NCLEX 10,000 minus right OUT

A client with a bleeding ulcer is vomiting bright red blood. The nurse should assess the client for which of the following indicators of early shock? a) Tachycardia. b) Dry, flushed skin. c) Increased urine output. d) Loss of consciousness.

a - In early shock, the body attempts to meet its perfusion needs through tachycardia, vasoconstriction, and fluid conservation. The skin becomes cool and clammy. Urine output in early shock may be normal or slightly decreased. The client may experience increased restlessness and anxiety from hypoxia, but loss of consciousness is a late sign of shock.

Which nursing action is required before a client in labor receives epidural anesthesia? a) Give a fluid bolus of 500 ml. b) Check for maternal pupil dilation. c) Assess maternal reflexes. d) Assess maternal gait.

a) CORRECT ANSWER Give a fluid bolus of 500 ml. Reason: One of the major adverse effects of epidural administration is hypotension. Therefore, a 500-ml fluid bolus is usually administered to prevent hypotension in the client who wishes to receive an epidural for pain relief. Assessing maternal reflexes, pupil response, and gait isn't necessary.

While assessing the fundus of a multiparous client on the first postpartum day, the nurse performs hand washing and dons clean gloves. Which of the following should the nurse do next? a. place the non-dominant hand above the symphysis pubis and the dominant hand at the umbilicus b. ask the client to assume a side-lying position with the knees flexed c. perform massage vigorously at the level of the umbilicus if the fundus feels boggy d. place the client on a bedpan in case the uterine palpation stimulates the client to void

D - The nurse should place the non-dominant hand above the symphysis pubis and the dominant hand at the umbilicus to palpate the fundus. This prevents the uterine inversion and trauma, which can be very painful to the client. The nurse should ask the client to assume a supine, not side-lying, position with the knees flexed. The fundus can be palpated in this position and the perineal pads can be evaluated for lochia amounts. The fundus should be massaged gently if the fundus feels boggy. Vigorous massaging may fatigue the uterus and cause it to become firm and then boggy again. The nurse should ask the client to void before fundal evaluation. A full bladder can cause discomfort to the client, the uterus to be deviated to one side, and postpartum hemorrhage.

Total parenteral nutrition (TPN) is prescribed for a client who has recently had a significant small and large bowel resection and is currently not taking anything by mouth. The nurse should: a. administer TPN through a nasogastric or gastrostomy tube b. handle TPN using strict aseptic technique c. auscultate for bowel sounds prior to administering TPN d. designate a peripheral intravenous (IV) site for TPN administration

a - TPN is hypertonic, high-calorie, high-protein, intravenous (IV) fluid that should be provided to clients without functional gastrointestinal tract motility, to better meet their metabolic needs and to support optimal nutrition and healing. TPN is ordered once daily, based on the client's current electrolyte and fluid balance, and must be handled with strict aseptic technique (because of its high glucose content, it is a perfect medium for bacterial growth). Also, because of the high tonicity, TPN must be administered through a central venous access, not a peripheral IV line. There is no specific need to auscultate for bowel sounds to determine whether TPN can safely be administered

Prochlorperazine (Compazine) is prescribed postoperatively. The nurse should evaluate the drug's therapeutic effect when the client expresses relief from which of the following? a) Nausea. b) Dizziness. c) Abdominal spasms. d) Abdominal distention.

a) CORRECT ANSWER Nausea. Reason: Prochlorperazine is administered postoperatively to control nausea and vomiting. Prochlorperazine is also used in psychotherapy because of its effects on mood and behavior. It is not used to treat dizziness, abdominal spasms, or abdominal distention.

A nurse takes informed consent from a client scheduled for abdominal surgery. Which of the following is the most appropriate principle behind informed consent? a) Protects the client's right to self-determination in health care decision making. b) Helps the client refuse treatment that he or she does not wish to undergo. c) Helps the client to make a living will regarding future health care required. d) Provides the client with in-depth knowledge about the treatment options available.

a) CORRECT ANSWER Protects the client's right to self-determination in health care decision making. Reason: Informed consent protects the client's right to self-determination in health care decision making. Informed consent helps the client to refuse a treatment that the client does not wish to undergo and helps the client to gain in-depth knowledge about the treatment options available, but the most important function is to encourage shared decision making. Informed consent does not help the client to make a living will.

A nurse has received change-of-shift-report and is briefly reviewing the documentation about a client in the client's medical record. A recent entry reads, "Client was upset throughout the morning." How could the charting entry be best improved? a) The entry should include clearer descriptions of the client's mood and behavior. b) The entry should avoid mentioning cognitive or psychosocial issues. c) The entry should list the specific reasons that the client was upset. d) The entry should specify the subsequent interventions that were performed.

a) CORRECT ANSWER The entry should include clearer descriptions of the client's mood and behavior. Reason: Entries in the medical record should be precise, descriptive, and objective. An adjective such as "upset" is unclear and open to many interpretations. As such, the nurse should elaborate on this description so a reader has a clearer understanding of the client's state of mind. Stating the apparent reasons that the client was "upset" does not resolve the ambiguity of this descriptor. Cognitive and psychosocial issues are valid components of the medical record. Responses and interventions should normally follow assessment data but the data themselves must first be recorded accurately.

A 7 year old with a history of tonic-clonic seizures has been actively seizing for 10 minutes. The child weighs 22 kg and currently has an intravenous (IV) line of D5 1/2 NS + 20 meq KCL/L running at 60 ml/hr. Vital signs are a temperature of 38 degrees C, heart rate of 120, respiratory rate of 28, and oxygen saturation of 92%. Using the SBAR (Situation-Background-Assessment-Recommendation) technique for communication, the nurse calls the primary healthcare provider with a recommendation for: a) Rectal diazepam (Diastat). b) IV lorazepam (Ativan). c) Rectal acetaminophen (Tylenol). d) IV fosphenytoin.

b - IV ativan is the benzodiazepine of choice for treating prolonged seizure activity. IV benzodiazepines potentiate the action of the gamma-aminobutyric acid (GABA) neurotransmitter, stopping seizure activity. If an IV line is not available, rectal Diastat is the benzodiazepine of choice. The child does have a low-grade fever; however, this is likely caused by the excessive motor activity. The primary goal for the child is to stop the seizure in order to reduce neurologic damage. Benzodiazepines are used for the initial treatment of prolonged seizures. Once the seizure has ended, a loading dose of fosphenytoin or phenobarbital is given.

