure ulcer development.

The nurse is planning care for a child with Trisomy 21 who is admitted with recurrent upper respiratory infections and chronic constipation. Which intervention should the nurse include in the plan of care? Provide a high caloric diet that meets the child's mental age. Delay solid food introduction until the child's tongue thrust subsides. Maintain regular meal times to minimize frequency of constipation. Use a bedside cool-mist vaporizer during naps and night time.

Use a bedside cool-mist vaporizer during naps and night time. Rationale A child with Trisomy 21, Down syndrome, typically has an under-developed nasal bone that compromises respiratory expansion and causes a chronic problem of inadequate drainage of nasal mucus. This persistent nasal congestion forces the child to mouth-breathe, which dries the oropharyngeal membranes and increases the susceptibility to upper respiratory tract and ear infections. Using a cool-mist vaporizer moistens the nasal mucous membranes, liquefies, and drains nasal secretions to reduce this medium for infection.

A male client with gastric cancer is 1 week postoperative for a total gastrectomy and has normal hematologic parameters. Which vitamin should the nurse explain to the client is indicated to take for his lifetime? Vitamin A. Vitamin C. Vitamin E. Vitamin B12.

Vitamin B12. Rationale The gastric mucosa secretes the intrinsic factor which is required for the absorption of the extrinsic factor (Vitamin B12 ) that is used in the maturation and release of erythrocytes from the bone marrow. Following gastrectomy, a client should be prepared to take a maintainance dose of an injectable Vitamin B12 for the rest of his life to prevent pernicious anemia.

Which individual may legally sign an informed consent? A 42-year-old client who is sedated. A 16-year-old mother for her newborn. The friend of an 84-year-old married client. A 56-year-old who questions a proposed treatment plan.

A 16-year-old mother for her newborn. Rationale A mother who is younger than 18 years is an emancipated minor who may legally sign an informed consent for the care of her child. A client who is sedated cannot legally give informed consent, which should be obtained before a sedative is administered. A spouse can legally provide authorized informed consent on the client's behalf, but a friend does not have these legal rights unless the friend holds a power of attorney or legal guardianship of the client. If a client questions a proposed treatment plan that requires informed consent, the nurse should notify the healthcare provider who is responsible for explaining the treatment plan before the client signs a consent form.

A male client calls the crisis center and tells the nurse that he wants to die and is planning to commit suicide. What means of suicide should the nurse determine is most lethal if in the client's possession? A loaded gun. A garden hose. Two bottles of Prozac. A bottle of an alcoholic beverage.

A loaded gun. Rationale Assessment of suicidal ideation should include determining the degree of lethality of the method, the individual's access to whatever is needed to carry out the attempt, and if there is a specific plan of action. The more detailed the plan, the greater the risk for a successful attempt. Violent and traumatic means, such as a loaded gun are frequently used by males, and accessible firearms are a highly lethal method that causes minimal chance for survival after an attempt is made.

A client with cellulitis is recovering at home after experiencing a severe reaction to a new prescription for ampicillin (Unisyn) that was administered by a home health nurse. The client's allergies to penicillin and sulfonamide are noted in all critical areas of the home health record. What consequence can occur based on the nurse's action? None since the action did not result in the client's wrongful death. A malpractice suit based on lack of reasonable and prudent care. Disciplinary action initiated by the state's nurse licensing board. An intentional tort based on failure to note the client's allergies.

A malpractice suit based on lack of reasonable and prudent care. Rationale Medication errors involving failure to provide reasonable and prudent care, including improper documentation of medication administration, failure to recognize side effects or contraindications, and negligence in verifying a client's allergies, may result in a malpractice suit against the nurse.

A client is comatose upon arrival to the emergency department after falling from a roof. The client flexes with painful stimuli, and the nurse determines the client's Glasgow Coma Scale (GCS) is 6. Which intervention should the nurse prepare to implement to maintain the client's airway? Tracheostomy tube insertion. An endotracheal tube. A nasopharyngeal tube. An oral airway.

A nasopharyngeal tube. Rationale If head and neck injuries are suspected, a client with a GCS of 6 who demonstrates motor flexion in response to painful stimuli requires airway maintenance without risk of compromise to spinal cord function. Nasal intubation using a nasopharyngeal tube is the airway of choice for a client with suspected spinal cord injury because less cervical spine manipulation is needed during insertion, as compared with endotracheal intubation.

The nurse is obtaining a client's consent for a paracentesis. Which information should the nurse provide to ensure the client understands the purpose of the procedure? A needle is inserted to remove excessive fluid from the abdominal peritoneal cavity. A biopsy is taken from the stomach wall to determine the presence of Helicobacter pylori. Dye is injected into the biliary tract using an esophagogastroduodenoscopy (EGD). Fluid removal from the pleural space uses an x-ray guided insertion of a needle.

A needle is inserted to remove excessive fluid from the abdominal peritoneal cavity. Rationale The nurse should ensure the client's understanding and explain that a paracentesis is a procedure that removes excessive fluid (ascites) from the peritoneal cavity.

Which evidence supports the application of healthcare informatics and client care technology? The elimination of chaos in solving informatics problems. The emergence of new and appropriate knowledge structures. A solution for informatics problems with data flow records and work flow documentation. A new sense of order to a problem that facilitates cost-effective analysis and evaluation of care.

A new sense of order to a problem that facilitates cost-effective analysis and evaluation of care. Rationale Chaordic theory is the mix of chaos and order that is often a harmonious coexistence of both. This theory is seen in living organisms and its principles have been used as guidelines for creating human organizations or businesses, such as informatics. Electronic medical records and client care technology produce a vast amount of data, such as client assessments, planning, documentation of treatment, and evaluation of client care, that must be cost-effectively organized.

The nurse is teaching a client with Addison's disease about this new diagnosis. What pathophysiological explanation should the nurse share with the client? End stage renal disease causes hypertension due to decreased renal perfusion that results in an increased secretion of renin. Hyperthyroidism is an autoimmune disease that causes an increased secretion of thyroxine resulting in an increased basal metabolic rate. Adrenal insufficiency is an autoimmune dysfunction that results from white blood cells damaging the adrenal cortex. Pituitary dysfunction, such as diabetes insipidus, can occur after a head injury or primary tumor that causes increased intracranial pressure.

Adrenal insufficiency is an autoimmune dysfunction that results from white blood cells damaging the adrenal cortex. Rationale Addison's disease is primary adrenal insufficiency related to autoimmune dysfunction and lymphocytic infiltration. Adrenal glands are located on top of your kidneys. These glands produce many of the hormones that your body needs for normal functions. Addison's disease occurs when the adrenal cortex is damaged and the adrenal glands do not produce enough of the steroid hormones cortisol and aldosterone. Cortisol regulates the body's reaction to stressful situations. Aldosterone helps with sodium and potassium regulation. The adrenal cortex also produces sex hormones (androgens).

On admission to the hospital, a male client gives the nurse a copy of his living will that indicates his decision to withhold resuscitative measures to prolong his life. What action should the nurse implement if the client is unable to express his desire about life-prolonging measures? Ask the spouse to make decisions regarding life-saving measures. Allow the client to die with dignity and without life-prolonging techniques. Administer medications to ensure a painless death and end the client's suffering. Implement all measures of technical assistance and equipment to prolong life.

Allow the client to die with dignity and without life-prolonging techniques. Rationale A living will is an advance directive that is prepared when an individual is competent to make decisions about end-of-life care that specifies withholding resuscitative measures that prolong life. The spouse can make decisions regarding the client's care if there is a legal power-of-attorney document, not a living will. An individual should be provided life-support unless a living will is available to define a client's wishes to withhold treatment that prolongs life.

An adolescent female who lost fifty pounds during the past three months is hospitalized. During the admission assessment, the client complains of dry skin, poor skin turgor, hair breakage, brittle nails, and a history of menstrual cycle problems. Which finding is most important for the nurse to obtain additional assessment information? Amenorrhea. Dysmenorrhea. Heavy menstrual flow. Premenstrual syndrome.

Amenorrhea. Rationale As a result of anorexia nervosa, a hypoestrogenic condition can result from a decreased percentage of body fat and cause amenorrhea, absence of three or more menstrual cycles, which should be determined if this finding is a characteristic feature of anorexia or if the adolescent may possibly be pregnant. Dysmenorrhea (painful menstruation) is heavy menstrual flow.

The mother of an 8-year-old child with a chronic illness and tracheotomy is rooming-in during this hospitalization. The mother insists on providing all of the child's care and tells the nurse how to care for the child. The nurse should recognize that the mother plays which function when planning this child's care? The nurse's role. Source of the child's safety. An expert in care of the child. Supervisor of nurses providing care.

An expert in care of the child. Rationale An important component of family-centered care is parent-professional collaboration, which shows respect for families and provides support. A basic characteristic is the belief that parents are experts concerning their child. Collaboration reflects a change from the traditional models of care but does not assume the nurse's role. Although consistent parenting and care-taking provides the child with a sense of security and safety, the mother's knowledge of her child is vital in individualizing care. The plan for a family-centered approach should include awareness, acceptance, respect, and recognition by the nurse that the parent is a full partner in the care of the child.

A primiparous client has been in labor for 15 hours. Two hours ago, vaginal examination revealed the cervix dilated to 5 cm, 100% effaced, and the presenting part at station 0. Five minutes ago, the vaginal examination reveals no change in the cervix or decent of the fetus. Which labor pattern should the nurse document to describe the client's progress? Protracted descent. Arrest of active phase. Prolonged latent phase. Protracted active phase.

Arrest of active phase. Rationale Arrest of active phase is indicated if there is no change in the dilation of the cervix for 2 hours or more in a primigravida. Prolonged latent phase is labor lasting longer than 20 hours in a primigravida. Protracted active phase occurs when dilatation of the cervix is less than 1.2 cm/hour. Protracted descent occurs when the fetus decends less than 1 cm/hour into the pelvis.

The nurse is caring for a client who is scheduled for surgery in 2 hours. The client tells the nurse, "My doctor came by to tell me a lot of stuff that I didn't understand, but I signed the papers for surgery anyway." To fulfill the role of advocate, which action should the nurse implement? Reassure the client that surgery should progress as planned. Explain the surgery and possible outcomes to the client. Complete the client's preoperative teaching plan. Ask the surgeon to return to clarify questions for the client.

Ask the surgeon to return to clarify questions for the client Rationale Examples of nursing advocacy include questioning prescriptions, promoting client comfort, and supporting client decisions regarding healthcare choices. Requesting the surgeon to return to clarify the client's concerns best fulfills the role of client advocate. Although a well-planned surgical experience is expected you should not provides false reassurance. Explanation of the surgical procedure and client outcomes is the surgeon's responsibility, not an action of client advocacy.

Three days after a colon resection, the nurse is assessing a client with a nasogastric tube (NGT) to intermittent suction. What assessment should the nurse implement to determine proper placement of the NGT? Auscultate bowel sounds in all quadrants. Percuss abdomen for stomach distention. Aspirate the tube contents to test the pH. Review the X-ray report from 3 days prior.

Aspirate the tube contents to test the pH. Rationale NGT placement should be verified every 4 hours and is best determined at the bedside by testing the pH of the aspirate from the NGT. Bowel sound assessment determines intestinal activity and peristalsis, not placement. Percussion of the abdomen for gastric distention provides evaluation of the effectiveness of postoperative nasogastric decompression, but it does not confirm NGT placement. The X-ray obtained 3 days ago is no longer reliable because the NGT may have moved.

A client with gastroesophageal reflux disease (GERD) is unconscious and unresponsive to stimuli. The nurse places the client in a side-lying position. The nurse should monitor the client for the risk of which complication? Stress ulcers. Aspiration pneumonia. Esophageal hemorrhage. Thromboembolic problems.

Aspiration pneumonia. Rationale A client with GERD who is unresponsive is at an increased risk for pneumonia due to aspiration of stomach contents.

A 38-year-old female client is admitted to the mental health unit after a recent manic episode of spending large amounts of money on new furniture, making excessive long-distance phone calls, and not sleeping for three days. During the admission process, the client is wearing a green bathing suit. What intervention should the nurse implement? Conduct a suicide assessment. Assess the client's needs for food, liquids, and rest. Set strict limits on the client's dress and actions. Obtain a psychosocial assessment.

Assess the client's needs for food, liquids, and rest. Rationale The lack of sleep during the past three days identifies the client's physiological needs as the first priority of care to ensure physical safety. A client who is in the manic phase is unable to concentrate. During mania, the client needs assistance with selecting socially acceptable dress and behaviors becausethe client's inflated ego and delusions of grandiosity impede the ability to be self-directed with limit setting.

The parents of a 4-month-old infant who is hospitalized tell the nurse that they have to work and cannot stay with the baby except on weekends. Which actions should the nurse-manager implement to address the infant's emotional needs? Place the child in a room away from other children. Tell the parents that frequent visiting is unnecessary. Assign the same nurse to care for the child each day. Allow several nurses to care for the child each shift.

Assign the same nurse to care for the child each day. Rationale A primary nursing goal for a hospitalized child is prevention of separation anxiety, which is common in children under 5. Strategies to minimize the effects of temporary separation should be implemented when parents are unable to stay with young children who are hospitalized. Assigning the same nurse to comfort and care for the infant provides continuity of care, familiarity, and allows the nurse to establish a relationship that meets the emotional needs of the infant and parents.

The nurse is administering a nasogastric tube feeding to a client who is comatose. Which finding requires further action by the nurse? Gastric residual of 150 ml. Minimal abdominal distention. Glucose blood level of 100 mg/dl. Bowel sounds auscultated in 4 quadrants.

Gastric residual of 150 ml. Rationale When administering nasogastric tube feedings, gastric residual greater than 100 ml indicates a delay in gastric emptying and requires withholding the feeding and reporting to the primary care provider.

The nurse instills an atropine ophthalmic solution into both eyes for a client who is having a routine eye examination. Which side effects should the nurse tell the client to anticipate? Blurred vision. Halos around objects. Inability to see at night. Itching of the conjunctiva.

Blurred vision. Rationale Atropine ophthalmic solution is used during eye examinations to dilate the pupil (mydriasis) and paralyze the ciliary muscle (cycloplegic refraction), which prevents accommodation and causes blurred vision.

Which information is most accurate for the nurse to use when calculating safe drug dosages for a child? Age. Height. Weight. Body surface area.