A 10-month-old child with recurrent otitis media is brought to the clinic for evaluation. To help determine the cause of the child's condition, the nurse should ask the parents: a) "Does water ever get into the baby's ears during shampooing?" b) "Do you give the baby a bottle to take to bed?" c) "Have you noticed a lot of wax in the baby's ears?" d) "Can the baby combine two words when speaking?"

b - In a young child, the eustachian tube is relatively short, wide, and horizontal, promoting drainage of secretions from the nasopharynx into the middle ear. Therefore, asking if the child takes a bottle to bed is appropriate because drinking while lying down may cause fluids to pool in the pharyngeal cavity, increasing the risk of otitis media. Asking if the parent noticed earwax, or cerumen, in the external ear canal is incorrect because wax doesn't promote the development of otitis media. During shampooing, water may become trapped in the external ear canal by large amounts of cerumen, possibly causing otitis external (external ear inflammation) as opposed to internal ear inflammation. Asking if the infant can combine two words is incorrect because a 10-month-old child isn't expected to do so.

The nurse is caring for several mother-baby couplets. In planning the care for each of the couplets, which mother would the nurse expect to have the most severe afterbirth pains? a) G 4, P 1 client who is breastfeeding her infant. b) G 3, P 3 client who is breastfeeding her infant. c) G 2, P 2 cesarean client who is bottle-feeding her infant. d) G 3, P 3 client who is bottle-feeding her infant.

b - The major reasons for afterbirth pains are breast-feeding, high parity, overdistended uterus during pregnancy, and a uterus filled with blood clots. Physiologically, afterbirth pains are caused by intermittent contraction and relaxation of the uterus. These contractions are stronger in multigravidas in order to maintain a contracted uterus. The release of oxytocin when breast-feeding also stimulates uterine contractions. There is no data to suggest any of these clients has had an overdistended uterus or currently has clots within the uterus. The G 3, P 3 client who is breast-feeding has the highest parity of the clients listed, which—in addition to breast-feeding—places her most at risk for afterbirth pains. The G 2, P 2 postcesarean client may have cramping but it should be less than the G 3, P 3 client. The G 3, P 3 client who is bottle-feeding would be at risk for afterbirth pains because she has delivered several children, but her choice to bottle-feed reduces her risk of pain.

A nurse is instructing a client with bipolar disorder on proper use of lithium carbonate (Eskalith), the drug's adverse effects, and symptoms of lithium toxicity. Which client statement indicates that additional teaching is required? a. "I can still eat my favorite salty foods." b. "when my moods fluctuate, I'll increase my dose of lithium." c. "a good blood level of the drug means the drug concentration has stabilized." d. "eating too much watermelon will affect my lithium level."

b - a client who states that he'll increase his dose of lithium if his mood fluctuates requires additional teaching because increasing the dose of lithium without evaluating the client's laboratory values can cause serious health problems, such as lithium toxicity, overdose, and renal failure. Clients taking lithium don't need to limit their sodium intake. A low sodium diet causes lithium retention. A therapeutic lithium blood level indicates that the drug concentration has stabilized. The client demonstrates effective teaching by stating his lithium levels will be affected by foods that have a diuretic effect, such as watermelon, cantaloupe, grapefruit juice and cranberry juice.

A client with Rh isoimmunization gives birth to a neonate with an enlarged heart and severe, generalized edema. The neonate is immediately transferred to the neonatal intensive care unit. Which nursing diagnosis is most appropriate for the client? a. ineffective parenting related to the neonate's transfer to the intensive care unit b. impaired parenting related to the neonate's transfer to the intensive care unit c. deficient fluid volume related to severe edema d. fear related to removal and loss of the neonate by statute

b - because the neonate is severely ill and needs to be placed in the neonatal intensive care unit, the client may have a nursing diagnosis of 'impaired parenting related to the neonate's transfer to the neonatal intensive care unit.' (another pertinent nursing diagnosis may be 'compromised family coping related to lack the opportunity for bonding.) Rh isoimmunization isn't a socially unacceptable infection. This condition causes an excess fluid volume (not deficient) related to cardiac problems. Rh isoimmunization doesn't lead to loss of the neonate by statute.

The major goal of therapy in crisis intervention is to: a. withdraw from the stress b. resolve the immediate problem c. decrease anxiety d. provide documentation of events

b - during a period of crisis, the major goal is to resolve the immediate problem, with hopes of getting the individual to the level of functioning that existed before the crisis or to a higher level of functioning. Withdrawing from stress doesn't address the immediate problem and isn't therapeutic. The client's anxiety will decrease after the immediate problem is resolved. Providing support and safety are necessary interventions while working toward accomplishing the goal. Documentation is necessary for maintaining accurate records of treatment, but isn't a major goal.

A client has a herniated disk in the region of the third and fourth lumbar vertebrae. Which nursing assessment finding most supports this diagnosis? a. hypoactive bowel sounds b. severe lower back pain c. sensory deficits in one arm d. weakness and atrophy of the arm muscles

b - the most common finding in a client with a herniated lumbar disk is severe lower back pain, which radiates to the buttocks, legs, and feet - usually unilaterally. A herniated disk also may cause sensory and motor loss (such as foot drop) in the area innervated by the compressed spinal nerve root. During later stages, it may cause weakness and atrophy of leg muscles. The condition doesn't affect bowel sounds or the arms.

A home health nurse who sees a client with diverticulitis is evaluating teaching about dietary modifications necessary to prevent future episodes. Which statement by the client indicates effective teaching? a) "I'll increase my intake of protein during exacerbations." b) "I should increase my intake of fresh fruits and vegetables during remissions." c) "I'll snack on nuts, olives, and popcorn during flare-ups." d) "I'll incorporate foods rich in omega-3 fatty acids into my diet."

b) CORRECT ANSWER "I should increase my intake of fresh fruits and vegetables during remissions." Reason: A client with diverticulitis needs to modify fiber intake to effectively manage the disease. During episodes of diverticulitis, he should follow a low-fiber diet to help minimize bulk in the stools. A client with diverticulosis should follow a high-fiber diet. Clients with diverticular disease don't need to modify their intake of protein and omega-3 fatty acids.

A client with an incomplete small-bowel obstruction is to be treated with a Cantor tube. Which of the following measures would most likely be included in the client's care once the Cantor tube has passed into the duodenum? a) Maintain bed rest with bathroom privileges. b) Advance the tube 2 to 4 inches at specified times. c) Avoid frequent mouth care. d) Provide ice chips for the client to suck.

b) CORRECT ANSWER Advance the tube 2 to 4 inches at specified times. Reason: Once the intestinal tube has passed into the duodenum, it is usually advanced as ordered 2 to 4 inches every 30 to 60 minutes. This, along with gravity and peristalsis, enables passage of the tube forward. The client is encouraged to walk, which also facilitates tube progression. A client with an intestinal tube needs frequent mouth care to stimulate saliva secretion, to maintain a healthy oral cavity, and to promote comfort regardless of where the tube is placed in the intestine. Ice chips are contraindicated because hypotonic fluid will draw extra fluid into an already distended bowel.