Body surface area. Rationale The most accurate method of calculating pediatric doses is based on a child's body surface area (BSA). Drug calculations are not consistently precise when made on the basis of a child's age since children vary widely in size and maturity for chronologic age. Although the calculation of a child's BSA utilizes a child's height and weight. Height and weight alone do not correlate with the distribution or metabolism of a drug due to the variance in each child's growth and development.

The nurse is reviewing the laboratory results of an older client who is admitted to a medical unit. Which serum chemistry values should the nurse recognize as most commonly affected by the aging process? (Select all that apply.) Select all that apply Calcium. Chloride. Phosphorus. Potassium. Sodium. Magnesium.

Calcium. Potassium. Sodium. Rationale Calcium, potassium, and sodium are common electrolyte abnormalities seen in the older adult population that are related to degenerative processes, such as renal insufficiency.

The nurse notes a client with decreased alertness is having difficulty managing saliva. What is the priority assessment for the nurse to implement prior to feeding? Food and drug allergies. The apical pulse rate. Elimination patterns. Presence of gag reflex.

Presence of gag reflex. Rationale A client who needs assistance with feeding should be assessed prior to feeding, so checking for the presence of a gag reflex determines the client's risk for aspiration.

What is the largest contributing factor for the increase in the need for home care? Government funding of the home care setting has increased greatly. Clients are more acutely ill when discharged from acute care facilities. Home care agencies can provide seven-day services for older adults. Fixed single-incomes of older adults has increased the need for home care.

Clients are more acutely ill when discharged from acute care facilities. Rationale Based on shortened durations of hospital stays that aim to control healthcare costs, clients are returning home more acutely ill which is the largest contributing factor to the increased need for home care.

The nurse-manager is developing a plan to increase the local population's utilization of a new community-based public clinic. Which approach should the nurse utilize to obtain the most impact on developing a collaborative partnership with the community? Provide free services for those whose income is defined within the poverty range. Distribute flyers about recommended health screenings in the community. Create an "Ask a Nurse" telephone service for health related questions. Conduct a focus group in community to gather data on culturally significant needs.

Conduct a focus group in community to gather data on culturally significant needs. Rationale Nursing's unique role in improving community health relies on an approach based on knowledge of the community's diversities and specific needs, which is obtain through relationships with leaders and members of the community. Utilization of the clinic's services and collaboration with members of the community is best established when the healthcare facility and staff are recognized as providing consistent, culturally sensitive care.

The nurse enters a client's room to complete discharge preparations and finds the client in tears. The client states that someone from the business office insisted that a payment for the hospital bill be made before the client could leave. After providing comfort to the client, what is the best nursing action? Call the family to ask about the payment. Continue the client's discharge process. Resume the discharge when payment occurs. Notify the healthcare provider of the situation.

Continue the client's discharge process. Rationale Detaining someone against one's wishes, such as physically or emotionally preventing a client from leaving a healthcare facility, is false imprisonment, which is an intentional tort. To prevent infringement of the clients' rights, the best action for the nurse is to continue the client's discharge preparations.

The nurse is assessing a child of Chinese descent who arrives in the clinic with a upper respiratory infection and identifies a 5-inch, circular ecchymoses on the child's forehead and back. What factor should the nurse consider as the most likely cause of this finding? Child abuse. Pinching to relieve headaches. Beatings to remove evil spirits. Cupping to remove colds and coughs.

Cupping to remove colds and coughs. Rationale A common practice used in Eastern medicine and the Chinese culture is cupping), which is a dermal practice that involves placing a heated cup on the skin to draw infectious toxicity into the cup as it cools and contracts, which can leave bruises or welts at the site of the treatment.

The nurse is supervising an unlicensed assistive personnel (UAP) who is feeding an older client with dysphagia. Which action by the UAP requires the nurse's intervention? Thickens the broth and juice on the client's tray. Assists the client from the bed to a chair for the meal. Divides solid food items into one inch cube pieces. Keeps the client upright for 60 minutes after eating.

Divides solid food items into one inch cube pieces. Rationale Solid food should be smaller to minimize the risk of food becoming lodged in the oropharynx or aspirated. Thickened liquids, sitting the client upright for 45 to 60 minutes after eating helps reduce the risk of aspiration that threatens an older adult who is dysphagic.

A client who is a laboratory technician and has a history of allergic rhinitis, asthma, and multiple food allergies is scheduled for surgery. Which action should the nurse implement? Document a possible Type I latex allergy. Determine if the client carries an epinephrine kit for Type IV allergic reaction. Advise the client to use oil-based hand creams when wearing latex gloves. Encourage the client to use vinyl gloves at work.

Document a possible Type I latex allergy. Rationale Risk factors for latex allergy include long-term multiple exposures, such as healthcare personnel, multiple surgeries, and a client history of allergies, such as hay fever, asthma, and foods. Documentation of the client's risk for a Type I latex allergy should be noted in the client's medical record.

During a group therapy session, a client with hypomania threatens to strike another client. What intervention is best for the nurse to implement? Summon assistance of several other staff. Send the other clients out of the group setting. Tell the client to leave the group to gain control of the behavior. Firmly inform the client that acting out anger is not acceptable.

Firmly inform the client that acting out anger is not acceptable. Rationale A client with hypomania may demonstrate a varying degree of feelings, rapid thoughts, speech patterns, and impulsive acts. The client should be informed firmly that threats or behavior to act out feelings of anger is not acceptable. Staff assistance should be summoned only if the client becomes aggressive and out of control. If a client persists with threats or aggressive behavior, changing the client's environment should be implemented before sending others out of the group setting. Although personal time away from the group may allow the client time out, the client should be confronted to recognize that the behavior is unacceptable.

What assessment finding should the nurse identify in a client with fluid volume excess? Flushed skin. Elevated blood pressure. Weak, thready pulse. Dry mucous membranes.

Elevated blood pressure. Rationale Blood pressure is the product of heart rate, stroke volume, and peripheral resistance, so an elevated blood pressure occurs as fluid volume increases.

An infant who is delivered at 32-weeks gestation arrives in the nursery intubated. After the infant is placed under a radiant warmer with prescribed ventilator settings, the nurse applies a cardiorespiratory monitor and pulse oximeter, which indicates an oxygen saturation of 80%. What action should the nurse implement first? Inform the parents about the infant's status. Notify the healthcare provider. Continue with the admission assessment. Ensure patency of the endotracheal tube.

Ensure patency of the endotracheal tube. Rationale The infant's oxygenation is crucial, so airway patency should be implemented first to ensure the prescribed rate of oxygen administration to maintain the infant's saturation rate above 92%. Before notifying the healthcare provide, the endotracheal tube should be suctioned to ensure patency. To prevent further oxygen de-saturation, other tasks of the admission assessment should be delayed until the infant is stabilized.

Which intervention demonstrates the nurse's accountability in a specific decision-making process? Selecting the best medication administration schedule for a client. Evaluating a client's outcomes after implementation of care. Promoting participation of all staff members in unit meetings. Implementing discharge teaching plans that meet individual needs.

Evaluating a client's outcomes after implementation of care. Rationale Accountability is being responsible, professionally and legally, for the delivery of nursing care, which includes competency in nursing, scientific knowledge, technical skills, and maintaining standards of practice in the nursing profession. Accountability involves follow-up and a reflective analysis of implementation of care and client outcomes.

A client with chronic kidney disease (CKD) receives peritoneal dialysis at home and is upset because of the expenses of therapy. What information response should the home health nurse provide as the client's advocate? An alternative option to consider is renal transplant. Peritoneal dialysis is less expensive than hemodialysis. Self pity and angry is common with chronic disease that requires life sustaining treatment. Explore options with the regional dialysis center about reducing the cost of home dialysis.

Explore options with the regional dialysis center about reducing the cost of home dialysis. Rationale Identifying the client's need for assistance in contacting the appropriate agency for information and resources demonstrates client advocacy. Information about alternatives in treatment does not demonstrate client advocacy about the client's concerns of therapy expenses. Recognizes the client's feelings does not advocate or address the client's financial concerns.

The nurse is assessing an adult who displays stagnation, boredom, and interpersonal impoverishment. Based on Erikson's developmental model, which stage should the nurse develop interventions for this client? Identity versus role confusion. Intimacy versus isolation. Generativity versus stagnation. Integrity versus despair.

Generativity versus stagnation. Rationale An important part of client assessment is the analysis of behavior patterns using Erikson's framework. In the therapeutic encounter, interventions can be tailored to address the client's arrested development in middle adulthood, the stage of generativity versus stagnation, when self responsibility and guiding the next generation is a primary task.

A female client arrives at the clinic because her boyfriend received the results of a Gram stain smear that revealed the presence of Neisseria gonorrhoeae. The client tells the nurse that she has not had any symptoms and almost did not come to the clinic. What information should the nurse provide the client? Subclinical cases of gonorrhea occur in women but do not cause damage. Women serve as carriers of gonorrheal infections that are manifested in men. Gonorrhea is often asymptomatic in women because the infection is not visible. Infertility in women is the result of ovarian dysfunction due to gonorrheal infections.

Gonorrhea is often asymptomatic in women because the infection is not visible. Rationale Gonorrhea in women is often asymptomatic and frequently dismissed or overlooked as a yeast discharge or urinary infection.

Which change in sleep patterns is most likely to occur in an older adult? Becomes more difficult to arouse from sleep. Takes less time to fall asleep. Has a decline in stage 4 sleep. Requires more sleep than a younger adult.

Has a decline in stage 4 sleep. Rationale With aging, a progressive decrease in the amount of non-rapid eye movement (NREM) sleep occurs during stage 3 and 4, and some older adults have minimal amounts of stage 4, or deep sleep. As people age, they do not become more difficult to arouse. An older adult awakens more often during the night, and it may take more time for an older adult to fall asleep. The older adult does not require more sleep than a younger adult.

A male client with degenerative arthritis of the knees and hips takes an over-the-counter (OTC) nonsteroidal antiinflammatory drug (NSAID) for pain. During a routine clinic visit, the client tells the nurse, "For the past month I've been having a lot of trouble sleeping. I can't seem to fall asleep, and when I finally do get to sleep, I find that I wake up a number of times during the night." Which information should the nurse obtain first? Does the client snore or experience sleep apnea? How intense does the client rate his pain on a scale of 1 to 10? What type of medications does the client take before bedtime? Are there any white noise or lights on during the night?

How intense does the client rate his pain on a scale of 1 to 10? Rationale A client with degenerative arthritis may have sleep disturbances related to chronic pain, so the client's pain intensity should be determined. Other factors that may affect the client's sleep patterns and should be considered after assessing the client's arthritic pain and how it is managed.

A mother brings her 4-year-old boy to the clinic because he spends his day in constant motion, talks excessively, and is easily distracted from playing with his toys. His preschool teacher is unable to keep him focused in the classroom and suggested he undergo a mental health evaluation. Which nursing diagnosis should the nurse formulate? Risk for Injury. Compromised Family Coping. Impaired Social Interaction. Deficient Knowledge.

Impaired Social Interaction. Rationale Attention-deficit hyperactivity disorder (ADHD) is a behavioral disorder of children with significant problems in attention and concentration, impulse control, and overactivity. The nursing diagnosis, "Impaired Social Interaction" addresses the child's hyperverbalism, shortened attention span, and increased need for mobility that created his classroom difficulties.

A male client tells the nurse that he is frequently constipated. Which finding should the nurse identify as a common dietary cause of constipation? Megacolon or Hirschsprung's disease. Inadequate intake of dietary fiber and fluids. Chronic intake of excessive amounts of caffeine. Inadequate intake of fruit and vegetable juices.

Inadequate intake of dietary fiber and fluids. Rationale Functional causes of constipation include failure to respond to the urge to defecate, lack of fiber and fluids prolonged bed rest or lack of regular exercise, and habitual use of laxatives or enemas. The colon becomes atonic when these conditions are prolonged or not treated. Megacolon or Hirschsprung's disease occurs when constipation becomes severe, as feces accumulate in the colon, causing its diameter to extend, ultimately leading to loss of defecation reflexes and peristalic mobility. Chronic and heavy use of caffeine may cause diarrhea. Fruit and vegetable juices have minimal fiber compared to fresh, raw fruits and uncooked vegetables

The nurse is teaching an obese adolescent about lifestyle choices and ways to improve diet. Which interventions should the nurse include in the teaching plan? Plan a low-calorie, low-protein diet. Use nutritious foods as a method of reward. Encourage diversional activities during mealtimes. Incorporate favorite foods into the adolescent's diet.

Incorporate favorite foods into the adolescent's diet. Rationale The most successful diets are those that use ordinary foods in controlled portions rather than diets that require the avoidance of specific foods. To promote compliance, an adolescent should be taught how to incorporate favorite foods and to select substitutes that are satisfying and also maintain a healthy diet. Focusing on fat or caloric count of foods or meals can contribute to a "fat phobia" or "calorie conscious" as the adolescent tries to avoid certain foods. Food should not be used as a reward.

Which infant is at risk for Rh incompatibility? Infant who is Rh-negative and mother who is Rh-negative. Infant who is Rh-positive and mother who is Rh-positive. Infant of an Rh-negative mother and a father who is Rh-positive and homozygous for the Rh factor. Infant of an Rh-negative mother and a father who is Rh-positive and heterozygous for the Rh factor.

Infant of an Rh-negative mother and a father who is Rh-positive and homozygous for the Rh factor. Rationale Rh incompatibility occurs when a Rh-negative mother responds to previous exposure to Rh positive erythrocytes, and these antibodies cross the placental barrier to agglutinate erythrocytes of a Rh-positive fetus. If a mother is Rh negative and a father is Rh-positive and homozygous for the Rh factor (C), each Rh-positive fetus is at risk for Rh incompatibility.

Which intervention is most important for the nurse to include in the plan of care for a client with ankylosing spondylitis? Limit the client's daily fat intake to 30%. Increase the client's fluid intake to 3000 ml daily. Place pillows under the client when lying supine. Initiate a smoking cessation program.

Initiate a smoking cessation program. Rationale As the spine progressively stiffens, the client with ankylosing spondylitis should be encouraged to stop smoking to decrease the risk for pulmonary complications related to reduced chest expansion and movement. Although recommended health promotion practices should be encouraged, the risk of complications with ankylosing spondylitis is increased if the client continues to smoke. Using pillows under the client when lying supine may promote comfort, but should be evaluated to prevent flexion that increases the client's risk for flexion or fixation deformity

The nurse is catheterizing a 7-year-old boy who has been admitted to the pediatric unit. After cleansing the glans penis, what should the nurse do first to minimize discomfort? Insert 5 ml of 2% lidocaine lubricant into the urethra. Compress the glans to retain the lidocaine lubricant. Apply sterile lubricant to catheter tip prior to insertion. Wait 2 to 5 minutes before insertion of the catheter.