A nurse, a licensed practical nurse (LPN), and a nursing assistant are caring for a group of clients. The nurse asks the nursing assistant to check the pulse oximetry level of a client who underwent laminectomy. The nursing assistant reports that the pulse oximetry reading is 89%. The client Kardex contains an order for oxygen application at 2 L/min should the pulse oximetry level fall below 92%. The nurse is currently assessing a postoperative client who just returned from the postanesthesia unit. How should the nurse proceed? a. immediately go the client's room and assess vital signs, administer oxygen at 2 L/minute, and notify the physician. b. ask the nursing assistant to notify the physician of the low pulse oximetry level c. ask the LPN to obtain vital signs and administer oxygen at 2 L/min to the client who underwent laminectomy d. complete the assessment of the new client before attending to the client who underwent laminectomy

c - because it's important to get more information about the client with a decreased pulse oximetry level, the nurse should ask the LPN to obtain vital signs and administer oxygen as ordered. The nurse must attend to the newly admitted client without delaying treatment to the client who is already in her care. The nurse can effectively do this by delegating tasks to an appropriate health team member such as an LPN. The nurse doesn't need to immediately attend to the client with a decreased pulse oximetry level; she may wait until she completes the assessment of the newly admitted client. The physician doesn't need to be notified at this time because an order for oxygen administration is already on record.

A client in the triage area who is at 19 weeks' gestation states that she has not felt her baby move in the past week and no fetal heart tones are found. While evaluating this client, the nurse identifies her as being at the highest risk for developing which problem? a) Abruptio placentae. b) Placenta previa. c) Disseminated intravascular coagulation. d) Threatened abortion.

c) CORRECT ANSWER Disseminated intravascular coagulation. Reason: A fetus that has died and is retained in utero places the mother at risk for disseminated intravascular coagulation (DIC) because the clotting factors within the maternal system are consumed when the nonviable fetus is retained. The longer the fetus is retained in utero, the greater the risk of DIC. This client has no risk factors, history, or signs and symptoms that put her at risk for either abruptio placentae or placenta previa, such as sharp pain and "woody," firm consistency of the abdomen (abruption) or painless bright red vaginal bleeding (previa). There is no evidence that she is threatening to abort as she has no complaints of cramping or vaginal bleeding.

A 16-year-old academically gifted boy is about to graduate from high school early, because he has completed all courses needed to earn a diploma. Within the last 3 months, he has experienced panic attacks that have forced him to leave classes early and occasionally miss a day of school. He is concerned that these attacks may hinder his ability to pursue a college degree. What would be the best response by the school nurse who has been helping him deal with his panic attacks? a) "It is natural to be worried about going into a new environment. I am sure with your abilities you will do well once you get settled." b) "You are putting too much pressure on yourself. You just need to relax more and things will be alright." c) "It might be best for you to postpone going to college. You need to get these panic attacks controlled first." d) "It sounds like you have a real concern about transitioning to college. I can refer you to a health care provider for assessment and treatment."1

d) CORRECT ANSWER "It sounds like you have a real concern about transitioning to college. I can refer you to a health care provider for assessment and treatment." Reason: The client's concerns are real and serious enough to warrant assessment by a physician rather than being dismissed as trivial. Though he is very intelligent, his intelligence cannot overcome his anxiety. In fact, his anxiety is likely to interfere with his ability to perform in college if no assessment and treatment are received. Just postponing college is likely to increase rather than lower the client's anxiety, because it does not address the panic he is experiencing.

A multigavid client in labor at 38 weeks' gestation has been diagnosed with Rh sensitization and probably fetal hydrops and anemia. When the nurse observes the fetal heart rate pattern on the monitor, which of the following patterns is most likely? a. early deceleration pattern b. sinusoidal pattern c. variable deceleration pattern d. late deceleration pattern

B - The fetal heart rate of a multipara diagnosed with Rh sensitization and probably fetal hydrops and anemia will most likely demonstrate a sinusoidal pattern that resembles a sine wave. It has been hypothesized that this pattern reflects an absence of autonomic nervous control over the fetal heart rate resulting from severe hypoxia. This client will most likely requires a cesarean delivery to improve the fetal outcome. Early decelerations are associated with cord compression; and late deceleration are associated with poor placental perfusion

A 40-year-old executive who was unexpectedly laid off from work 2 days earlier complains of fatigue and an inability to cope. He admits drinking excessively over the previous 48 hours. This behavior is an example of: a. alcoholism b. manic episode c. situational crisis d. depression

C - A situational crisis results from a specific event in the life of a person who is overhwlemed by the situation and reacts emotional. Fatigue, insomnia, and inability to make decisions are common signs and symtpoms. The situations crisis may precipitate behavior that causes a criss (alcohol or drug abuse). There isn't enough information to label this client an alcoholic. A manic episodes is characterized by euphoria and labile effect. Symptoms of depression are usually present for 2 or more weeks.

A child, age 3, is brought to the emergency department in respiratory distress caused by acute epiglottiditis. Which clinical manifestations should the nurse expect to assess? a. severe sore throat, drooling, and inspiratory strider b. low grade fever, stridor, and a barking cough c. pulmonary congestion, a productive cough, and a fever d. sore throat, a fever, and general malaise

a - a child with acute epiglottiditis appears acutely ill and clinical manifestations may include drooping (because of difficulty swallowing), severe sore throat, hoarseness, a high temperature, and severe inspiratory stridor. A low grade fever, stridor, and barking cough that worsens at night are suggestive of croup. Pulmonary congestion, productive cough, and fever along with nasal flaring, retractions, chest pain, dyspnea, decreased breath sounds, and crackles indicate pneumococcal pneumonia. A sore throat, fever, and general malaise point to viral pharyngitis.

A nurse is caring for a client with lower back pain who is scheduled for myelography using metrizamide (a water-soluble contrast dye). After the test, the nurse should place the client in which position? a. head of the bed elevated 45 degrees b. prone c. supine with feet raised d. supine with the head lower than the trunk

a - after a myelogram, positioning depends on the dye injected. When a water-soluble dye such as metrizamide in injected, the head of the bed is elevated to a 45-degree angle to slow the upward dispersion of the dye. The prone and supine positions are contraindicated when a water-soluble contrast dye is used. The client should be positioned supine with the head lower than the trunk after an air-contrast study.

when caring for a client after a closed renal biopsy, the nurse should: a. maintain the client on strict bed rest in a supine position for 6 hours b. insert an indwelling catheter to monitor urine output c. apply a sandbag to the biopsy site to prevent bleeding d. administer IV opioid medications to promote comfort

a - after a renal biopsy, the client is maintained on strict bed rest in a supine position for at least 6 hours to prevent bleeding. If no bleeding occurs, the client typically resumes general activity after 24 hours. Urine output is monitored, but an indwelling catheter is not typically inserted. A pressure dressing is applied over the site, but a sandbag is not necessary. Opioids to control pain would not be anticipated; local discomfort at a biopsy site can be controlled with analgesics.

the comatose victim of the car accident is to have a gastric lavage. Which of the following positions would be most appropriate for the client during this procedure? a. lateral b. supine c. trendelenburg's d. lithotomy

a - an unconscious client is best positioned in a lateral or semiprone position because these positions allow the jaw and tongue to fall forward, facilitate drainage of secretions, and prevent aspiration. Positioning the client supine carries a major risk of airway obstruction from the tongue, vomit, or nasopharyngeal secretions. Trendeleburg's position, with the head lower than the heart, decreases effective lung volume and increases the risk of cerebral edema. The lithotomy position has no purpose in this situation.

The nurse is assessing a client at her postpartum checkup 6 weeks after a vaginal delivery. The mother is bottle feeding her baby. Which client finding indicates a problem at this time? a. firm fundus at the symphysis b. white, thick vaginal discharge c. striae that are silver in color d. soft breasts without milk

a - by 4 to 6 weeks postpartum, the fundus should be deep in the pelvis and the size of a non-pregnant uterus. Subinvolution, caused by infection or retained placental fragments, is a problem associated with a uterus that is larger than expected at this time. Normal expectations include a white, thick vaginal discharge, striae that are beginning to fade to silver, and breasts that are soft without evidence of milk production (in a bottle feeding mother).

A client with type 1 diabetes must undergo bowel resection in the morning. How should the nurse proceed while caring for him on the morning of surgery? a. administer half of the client's typical morning insulin dose as ordered b. administer an oral antidiabeteic agent as ordered c. administer an I.V. insulin infusion as ordered d. administer the client's normal daily dose of insulin as ordered

a - if the nurse administers the client's normal daily dose of insulin while he's on nothing-by-mouth status before surgery, he'll experience hypoglycemia. Therefore, the nurse should administer half the daily insulin dose as ordered. Oral antidiabetic agents aren't effective for type 1 diabetes I.V. insulin infusions aren't necessary to manage blood glucose levels in clients undergoing routine surgery.

Which of the following client statements indicates that the client with hepatitis B understands discharge teaching? a) "I will not drink alcohol for at least 1 year." b) "I must avoid sexual intercourse." c) "I should be able to resume normal activity in a week or two. d) "Because hepatitis B is a chronic disease, I know I will always be jaundiced."

a) CORRECT ANSWER "I will not drink alcohol for at least 1 year." Reason: It is important that the client understand that alcohol should be avoided for at least 1 year after an episode of hepatitis. Sexual intercourse does not need to be avoided, but the client should be instructed to use condoms until the hepatitis B surface antigen measurement is negative. The client will need to restrict activity until liver function test results are normal; this will not occur within 1 to 2 weeks. Jaundice will subside as the client recovers; it is not a permanent condition.

A client is scheduled for an excretory urography at 10 a.m. An order directs the nurse to insert a saline lock I.V. device at 9:30 a.m.. The client requests a local anesthetic for the I.V. procedure and the physician orders lidocaine-prilocaine cream (EMLA cream). The nurse should apply the cream at: a) 7:30 a.m. b) 8:30 a.m. c) 9 a.m. d) 9:30 a.m.

a) CORRECT ANSWER 7:30 a.m. Reason: It takes up to 2 hours for lidocaine-prilocaine cream (EMLA cream) to anesthetize an insertion site. Therefore, if the insertion is scheduled for 9:30 a.m., EMLA cream should be applied at 7:30 a.m. The local anesthetic wouldn't be effective if the nurse administered it at the later times.

The nurse is serving on the hospital ethics committee which is considering the ethics of a proposal for the nursing staff to search the room of a client diagnosed with substance abuse while he is off the unit and without his knowledge. Which of the following should be considered concerning the relationship of ethical and legal standards of behavior? a) Ethical standards are generally higher than those required by law. b) Ethical standards are equal to those required by law. c) Ethical standards bear no relationship to legal standards for behavior. d) Ethical standards are irrelevant when the health of a client is at risk.

a) CORRECT ANSWER Ethical standards are generally higher than those required by law. Reason: Some behavior that is legally allowed might not be considered ethically appropriate. Legal and ethical standards are often linked, such as in the commandment "Thou shalt not kill." Ethical standards are never irrelevant, though a client's safety or the safety of others may pose an ethical dilemma for health care personnel. Searching a client's room when they are not there is a violation of their privacy. Room searches can be done with a primary health care provider's order and generally are done with the client present.

A client is prescribed metaproterenol (Alupent) via a metered-dose inhaler, two puffs every 4 hours. The nurse instructs the client to report adverse effects. Which of the following are potential adverse effects of metaproterenol? a) Irregular heartbeat. b) Constipation. c) Pedal edema. d) Decreased pulse rate.

a) CORRECT ANSWER Irregular heartbeat. Reason: Irregular heartbeats should be reported promptly to the care provider. Metaproterenol (Alupent) may cause irregular heartbeat, tachycardia, or anginal pain because of its adrenergic effect on beta-adrenergic receptors in the heart. It is not recommended for use in clients with known cardiac disorders. Metaproterenol does not cause constipation, pedal edema, or bradycardia.

Which of the following should the nurse use to determine achievement of the expected outcome for an infant with severe diarrhea and a nursing diagnosis of Deficient fluid volume related to passage of profuse amounts of watery diarrhea? a) Moist mucous membranes. b) Passage of a soft, formed stool. c) Absence of diarrhea for a 4-hour period. d) Ability to tolerate intravenous fluids well.

a) CORRECT ANSWER Moist mucous membranes. Reason: The outcome of moist mucous membranes indicates adequate hydration and fluid balance, showing that the problem of fluid volume deficit has been corrected. Although a normal bowel movement, ability to tolerate intravenous fluids, and an increasing time interval between bowel movements are all positive signs, they do not specifically address the problem of deficient fluid volume.