Insert 5 ml of 2% lidocaine lubricant into the urethra. Rationale In a pediatric male client, 5 ml of lidocaine lubricant, a topical anesthetic, should be inserted slowly into the urethra after cleansing the glans penis. To facilitate retention, gentle compression should be applied to the glans followed by a wait of 2 to 5 minutes to allow a therapeutic response prior to catheterization. Although additional sterile lubricate facilitates insertion, the lidocaine lubricant should be used first to reduce discomfort.

A client is prescribed a STAT dose of IV insulin. Which vial should the nurse select to prepare the dose? Insulin glulisine (Apidra). Insulin regular (Humulin R). Insulin detemir (Levemir). Insulin glargine (Lantus).

Insulin regular (Humulin R). Rationale Regular insulin (Humulin R, Novolin R, Exubera) is the only insulin that should be administered intravenously. Insulin glulisine (Apidra) is a very rapid acting insulin that should be administer subcutaneously or continuous subcutaneous (SUBQ) infusion, but not by IV injection or infusion. Insulin detemir (Levemir) has an intermediate duration and is administered SUBQ. Insulin glargine (Lantus) has a long duration and is administered SUBQ.

What information in a client's history indicates the highest risk factor for hepatitis C? Monogamous sexual activity. Intravenous drug abuse. Eating contaminated shellfish. Recent travel to an underdeveloped country.

Intravenous drug abuse. Rationale Major sources of infection for hepatitis C include blood and blood products, IV needles and syringes, and sexual activity with infected partners.

A client returns to the unit after abdominal Nissen fundoplication for treatment of gastroesophageal reflux disease. After 4 hours, the nurse determines the client has no drainage from the nasogastric tube (NGT) and has absent bowel sounds. What action should the nurse implement? Notify the healthcare provider. Continue to monitor the client. Reposition the nasogastric tube. Irrigate the NGT with normal saline.

Irrigate the NGT with normal saline Rationale After abdominal surgery, patency of the NGT should be maintained to avoid the need to reinsert the tube, which could possibility perforate the surgical repair site, so irrigation of the NGT should be implemented to promote gastric drainage and decompression

The nurse is caring for a client with diabetic ketoacidosis (DKA) who is manifesting rapid and deep respirations. Which respiratory pattern should the nurse document? Kussmaul respirations. Hyperventilation. Apneustic respirations. Biot's breathing.

Kussmaul respirations. Rationale Respirations that increase in rate and depth are considered Kussmaul's respirations . Respirations that are rapid and short in duration are described as hyperventilation. Respirations that are rapid and shallow are described as apneustic. Respirations that are fast, with periods of apnea, are described as Biot's respiration.

Which fetal heart rate (FHR) finding should the nurse report to the healthcare provider immediately? Late decelerations. Early decelerations. Accelerations with fetal movement. Average FHR of 126 beats per minute.

Late decelerations. Rationale Late decelerations are caused by uteroplacental insufficiency and result in fetal hypoxemia, an ominous sign if persistent and should be reported to the healthcare provider immediately. Early decelerations in the FHR are associated with head compression as the fetus descends into the maternal pelvic outlet and are common during normal labor. FHR accelerations with fetal movement are an indication of fetal well-being. An average FHR of 126 beats per minute is within normal limits.

A client returns from surgery after undergoing an abdominal-perineal resection with a sigmoid colostomy. The colostomy is dressed with petroleum jelly gauze and dry gauze dressings. The perineal incision is partially closed with two drains attached to Jackson-Pratt suction bulbs. During the early postoperative period, the nurse should give the highest priority to which nursing action? Provide a low-residue diet. Monitor drainage from the colostomy stoma. Maintain dry perineal dressings. Encourage looking at the colostomy site.

Maintain dry perineal dressings. Rationale During the immediate postoperative period, the perineal dressing should be assessed, reinforced, and changed frequently because profuse drainage during the first hours after surgery macerates tissue and compromises incisional approximation and healing. The priority action should include measures to promote healing and prevent infection.

Upon admission, the nurse determines a male client with alcohol withdrawal syndrome is experiencing visual and auditory hallucinations, confusion, dehydration, a swollen tongue, and bruising. Which action should the nurse include in this client's plan of care to ensure physiological stability? Keep the room dark. Monitor vital signs. Encourage oral fluids. Apply ice to his tongue.

Monitor vital signs. Rationale The client is manifesting symptoms of alcohol withdrawal delirium, which is considered a medical emergency and can result in death, so the best indicator of autonomic hyperactivity is monitoring the client's vital signs to evaluate physiological stability. Although a dark environment may reduce light stimuli, the client's perception is altered by shadows, which contribute to the client's anxiety, agitation, and hallucinations. The risk for seizures during alcohol withdrawal delirium increases the client's risk for aspiration, so oral fluids should be withheld at this time.

A client returns to the postoperative unit after a gastroduodenostomy (Billroth I) for treatment of a perforated ulcer. The healthcare provider's prescriptions include morphine with a patient-controlled analgesia (PCA), nasogastric tube (NGT) to low intermittent nasogastric suction, and IV fluids and antibiotics. The client complains of increasing abdominal pain 12 hours after returning to the surgical unit. The nurse determines the client has no bowel sounds, and 200 ml of bright red nasogastric drainage is in the suction canister in the past hour. What is the priority action the nurse should implement? Notify the healthcare provider. Irrigate the nasogastric tube per prescription. Assess the client's use of the PCA device. Splint the abdomen to relieve pressure on the incision.

Notify the healthcare provider. Rationale Although nasogastric aspirate can be bright red initially, the color should gradually darken over the first 24 hours. A sudden increase in the volume of bright red gastric drainage indicates bleeding, and the healthcare provider should be notified immediately. The client's complaints of pain and signs of bleeding require immediate action to prevent hemorrhagic shock.

A client with an open reduction and application of an external fixator for open, comminuted fractures of the tibia and fibula begins to complain of severe pain in the affected leg, which is not relieved by analgesics. The client says the toes are numb and tingling, although they appear pink. What action should the nurse implement? Notify the healthcare provider. Check the client's temperature. Loosen the screws on the external fixator pins. Elevate the extremity with ice at the wound site.

Notify the healthcare provider. Rationale Early recognition and treatment of compartment syndrome is critical, so the healthcare provider should be notified as soon as an elevated intra-compartmental pressure is suspected. The client's core body temperature has no relationship to the numbness and tingling in the toes distal to the fractures and surgical immobilization. Loosening the screws on the external fixatoris ineffective and not a nursing function. Elevating the extremity may raise venous pressure but slows arterial perfusion, while cold compresses cause vasoconstriction; both interventions exacerbate the compartment syndrome.

A nurse gives a client a narcotic for pain and must now leave the unit. To whom should the nurse delegate the task of evaluating the client's response to the pain medication? Unit clerk. Student nurse. Nurse-manager. Unlicensed assistive personnel.