A client has the following arterial blood gas values: pH, 7.30; PaO2, 89 mm Hg; PaCO2, 50 mm Hg; and HCO3-, 26 mEq/L. Based on these values, the nurse should suspect which condition? a) Respiratory acidosis b) Respiratory alkalosis c) Metabolic acidosis d) Metabolic alkalosis

a) CORRECT ANSWER Respiratory acidosis Reason: This client has a below-normal (acidic) blood pH value and an above-normal partial pressure of arterial carbon dioxide (PaCO2) value, indicating respiratory acidosis. In respiratory alkalosis, the pH value is above normal and the PaCO2 value is below normal. In metabolic acidosis, the pH and bicarbonate (HCO3-) values are below normal. In metabolic alkalosis, the pH and HCO3- values are above normal.

A 10-year-old child diagnosed with acute glomerulonephritis is admitted to the pediatric unit. The nurse should ensure that which action is a part of the child's care? a) Taking vital signs every 4 hours and obtaining daily weight b) Obtaining a blood sample for electrolyte analysis every morning c) Checking every urine specimen for protein and specific gravity d) Ensuring that the child has accurate intake and output and eats a high-protein diet

a) CORRECT ANSWER Taking vital signs every 4 hours and obtaining daily weight Reason: Because major complications — such as hypertensive encephalopathy, acute renal failure, and cardiac decompensation — can occur, monitoring vital signs (including blood pressure) is an important measure for a child with acute glomerulonephritis. Obtaining daily weight and monitoring intake and output also provide evidence of the child's fluid balance status. Sodium and water restrictions may be ordered depending on the severity of the edema and the extent of impaired renal function. Typically, protein intake remains normal for the child's age and is only increased if the child is losing large amounts of protein in the urine. Checking urine specimens for protein and specific gravity and daily monitoring of serum electrolyte levels may be done, but their frequency is determined by the child's status. These actions are less important nursing measures in this situation.

A client complains of severe abdominal pain. To elicit as much information as possible about the pain, the nurse should ask: a) "Do you have the pain all the time?" b) "Can you describe the pain?" c) "Where does it hurt the most?" d) "Is the pain stabbing like a knife?"

b - Asking an open-ended question such as "Can you describe the pain?" encourages the client to describe any and all aspects of the pain in his own words. The other options are likely to elicit less information because they're more specific and would limit the client's response.

A pregnant client in her third trimester is started on chlorpromazine (Thorazine) 25 mg four times daily. Which of the following instructions is most important for the nurse to include in the client's teaching plan? a) "Don't drive because there's a possibility of seizures occurring." b) "Avoid going out in the sun without a sunscreen with a sun protection factor of 25." c) "Stop the medication immediately if constipation occurs." d) "Tell your doctor if you experience an increase in blood pressure."

b - Chlorpromazine is a low-potency antipsychotic that is likely to cause sun-sensitive skin. Therefore the client needs instructions about using sunscreen with a sun protection factor of 25 or higher. Typically, chlorpromazine is not associated with an increased risk of seizures. Although constipation is a common adverse effect of this drug, it can be managed with diet, fluids, and exercise. The drug does not need to be discontinued. Chlorpromazine is associated with postural hypotension, not hypertension. Additionally, if postural hypotension occurs, safety measures, such as changing positions slowly and dangling the feet before arising, not stopping the drug, are instituted.

The mother of a client with chronic undifferentiated schizophrenia calls the visiting nurse in the outpatient clinic to report that her daughter has not answered the phone in 10 days. "She was doing so well for months. I don't know what's wrong. I'm worried." Which of the following responses by the nurse is most appropriate? a) "Maybe she's just mad at you. Did you have an argument?" b) "She may have stopped taking her medications. I'll check on her." c) "Don't worry about this. It happens sometimes." d) "Go over to her apartment and see what's going on."

b - Noncompliance with medications is common in the client with chronic undifferentiated schizophrenia. The nurse has the responsibility to assess this situation. Asking the mother if they've argued or if the client is mad at the mother or telling the mother to go over to the apartment and see what's going on places the blame and responsibility on the mother and therefore is inappropriate. Telling the mother not to worry ignores the seriousness of the client's symptoms.

A client with inflammatory bowel disease is receiving total parenteral nutrition (TPN). The basic component of the client's TPN solution is most likely to be: a) An isotonic dextrose solution. b) A hypertonic dextrose solution. c) A hypotonic dextrose solution. d) A colloidal dextrose solution.

b - The TPN solution is usually a hypertonic dextrose solution. The greater the concentration of dextrose in solution, the greater the tonicity. Hypertonic dextrose solutions are used to meet the body's calorie demands in a volume of fluid that will not overload the cardiovascular system. An isotonic dextrose solution (e.g., 5% dextrose in water) or a hypotonic dextrose solution will not provide enough calories to meet metabolic needs. Colloids are plasma expanders and blood products and are not used in TPN.

A nurse is monitoring a client receiving tranylcypromine sulfate (Parnate). Which serious adverse reaction can occur with high dosages of this monoamine oxidase (MAO) inhibitor? a) Hypotensive episodes b) Hypertensive crisis c) Muscle flaccidity d) Hypoglycemia

b - The most serious adverse reaction associated with high doses of MAO inhibitors is hypertensive crisis, which can lead to death. Although not a crisis, orthostatic hypotension is also common and may lead to syncope with high doses. Muscle spasticity (not flaccidity) is associated with MAO inhibitor therapy. Hypoglycemia isn't an adverse reaction of MAO inhibitors.

A 10-year-old with glomerulonephritis reports a headache and blurred vision. The nurse should immediately: a) Put the client to bed. b) Obtain the child's blood pressure. c) Notify the physician. d) Administer acetaminophen (Tylenol).

b) CORRECT ANSWER Obtain the child's blood pressure. Reason: Hypertension occurs with acute glomerulonephritis. The symptoms of headache and blurred vision may indicate an elevated blood pressure. Hypertension in acute glomerulonephritis occurs due to the inability of the kidneys to remove fluid and sodium; the fluid is reabsorbed, causing fluid volume excess. The nurse must verify that these symptoms are due to hypertension. Calling the physician before confirming the cause of the symptoms would not assist the physician in his treatment. Putting the client to bed may help treat an elevated blood pressure, but first the nurse must establish that high blood pressure is the cause of the symptoms. Administering Tylenol for high blood pressure is not recommended.

When measuring the fundal height of a primigravid client at 20 weeks' gestation, the nurse will locate the fundal height at which of the following points? a) Halfway between the client's symphysis pubis and umbilicus. b) At about the level of the client's umbilicus. c) Between the client's umbilicus and xiphoid process. d) Near the client's xiphoid process and compressing the diaphragm.

b) CORRECT ANSWER At about the level of the client's umbilicus. Reason: Measurement of the client's fundal height is a gross estimate of fetal gestational age. At 20 weeks' gestation, the fundal height should be at about the level of the client's umbilicus. The fundus typically is over the symphysis pubis at 12 weeks. A fundal height measurement between these two areas would suggest a fetus with a gestational age between 12 and 20 weeks. The fundal height increases approximately 1 cm/week after 20 weeks' gestation. The fundus typically reaches the xiphoid process at approximately 36 weeks' gestation. A fundal height between the umbilicus and the xiphoid process would suggest a fetus with a gestational age between 20 and 36 weeks. The fundus then commonly returns to about 4 cm below the xiphoid owing to lightening at 40 weeks. Additionally, pressure on the diaphragm occurs late in pregnancy. Therefore, a fundal height measurement near the xiphoid process with diaphragmatic compression suggests a fetus near the gestational age of 36 weeks or older.

A nurse is assessing the legs of a client who's 36 weeks pregnant. Which finding should the nurse expect? a) Absent pedal pulses b) Bilateral dependent edema c) Sluggish capillary refill d) Unilateral calf enlargement

b) CORRECT ANSWER Bilateral dependent edema Reason: As the uterus grows heavier during pregnancy, femoral venous pressure rises, leading to bilateral dependent edema. Factors interfering with venous return, such as sitting or standing for long periods, contribute to edema. Absence of pedal pulses and sluggish capillary refill signal inadequate circulation to the legs — an unexpected finding during pregnancy. Unilateral calf enlargement, also an abnormal finding, may indicate thrombosis.

A parent brings a 5-year-old child to a vaccination clinic to prepare for school entry. The nurse notes that the child has not had any vaccinations since 4 months of age. To determine the current evidence for best practices for scheduling missed vaccinations the nurse should: a) Ask the primary care provider. b) Check the website at the Center for Disease Control and Prevention (CDC). c) Read the vaccine manufacturer's insert. d) Contact the pharmacist.

b) CORRECT ANSWER Check the website at the Center for Disease Control and Prevention (CDC). Reason: The CDC is the federal body that is ultimately responsible for vaccination recommendations for adults and children. A division of the CDC, the Advisory Committee on Immunization Practices, reviews vaccination evidence and updates recommendation on a yearly basis. The CDC publishes current vaccination catch-up schedules that are readily available on their website. The lack of vaccinations is a strong indicator that the child probably does not have a primary care provider. If consulted, the pharmacist would most likely have to review the CDC guidelines that are equally available to the nurse. Reading the manufacturer's inserts for multiple vaccines would be time consuming and synthesis of the information could possibly lead to errors.

A nurse is helping a physician insert a subclavian central line. After the physician has gained access to the subclavian vein, he connects a 10-ml syringe to the catheter and withdraws a sample of blood. He then disconnects the syringe from the port. Suddenly, the client becomes confused, disoriented, and pale. The nurse suspects an air embolus. She should: a) place the client in a supine position and prepare to perform cardiopulmonary resuscitation. b) place the client in high-Fowler's position and administer supplemental oxygen. c) turn the client on his left side and place the bed in Trendelenburg's position. d) position the client in the shock position with his legs elevated.

c - A nurse who suspects an air embolism should place the client on his left side and in Trendelenburg's position. Doing so allows the air to collect in the right atrium rather than enter the pulmonary system. The supine position, high-Fowler's position, and the shock position are therapeutic for other situations but not for air embolism.

A client has an episiotomy to widen her birth canal. Birth extends the incision into the anal sphincter. This complication is called: a. a first-degree laceration b. a second-degree laceration c. a third-degree laceration d. a fourth-degree laceration

c - birth may extend an episiotomy incision to the anal sphincter (a third degree laceration) or the anal canal (a fourth degree laceration). A first degree laceration involves the fourchette, perineal skin, and vaginal mucous membranes. A second degree laceration extends to the fasciae and muscle of the perineal body.

The nurse should instruct the family of a child with newly diagnosed hyperthyroidism to: a. keep their home warmer than usual b. encourage plenty of outdoor activities c. promote interactions with one friend instead of groups d. limit bathing to prevent skin irritation

c - children with hyperthyroidism experience emotional labiality that may strain interpersonal relationships. Focusing on one friend's is easier than adapting to group dynamics until the child's condition improves. Because of their high metabolic rate, children with hyperthyroidism complain of being too warm. Bright sunshine may be irritating because of disease-related ophthalmopathy. Sweating is common and bathing should be encouraged.

A client with pneumonia has a temperature of 102.6F (39.2C), is diaphoretic, and has a productive cough. The nurse should include which of the following measures in the plan of care? a. position changes every 4 hours b. nasotracheal suctioning to clear secretions c. frequent linen changes d. frequent offering of a bedpan

c - frequent linen changes are appropriate for this client because of the diaphoresis. Diaphoresis produces general discomfort. The client should be kept dry to promote comfort. Position changes need to be done every 2 hours. Nasotracheal suctioning is not indicated with the client's productive cough. Frequent offering of a bedpan is not indicated by the data provided in this scenario.

A client who has been diagnosed with gastroesophageal reflux disease (GERD) complains of heartburn. To decrease the heartburn, the nurse should instruct the client to eliminate which of the following items from the diet? a) Lean beef. b) Air-popped popcorn. c) Hot chocolate. d) Raw vegetables.

c) CORRECT ANSWER Hot chocolate. Reason: With GERD, eating substances that decrease lower esophageal sphincter pressure causes heartburn. A decrease in the lower esophageal sphincter pressure allows gastric contents to reflux into the lower end of the esophagus. Foods that can cause a decrease in esophageal sphincter pressure include fatty foods, chocolate, caffeinated beverages, peppermint, and alcohol. A diet high in protein and low in fat is recommended for clients with GERD. Lean beef, popcorn, and raw vegetables would be acceptable.

A client who has a history of Crohn's disease is admitted to the hospital with fever, diarrhea, cramping, abdominal pain, and weight loss. The nurse should monitor the client for: a) Hyperalbuminemia. b) Thrombocytopenia. c) Hypokalemia. d) Hypercalcemia.

c) CORRECT ANSWER Hypokalemia. Reason: Hypokalemia is the most expected laboratory finding owing to the diarrhea. Hypoalbuminemia can also occur in Crohn's disease; however, the client's potassium level is of greater importance at this time because a low potassium level can cause cardiac arrest. Anemia is an expected development, but thrombocytopenia is not. Calcium levels are not affected.