Nurse-manager. Rationale Pain assessment and evaluation of analgesia are components in the scope of nursing practice and are determined by a licensed nurse, so the nurse-manager should assume this responsibility. Although some client care tasks may be delegated to unlicensed personnel evaluation of analgesia is a component of the nursing process that requires the expertise of a nurse.

The nurse is caring for a client who is one-day post cardiac catheterization with stent placement. Assessment findings are: blood pressure 90/40, heart rate 45 beats/minute, and oxygen saturation at 95% on oxygen nasal cannula at 2 L/minute. Which task should the nurse delegate to the unlicensed assistive personnel (UAP) at this time? Obtain urine output for the past 4 hours. Watch the client take an oral dose of aspirin. Assist with a morning shower and oral care. Report vital signs to the healthcare provider.

Obtain urine output for the past 4 hours. Rationale Basic nursing care tasks, such as vital signs, hygiene, nutrition, elimination, and intake and output are within the scope of practice for delegation to a UAP. The client is hemodynamically unstable due to bradycardia and hypotension, and is likely to experience syncope if mobilized, so activities such as showering are not indicated at this time.

The nurse is providing comfort and palliative care for a terminally ill client who is experiencing nausea and vomiting. Which action is best for the nurse to take to promote the client's comfort? Increase fluid intake. Offer high-protein foods. Provide a high-residue diet. Give prompt mouth care.

Offer high-protein foods. Rationale Measures to manage nausea and vomiting include the use of antiemetics and avoiding foods and liquids that increase stomach acidity, such as coffee, milk, and citrus acid juices. For some clients, an empty stomach exacerbates the nausea, so offering frequent, small amounts of foods that appeal to the client, such as dry cracker or bland, high protein foods help maintain nutritional status.

At what phase of the therapeutic relationship should the nurse ask a male client about his reasons for seeking medical care and hospitalization? Working phase. Termination phase. Orientation phase. Prior to discharge.

Orientation phase. Rationale During a hospital admission assessment, a common interview strategy is to ask the client to express his "chief complaint." In the admission process, the nurse is initiating the orientation phase of the nurse-client relationship, and the client's perceptions of his problems are defined and clarified, and goals are set. The working phase allows the client to examine previous coping methods, evaluate problem-solving effectiveness, and test new solutions. The termination phase involves summarizing the client's progress and accomplishments and often occurs prior to discharge from the hospital.

What clinical problem is a suitable for research utilization in nursing? Computerized client billing. Patient-controlled analgesia. Medication errors associated with incorrect dispensing. The value of calcium channel blockers use over ACE inhibitors.

Patient-controlled analgesia. Rationale An intervention that is designed in the planning phase of research utilization must be consistent with the theory. For example, Orem's theory of self-care requisites use for nursing practice, a successful intervention, is one that emphasizes self-care rather than care received from others.

Which action should the hospice nurse implement to assist a client maintain self-worth during the end-of-life process? Arrange for a grief counselor to visit with the client. Plan regular visits with the client throughout the day. Allow the client time alone to finalize personal affairs. Ensure the client's spiritual advisor provides support.

Plan regular visits with the client throughout the day. Rationale Planning regular visits helps the client maintain a sense of self-worth because it demonstrates that the client is worthy of others and the nurse's time and attention. A grief counselor and spiritual advisor may be requested but do not help maintain a client's sense of self-worth because it may imply that the nurse is too busy to be present for the client. Although some clients may choose to finalize personal affairs alone, a hospice client may experience feelings of abandonment and isolation if left alone during the end-of-life process and should have frequent contact with the nurse and/or family members.

The nurse identifies a break in sterile technique as a client is draped for an operative procedure. What action should the nurse implement? Inform the surgeon before an incision is made. Tell the circulating nurse at the end of the surgery. Say nothing because someone else is likely to report it. Point out the observation immediately to the surgical team.

Point out the observation immediately to the surgical team. Rationale Any break in sterile technique in the operating room should be immediately identified and remedied. Subsequent contamination of the sterile field will occur if the staff continue without replacing any contaminated surgical supplies or instruments.

Which nursing diagnosis is best to formulate for a 76-year-old client who is exhibiting an external locus of control? Hopelessness. Powerlessness. Social isolation. Personal identity disturbance.

Powerlessness. Rationale Individuals with an external locus of control consider themselves to be controlled by other individuals and by their environment. These clients believe that they have no control over their destiny and think that their behaviors have no effect on any outcomes, which is best supported with the nursing diagnosis, "Powerlessness". Secondary locus of control describes an individual with an external locus of control who has learned to adapt to their beliefs and prefer others to decide for them, which is learned helplessness.

During a mass casualty incident involving a 1000 or more victims, which action is the priority for the nurse to implement? Supervise the least experienced nursing personnel in delivering first aide to victims. Send nurses with disaster management experience to be first-line providers for victims. Prioritize care for victims with life-threatening problems according to likelihood of survival. Request the delivery of adequate supplies for emergency staff throughout the disaster.

Prioritize care for victims with life-threatening problems according to likelihood of survival. Rationale The role of the nurse during a disaster depends on a nurse's experience, but flexibility and implementation of safe nursing practice for clients with life-threatening problems is the priority in a disaster response. Thefirst action in a mass casualty or disaster is triage, which focuses on assessment of victims, separating casualties, and allocating treatment based on the victims' potential for survival.

The neonatologist requests a mother to provide breast milk for her 32-week gestational premature newborn. The nurse provides instructions about pumping, storing, and transporting the breast milk. Which additional information should the nurse include to ensure the mother understands the request? To promote maternal production with neonatal demand, pump only the volume the newborn takes. Providing breast milk ensures the premature newborn can easily digest and absorb the nutrients. Pump every 2 to 3 hours, including during the night, to increase breast milk volume. A glass of wine prior to pumping reduces anxiety and increases breast milk production.

Providing breast milk ensures the premature newborn can easily digest and absorb the nutrients. Rationale Breast milk, rather than formula, provides antibodies and nutrition that is easily digested and readily absorbed by an immature newborn. Breast milk can be frozen and used if the mother is unable to provide breast milk every day.. The mother does not have to pump through the night. Alcohol is excreted in breast milk and is not safe for the newborn.

A client is admitted with myasthenia gravis (MG). During the admission assessment, the nurse identifies that the client's upper eyelids are drooping. Which term should the nurse document to describe this assessment finding? Ptosis. Myopia. Keratitis. Astigmatism.

Ptosis. Rationale Ptosis, a hallmark finding in MG, describes drooping of the eyelids associated with neuromuscular disorders, such as MG, a chronic disease from an autoimmune response that destroys acetylcholine receptors and affects the neuromuscular junction.Myopia is nearsightedness. Keratitis is inflammation of the cornea. Astigmatism is a refractive condition.

The nurse-manager is planning to study a unit problem that engages the nursing staff in evidence-based practice. What is the sequence of activities that the nurse-manager should use? (Arrange in the order from first on top to last on the bottom.) 1. Identification of practice problem. 2. Review of published research. 3. Implementation of data gathering methods and data evaluation. 4. Identify and develop plan for application of research findings.

Rationale The proper sequence in the research utilization process begins with the identification of a practice problem, which in turn sets the stage for the step-by-step approach incorporating critical thinking and decision making. Review of published research, implementation of data gathering methods, analysis and evaluation of data, conclusion and plan for application of findings to the practice problem should follow.

A 32-year-old male client is admitted with paranoid schizophrenia. The nurse observes the client walking around the unit muttering to himself and gesturing as if he is having auditory hallucinations. Which action provides the most effective psychotherapeutic management? Reassure the client that he is safe and should rest. Minimize the client's social contact with other clients. Give a PRN anxiolytic medication before interacting with the client. Use behavior modification to decrease the frequency of hallucinations.

Reassure the client that he is safe and should rest. Rationale To provide the most effective psychotherapeutic management for a client with paranoid schizophrenia and auditory hallucinations, the client is often fearful and should be reassured of his safety and asylum and encouraged to rest. To facilitate communication in a therapeutic milieu management, the client should not be isolated unless he is a danger to himself or others.

Before administering timolol maleate (Timoptic) to a client with open-angled glaucoma, which finding should the nurse report to the healthcare provider? Has a family history of diabetes mellitus, type I. Receives carvedilol (Coreg) for heart failure (HF). Works outdoors as a construction site supervisor. Drinks alcoholic beverages twice a week.

Receives carvedilol (Coreg) for heart failure (HF) Rationale A client who is receiving a beta-blocker, such as carvedilol (Coreg), for HF or hypertension is at risk for additional systemic effects from ophthalmic beta blockers, such as Timoptic, so the healthcare provider should be notified of the client's current prescriptions.

When administering an intramuscular (IM) injection to an adult client using the ventrogluteal site, which landmarks should the nurse identify to locate the area for injection? The greater trochanter and the knee. The acromion process and the dorsal surface of the upper arm. The greater trochanter and the posterior iliac spine. The anterosuperior iliac spine and the greater trochanter

The anterosuperior iliac spine and the greater trochanter Rationale The heel of the hand is placed on the greater trochanter and the fingers spread to palpate the anterosuperior iliac spine, which are the landmarks used to give an injection in the ventrogluteal site.

An older Chinese client refuses to perform the range-of-motion and breathing exercises after a surgical procedure and is hesitant to complete hygienic care and grooming. What cultural factor should the nurse consider that is related to this client's behavior? Dependence on healthcare providers. Denial of traditional medical treatment. Lack of motivation to participate in self-care. Reliance on family members to assist with care.

Reliance on family members to assist with care. Rationale Self-care is a caring pattern of Western cultures. Non-Western cultures rely on family members to provide care, and dependence on healthcare providers is unlikely.

A mother asks the nurse to explain how using "time-out" to discipline her 2-year-old child is an effective method. Which rationale should the nurse provide? Offers positive reinforcement. Provides a consequence to behavior. Extinguishes the behavior by ignoring it. Removes a reinforcer that a child is receiving.

Removes a reinforcer that a child is receiving. Rationale Time-out is a disciplinary approach that removes a reinforcer, such as the satisfaction or attention the child receives from a behavior or activity. When placed in an unstimulating and isolated place, the child becomes bored and consequently agrees to behave in order to reenter the family group.

The nurse is providing care for a 6-year-old boy who has a broken arm and multiple bruises. The boy tells the nurse that his father was mad and broke his arm so the boy remembers to be good. What is the best nursing action? Chart that the child is a victim of child abuse. Do nothing because abuse cannot be proven. Report the situation to appropriate authorities. Ignore him because little boys make up stories.

Report the situation to appropriate authorities. Rationale Failure to report suspected child abuse that results in continued injury to the child is an act of negligence, so safe nursing practice requires reporting the situation to ensure the safety of the child. Although the child's comments and clinical picture should be documented, reporting the situation to authorities provides follow-up evaluation. The child is at potential risk for further injury.

A client who begins an exercise program asks the nurse about carbohydrate loading. What concepts should the nurse include in teaching the client ways to increase glycogen store in muscles? Moderate exercise and low fat intake. Rest and increased carbohydrate intake. Intense exercise and decreased carbohydrate intake. Intense exercise and high intake of complex carbohydrates.

Rest and increased carbohydrate intake. Rationale Carbohydrate loading is the process of changing foods eaten and adjusting exercise intensity to increase glycogen stores in the muscle. To achieve maximum muscle glycogen stores, a high carbohydrate diet should be consumed as part of a regular exercise program (60%-70% of total kilocalories from carbohydrate that tapers off to allow muscles to rest.

The charge nurse assigns one nurse to care for a client with shingles and another nurse to care for a client with HIV/AIDS. Which client goal is addressed by the charge nurse's assignments? Physiologic integrity. Psychosocial integrity. Health promotion and maintenance. Safe and effective care environment.

Safe and effective care environment. Rationale Management of the delivery of care should consider the risk of infection for a client who is immunosuppressed. A safe and effective care environment is provided by the assignment of care for these two clients to two different nurses so nosocomial transmission is minimized.

The nurse is teaching a client who is newly diagnosed with Type 1 diabetes mellitus about diet and insulin. The client should be instructed to perform glucose self-monitoring when which symptom occurs after exercising? Shakiness. Unusual thirst. Sudden anorexia. Excessive urination.

Shakiness. Rationale The primary response to acute exercise is an increase in glucose utilization, so the client should recognize shakiness as an early sign of hypoglycemia. Excessive urination (polyuria) and unusual thirst (polydipsia) are manifestations of hyperglycemia related to excess dietary intake or stressors, such as infection. Anorexia may be experienced with hyperglycemia, but serum glucose should be evaluated if the client demonstrates signs of hypoglycemia, which is more likely after exercising.

Which information is most important for the nurse to provide parents about long-term care for their child with hydrocephalus and a ventriculoperitoneal (VP) shunt? Physical contact sports may be restricted during childhood. Shunt malfunction or infection requires immediate treatment. Normal intellectual ability is expected with surgical diversion. The use of a protective helmet is recommended during childhood.

Shunt malfunction or infection requires immediate treatment. Rationale A VP shunt is the standard procedure for hydrocephalus in neonates and young infants which allows for excess tubing that minimizes the number of revisions needed as the child grows. Parents should be taught about the immediacy for medical intervention of VP complications, such as infection and functional or mechanical malfunction that cause the accumulation of cerebrospinal fluid.

A 50-year-old male client with amyotropic lateral sclerosis (ALS) is becoming increasingly debilitated and tells the nurse, "Since I haven't been able to go to church, I feel out of touch with God. I pray, but I wonder whether my prayers are heard." Which nursing diagnosis should the nurse include in the client's plan of care? Death anxiety. Powerlessness. Spiritual distress. Disturbed thought processes.

Spiritual distress. Rationale Based on the client's verbalized concern about his relationship with God and the inability to participate in religious services are defining characteristics for the nursing diagnosis of spiritual distress. Although the client may be experiencing death anxiety and powerlessness about his clinical diagnosis and prognosis, the client's spiritual coping strategies are compromised.

The nurse is assessing a postpartum client who delivered in the car. Which finding should the nurse identify as the earliest manifestation of a puerperal infection? Dysuria and pyuria with each voiding. White blood cells (WBC) greater than 12,000/mm3. Increased vaginal bleeding with ambulation. Temperature of 100.8 F 24 hours after delivery.

Temperature of 100.8 F 24 hours after delivery. Rationale Postpartum or puerperal infection is any clinical infection of the genital canal that occurs within 28 days after miscarriage, induced abortion, or childbirth. The presence of a fever of 38 C (100.4 F) 24 hours after birth is the first indicator. Although infection stimulates leukocytosis, WBC counts after delivery are normal up to 15,000/mm3.