Which of the following is a priority during the first 24 hours of hospitalization for a comatose client with suspected drug overdose? a) Educate regarding drug abuse. b) Minimize pain. c) Maintain intact skin. d) Increase caloric intake.

c) CORRECT ANSWER Maintain intact skin. Reason: Maintaining intact skin is a priority for the unconscious client. Unconscious clients need to be turned every hour to prevent complications of immobility, which include pressure ulcers and stasis pneumonia. The unconscious client cannot be educated at this time. Pain is not a concern. During the first 24 hours, the unconscious client will mostly likely be on nothing-by-mouth status.

A nurse is performing a psychosocial assessment on a 14-year-old adolescent. Which emotional response is typical during early adolescence? a) Frequent anger b) Cooperativeness c) Moodiness d) Combativeness

c) CORRECT ANSWER Moodiness Reason: Moodiness may occur often during early adolescence. Frequent anger and combativeness are more typical of middle adolescence. Cooperativeness typically occurs during late adolescence.

The nurse walks into a client's room to administer the 9:00 a.m. medications and notices that the client is in an awkward position in bed. What is the nurse's first action? a) Ask the client his name. b) Check the client's name band. c) Straighten the client's pillow behind his back. d) Give the client his medications.

c) CORRECT ANSWER Straighten the client's pillow behind his back. Reason: The nurse should first help the client into a position of comfort even though the primary purpose for entering the room was to administer medication. After attending to the client's basic care needs, the nurse can proceed with the proper identification of the client, such as asking the client his name and checking his armband, so that the medication can be administered.

Before an incisional cholecystectomy is performed, the nurse instructs the client in the correct use of an incentive spirometer. Why is incentive spirometry essential after surgery in the upper abdominal area? a) The client will be maintained on bed rest for several days. b) Ambulation is restricted by the presence of drainage tubes. c) The operative incision is near the diaphragm. d) The presence of a nasogastric tube inhibits deep breathing.

c) CORRECT ANSWER The operative incision is near the diaphragm. Reason: The incisions made for upper abdominal surgeries, such as cholecystectomies, are near the diaphragm and make deep breathing painful. Incentive spirometry, which encourages deep breathing, is essential to prevent atelectasis after surgery. The client is not maintained on bed rest for several days. The client is encouraged to ambulate by the first postoperative day, even with drainage tubes in place. Nasogastric tubes do not inhibit deep breathing and coughing.

Which of the following interventions would be most appropriate for the nurse to recommend to a client to decrease discomfort from hemorrhoids? a) Decrease fiber in the diet. b) Take laxatives to promote bowel movements. c) Use warm sitz baths. d) Decrease physical activity.

c) CORRECT ANSWER Use warm sitz baths. Reason: Use of warm sitz baths can help relieve the rectal discomfort of hemorrhoids. Fiber in the diet should be increased to promote regular bowel movements. Laxatives are irritating and should be avoided. Decreasing physical activity will not decrease discomfort.

The client is taking risperidone (Risperdal) to treat the positive and negative symptoms of schizophrenia. Improvement of which of the following negative symptoms indicate the drug is effective? a) Abnormal thought form. b) Hallucinations and delusions. c) Bizarre behavior. d) Asocial behavior and anergia.

d - Asocial behavior, anergia, alogia, and affective flattening are some of the negative symptoms of schizophrenia that may improve with risperidone therapy. Abnormal thought form is a positive symptom of schizophrenia. Hallucinations and delusions are positive symptoms of schizophrenia. Bizarre behavior is a positive symptom of schizophrenia.

Which of the following is an early symptom of glaucoma? a) Hazy vision. b) Loss of central vision. c) Blurred or "sooty" vision. d) Impaired peripheral vision.

d - In glaucoma, peripheral vision is impaired long before central vision is impaired. Hazy, blurred, or distorted vision is consistent with a diagnosis of cataracts. Loss of central vision is consistent with senile macular degeneration but it occurs late in glaucoma. Blurred or "sooty" vision is consistent with a diagnosis of detached retina.

While assessing a male neonate whose mother desires him to be circumcised, the nurse observes that the neonate's urinary meatus appears to be located on the ventral surface of the penis. The primary health care provider is notified because the nurse suspects which of the following? a. phimosis b. hydrocele c. epispadias d. hydrospadias

d - The condition in which the urinary meatus is located on the ventral surface of the penis, termed hypospadias, occurs in 1 of every 500 male infants. Circumcision is delayed until the condition is corrected surgically, usually between 6 and 12 months of age. Phimosis is an inability to retract the prepuce at an age when it should be retractable or by age 3 years. Phimosis may necessitate circumcision or surgical intervention. Hydrocele is a painless swelling of the scrotum that is common in neonates. It is not a contraindication for circumcision. Epispadias occurs when the urinary meatus is located on the dorsal surface of the penis. It is extremely rare and is commonly associated with bladder extrophy.

A client diagnosed with pain disorder is talking with the nurse about fishing when he suddenly reverts to talking about the pain in his arm. Which of the following should the nurse do next? a) Allow the client to talk about his pain. b) Ask the client if he needs more pain medication. c) Get up and leave the client. d) Redirect the interaction back to fishing.

d - The nurse should redirect the interaction back to fishing or another focus whenever the client begins to ruminate about physical symptoms or impairment. Doing so helps the client talk about topics that are more therapeutic and beneficial to recovery. Allowing the client to talk about his pain or asking if he needs additional pain medication is not therapeutic because it reinforces the client's need for the symptom. Getting up and leaving the client is not appropriate unless the nurse has set limits previously by saying, "I will get up and leave if you continue to talk about your pain."

A client has refused to take a shower since being admitted 4 days earlier. He tells a nurse, "there are poison crystals hidden in the showerhead. They'll kill me if I take a shower." Which nursing action is most appropriate? a. dismantling the showerhead and showing the client that there is nothing in it b. explaining that other clients are complaining about the client's body odor c. asking a security officer to assist in giving the client a shower d. accepting these fears and allowing the client to take a sponge bath

d - by acknowledging the client's fears, the nurse can arrange to meet the client's hygiene needs in another way. Because these fears are real to the client, providing a demonstration of reality by dismantling the shower head wouldn't be effective at this time.

A nurse is performing a baseline assessment of a client's skin integrity. What is the priority assessment parameter? a) Family history of pressure ulcers b) Presence of pressure ulcers on the client c) Potential areas of pressure ulcer development d) Overall risk of developing pressure ulcers

d) CORRECT ANSWER Overall risk of developing pressure ulcers Reason: When assessing skin integrity, the overall risk potential of developing pressure ulcers takes priority. Overall risk encompasses existing pressure ulcers as well as potential areas for development of pressure ulcers. Family history isn't important when assessing skin integrity.