The nurse is conducting a retrospective chart audit to investigate whether outcomes recorded in each nursing care plan are client-centered and written in behavioral terms. The Continuous Quality Improvement (CQI) Committee's expected benchmark is 98% compliance. The sample size is 200 charts, and the results show 180 charts met the benchmark. Which evaluation outcome should the nurse conclude? No action plan is necessary because the benchmark was met. The benchmark was not met and an action plan should be developed. An immediate re-audit is necessary because the benchmark was not met. The rate of compliance was close to the benchmark, so an action plan is unnecessary.

The benchmark was not met and an action plan should be developed. Rationale A threshold, or cutoff point, is determined for each indicator, and this example represents a 90% compliance rate. The expected benchmark is 98%, so an action plan should be developed.

The parents of a 5-year-old are concerned because their child showed more outward grief when a pet died than when a sibling died from sudden infant death syndrome (SIDS). What response should the nurse provide? The child should be old enough to have the concept of death as final and irreversible. The child's behavior suggests maladaptive coping and referral for counseling is needed. The child focuses on another connection because the sibling's death is misunderstood. The child is not old enough to have formed a significant attachment to the infant sibling.

The child focuses on another connection because the sibling's death is misunderstood. Rationale Principles of magical thinking and omnipotence affect preschoolers when a sibling becomes critically ill or dies. A preschooler may find no evidence to support the unexpected death of a healthy sibling with SIDS and views the death as temporary. The preschooler often misunderstands the reality and focuses on a less important connection, such as a pet as an outlet for feelings. School-age children's reactions begin developing an increasingly adult-like concept that death is universal and irreversible and are greatly influenced by their parents' attitudes.

Which principle should the nurse use to delegate client care to an unlicensed assistive personnel (UAP)? Minimal delegation of tasks provides a safer client care environment. Responsibility and authority are given to the person who accepts a delegated task. Client care tasks may be delegated to a UAP who is knowledgeable and experienced. The scope of practice defines which nursing interventions that can be delegated.

The scope of practice defines which nursing interventions that can be delegated. Rationale The five rights of delegation include the task, the circumstance, the person performing the task, the directions or instructions, and supervision. The health status and complexity of the care needed should match the skill of the staff member assigned the delegation. The delegating nurse should use principles of scope of practice mandated in the rules and regulations of state Nursing Practice Act and the employment agency's policies and job descriptions.

A client who is taking nitroglycerin for angina is concerned about having headaches after taking more than one tablet. What information should the nurse provide? This means that the levels of the nitroglycerin are toxic. The bottle of tablets has passed the expiration date. Headaches after taking nitroglycerin are indicative that a stroke is imminent. This is a common side effect due to the vasodilatory effects of the medication.

This is a common side effect due to the vasodilatory effects of the medication. Rationale Nitroglycerin produces coronary and cerebral vasodilation which causes headaches, a common side effect that can be relieved with aspirin, acetaminophen, or another mild analgesic. Toxicity of nitroglycerin is uncommon due to its short duration of action. The shelf-life of nitroglycerin tablets is six months after the container is open, despite the bottle label expiration date. The presence of a headache following administration of nitroglycerin is more likely an indication of the medication's potency, not an impending stroke.

The nurse is evaluating the external fetal monitor and identifies variable fetal heart rate (FHR) decelerations. The nurse recognizes that this change in the FHR pattern is due to which pathophysiological incident? Fetal hypoxemia. Umbilical cord compression. Uteroplacental insufficiency. Altered fetal cerebral blood flow.

Umbilical cord compression. Rationale Variable decelerations occur any time during the uterine contracting phase and are caused by compression of the umbilical cord between the fetus and maternal pelvis, the fetal cord around the fetal neck, arm, leg, or other body part, a short cord, a knot in the cord, or a prolapsed cord.

Which client information should the nurse obtain that is indicative of the presence of cholelithiasis? Chest pain after swallowing that subsides when the food bolus moves into the stomach. Sharp, stabbing, thoracic pain that occurs during deep inspiration or coughing. Upper right abdominal pain that occurs after meals and radiates to the back or right shoulder. Abdominal pain relief that happens when foods are eaten on an empty stomach.

Upper right abdominal pain that occurs after meals and radiates to the back or right shoulder. Rationale Gallstone pain, biliary colic, is caused by spasm of the biliary ducts and gallbladder contractions that can dislodge stones, which can obstruction of the gallbladder outlet. Gallbladder pain starts in the upper midline area, and it may radiate to the back and right shoulder blade.

The nurse is instructing a mother about the care of her child who has pediculosis capitis. Which information should the nurse provide? Wash all nits out of hair with a regular shampoo. Cut hair shorter if infestation and nits are severe. Use a fine-toothed comb or tweezers to remove nits. Remove viable and moving parasites from hair shafts.

Use a fine-toothed comb or tweezers to remove nits. Rationale Pediculosis capitis (head lice) is an infestation of the scalp and a common parasite in school-age children. Therapeutic management consists of the application of pediculoides and daily manual removal of all nits (eggs) and lice using a metal nit or flea comb until no further parasites or eggs are found. Lice infest short hair as readily as long hair, and cutting a child's hair contributes to the child's distress and is not necessary.

What nursing intervention should the nurse include in the plan of care for a client following a bone marrow aspiration? Use of a compression dressing for firm pressure to the site. Proper positioning of the client in a prone position. Follow-up hematological laboratory studies. Application of warm, moist compresses to the puncture site.

Use of a compression dressing for firm pressure to the site. Rationale After the procedure, firm pressure using a compression dressing to the aspiration site should be applied to control bleeding if organ puncture or coagulopathy is present. Positioning the client prone is not necessary to control bleeding from the aspiration site. Although hematological laboratory studies should be reviewed before and after the procedure, the immediate risk is bleeding due to removal of bone marrow. Application of ice, not warm moist compresses reduces the potential for bleeding.

In reviewing the medical record, the nurse notes that a client's last eye examination revealed an intraocular pressure (IOP) of 28 mmHg. What information should the nurse ask the client? Length of time the client has been wearing prescription lenses. Recent experience of seeing light flashes or floaters. Complaints of any blind spots in the client's field of vision. Use of prescribed eye drops since last exam by ophthalmologist.

Use of prescribed eye drops since last exam by ophthalmologist. Rationale Normal intraocular pressures range between 10 and 21 mmHg, so the client's use of any prescribed eye drops should be determined to evaluate the client's intraocular pressure.

A male client has a prescription for disulfiram (Antabuse). Which adverse reaction should the nurse caution the client about while taking the medication? Euphoria. Vomiting. Hypertension. Hypoventilation.

Vomiting. Rationale A disulfiram reaction, includes nausea and severe vomiting if alcohol is ingested while taking disulfiram (Antabuse).

The nurse is assessing a client who is receiving risperidone (Risperdal). The nurse should monitor the client for which common side effect that is most likely to occur during therapy? Dystonia. Akathisia. Weight gain. Photosensitivity.

Weight gain. Rationale Risperidone (Risperdal, Consta) is an atypical antipsychotic agent with a lower potential for extrapyramidal effects, but cause common side effects, such as weight gain, insomnia, hypotension, and headache.