On the second postpartum day a gravida 6, para 5 complains of intermittent abdominal cramping. The nurse should assess for: a) endometritis. b) postpartum hemorrhage. c) subinvolution. d) afterpains.

d) CORRECT ANSWER afterpains. Reason: In a multiparous client, decreased uterine muscle tone causes alternating relaxation and contraction during uterine involution, which leads to afterpains. The client's symptoms don't suggest endometritis, hemorrhage, or subinvolution.

A nurse is providing care for a pregnant client in her second trimester. Glucose tolerance test results show a blood glucose level of 160 mg/dl. The nurse should anticipate that the client will need to: a) start using insulin. b) start taking an oral antidiabetic drug. c) monitor her urine for glucose. d) be taught about diet.

d) CORRECT ANSWER be taught about diet. Reason: The client will need to watch her overall diet intake to control her blood glucose level. The client's blood glucose level should be controlled initially by diet and exercise, rather than insulin. Oral antidiabetic drugs aren't used in pregnant clients. Urine glucose levels aren't an accurate indication of blood glucose levels.

When assessing an elderly client, the nurse expects to find various aging-related physiologic changes. These changes include: a) increased coronary artery blood flow. b) decreased posterior thoracic curve. c) decreased peripheral resistance. d) delayed gastric emptying.

d) CORRECT ANSWER delayed gastric emptying. Reason: Aging-related physiologic changes include delayed gastric emptying, decreased coronary artery blood flow, an increased posterior thoracic curve, and increased peripheral resistance.

A client with chronic undifferentiated schizophrenia is admitted to the psychiatric unit of a local hospital. During the next several days, the client is seen laughing, yelling, and talking to himself. This behavior is characteristic of: a) delusion. b) looseness of association. c) illusion. d) hallucination.

d) CORRECT ANSWER hallucination. Reason: Auditory hallucination, in which one hears voices when no external stimuli exist, is common in schizophrenic clients. Such behaviors as laughing, yelling, and talking to oneself suggest such a hallucination. Delusions, also common in schizophrenia, are false beliefs or ideas that arise without external stimuli. Clients with schizophrenia may exhibit looseness of association, a pattern of thinking and communicating in which ideas aren't clearly linked to one another. Illusion is a less severe perceptual disturbance in which the client misinterprets actual external stimuli. Illusions are rarely associated with schizophrenia.

A client with chronic heart failure is receiving digoxin (Lanoxin), 0.25 mg by mouth daily, and furosemide (Lasix), 20 mg by mouth twice daily. The nurse instructs the client to notify the physician if nausea, vomiting, diarrhea, or abdominal cramps occur because these signs and symptoms may signal digoxin toxicity. Digoxin toxicity may also cause: a) visual disturbances. b) taste and smell alterations. c) dry mouth and urine retention. d) nocturia and sleep disturbances.

a) CORRECT ANSWER visual disturbances. Reason: Digoxin toxicity may cause visual disturbances (such as, flickering flashes of light, colored or halo vision, photophobia, blurring, diplopia, and scotomata), central nervous system abnormalities (such as headache, fatigue, lethargy, depression, irritability and, if profound, seizures, delusions, hallucinations, and memory loss), and cardiovascular abnormalities (abnormal heart rate and arrhythmias). Digoxin toxicity doesn't cause taste and smell alterations. Dry mouth and urine retention typically occur with anticholinergic agents, not inotropic agents such as digoxin. Nocturia and sleep disturbances are adverse effects of furosemide — especially if the client takes the second daily dose in the evening, which may cause diuresis at night.

a nurse is caring for a client who required chest tube insertion for a pneumothorax. To assess for pneumothorax resolution, the nurse can anticipate that the client will require: a. monitoring of arterial oxygen saturation (SaO2) b. arterial blood gas (ABG) studies c. chest auscultation d. chest x ray

d - chest x ray confirms diagnosis by revealing air or fluid in the pleural space. SaO2 values may initially decrease with a pneumothorax but typically return to normal within 24 hours. ABG studies may show hypoxemia, possibly with respiratory acidosis and hypercapnia but these are not necessarily related to a pneumothorax. Chest auscultation will determine overall lung status, but it's difficult to determine if the best has re-expanded sufficiently.

To prevent development of peripheral neuropathies associated with isoniazid administration, the nurse should teach the client to: a. avoid excessive sun exposure b. follow a low-cholesterol diet c. obtain extra rest d. supplement the diet with pyridoxine (vitamin B6)

d - isoniazid competes for the available vitamin B6 in the body and leaves the client at risk for developing neuropathies related to vitamin deficiency. Supplemental vitamin B6 is routinely prescribed to address this issue. Avoiding sun exposure is a preventative measure to lower the risk of skin cancer. Following a low-cholesterol diet lowers the individual's risk of developing atherosclerotic plaque. Rest is important in maintaining homeostasis but has no real impact on neuropathies.

A child with a poor nutritional status and weight loss is at risk for a negative nitrogen balance. To help diagnose this problem, the nurse anticipates that the physician will order which laboratory test? a) Total iron-binding capacity b) Hemoglobin (Hb) c) Total protein d) Sweat test

c) CORRECT ANSWER Total protein Reason: The nurse anticipates the physician will order a total protein test because negative nitrogen balance may result from inadequate protein intake. Measuring total iron-binding capacity and Hb levels would help detect iron deficiency anemia, not a negative nitrogen balance. The sweat test helps diagnose cystic fibrosis, not a negative nitrogen balance.

A 16-year-old primigravida at 36 weeks' gestation who has had no prenatal care experienced a seizure at work and is being transported to the hospital by ambulance. Which of the following should the nurse do upon the client's arrival? a) Position the client in a supine position. b) Auscultate breath sounds every 4 hours. c) Monitor the vital signs every 4 hours. d) Admit the client to a quiet, darkened room.

d) CORRECT ANSWER Admit the client to a quiet, darkened room. Reason: Because of her age and report of a seizure, the client is probably experiencing eclampsia, a condition in which convulsions occur in the absence of any underlying cause. Although the actual cause is unknown, adolescents and women older than 35 years are at higher risk. The client's environment should be kept as free of stimuli as possible. Thus, the nurse should admit the client to a quiet, darkened room. Clients experiencing eclampsia should be kept on the left side to promote placental perfusion. In some cases, edema of the lungs develops after seizures and is a sign of cardiovascular failure. Because the client is at risk for pulmonary edema, breath sounds should be monitored every 2 hours. Vital signs should be monitored frequently, at least every hour.