NCLEX PassPoint Study
A client is admitted to the health care facility with abdominal pain, a low-grade fever, abdominal distention, and weight loss. The physician diagnoses acute pancreatitis. What is the primary goal of nursing care for this client? A. Preventing fluid volume overload B. Teaching about the disease and its treatment C. Relieving abdominal pain D. Maintaining adequate nutritional status
C. Relieving abdominal pain Explanation: The predominant clinical feature of acute pancreatitis is abdominal pain, which usually peaks in intensity several hours after onset of the illness. Therefore, relieving abdominal pain is the nurse's primary goal. Because acute pancreatitis causes nausea and vomiting, the nurse should try to prevent fluid volume deficit, not overload. The nurse can't help the client achieve adequate nutrition or teach the client about the disease and its treatment until the client is comfortable and no longer in pain.
An 18-month-old Hispanic toddler admitted to the hospital with bronchitis has red marks on his upper chest over both sides of his body. The mother states that she has been treating him at home. Which treatment has the mother most likely been administering to her toddler? A. Rolfing B. Reflexology C. Acupuncture D. Coin rubbing
D. Coin rubbing Explanation: Coin rubbing, also known as cao-gio, is used by many cultures to relieve pain. Bruising commonly occurs with the rubbing and can be easily mistaken for child abuse. The other options are examples of alternative therapies used by a variety of other cultures.
Which intervention might safely prevent constipation in a client who has end-stage ovarian cancer and requires high doses of opioids to control pain?
Explaining the importance of increasing the intake of fiber and fluids Explanation: The nurse should explain the importance of increasing the intake of fiber and fluids to prevent constipation. Avoiding alcohol won't prevent constipation; however, the client should be cautioned about its use with opioids. The client should be instructed to consult with her physician before taking over-the-counter medications. The client should also be cautioned against taking laxatives routinely because they can lead to dependency
Which nursing diagnosis takes priority for a client diagnosed with anorexia nervosa?
Imbalanced nutrition: Less than body requirements Explanation: The highest priority nursing diagnosis for a client with anorexia nervosa is Imbalanced nutrition: Less than body requirements. Deficient knowledge, Disturbed body image, and Social isolation may be applicable for this client, but they don't take priority over the client's nutritional status.
A nurse is collecting data on a client admitted with a diagnosis of small bowel obstruction. When evaluating the client's pulse rate, what should the nurse remember? Count the apical pulse only. Count for 15 seconds and multiply by 4. Count the apical or radial pulse for 60 seconds. Always count for 30 seconds and multiply by 2.
Count the apical or radial pulse for 60 seconds. Explanation: When evaluating a pulse rate, the nurse should count for 60 seconds. Counting for 30 seconds and then multiplying by 2 isn't always accurate. The radial or apical pulse can be used. Counting for only 15 seconds and multiplying by 4 isn't enough time to adequately evaluate the regularity of the pulse.
A hospitalized client notes difficulty resting. Which intervention would help promote rest?
assisting the client with deep-breathing exercises Explanation: Deep-breathing exercises are beneficial to promoting rest because they help the client to relax. The client's door should be closed to reduce noise and distractions. Tea contains caffeine, which acts as a stimulant. Although sedatives may be used occasionally for assistance with rest, regular use is not advised because dependence may develop.
A nurse demonstrates how to clean dentures to an unlicensed assistive personnel (UAP). Which action should the nurse make sure to teach the UAP? A. Clean the dentures over the sink with the drain closed. B. Rinse the dentures under hot running water. C. Scrub the dentures with a cleaning agent and cold water. D. Put a washcloth in the sink to prevent damage the dentures.
D. Put a washcloth in the sink to prevent damage the dentures. Explanation: When cleaning dentures over a sink, the UAP should place a paper towel or washcloth in the sink to prevent damage in case the dentures are dropped. The UAP should rinse dentures under tepid (not hot) running water because hot water could change their shape. The UAP should scrub dentures with a cleaning agent and tepid (not cold) water to make cleaning and denture reinsertion easier.
A client with chronic pain asks for assistance with non-pharmacological pain relief techniques. Which technique should be included when the nurse is reinforcing teaching?
using relaxation techniques that aid in reducing pain by releasing muscle tension and relieving anxiety Explanation: With chronic pain, it may not be possible for the client to be pain free but with relaxation techniques, it can be an effective method of assistance with pain control. The goal of therapy is to reduce the pain and make it more manageable. Administration of acetaminophen is considered a pharmacological method of pain control. Dependent upon the type of pain the client is experiencing, vigorous exercise may be counterproductive and cause more pain. Moderate or light exercise may be helpful with the release of endorphins, a natural pain suppressor.
A nurse is caring for a client with suspected acute pulmonary edema. What nursing intervention should the nurse perform to promote oxygenation? A. perform chest physiotherapy B. place the client in high Fowler position C. tell the client to take deep breaths and cough D. monitor oxygen saturation level and vital signs
B. place the client in high Fowler position Explanation: High Fowler's position initially promotes oxygenation in the client with suspected acute pulmonary edema and helps relieve shortness of breath. Secondary measures include monitoring oxygen saturation levels and vital signs at least every 15 minutes until the client is stable. Deep breathing and coughing improve oxygenation postoperatively but might not immediately relieve shortness of breath. Chest physiotherapy results in expectoration of secretions, which is not the primary problem in pulmonary edema.
A nurse is caring for a client with L1-L2 paraplegia who is undergoing rehabilitation. Which care intervention is appropriate? Prevent autonomic dysreflexia by preventing bowel impactions. Establish an ambulation program using short leg braces. Establish an intermittent catheterization routine every 4 hours. Manage spasticity with range-of-motion exercises and medications.
Establish an intermittent catheterization routine every 4 hours. Explanation: A client with a L1-L2 paraplegia will demonstrate flaccid paralysis. Developing an intermittent catheterization routine offers a way of manually draining the bladder, eliminating the need for an indwelling urinary catheter. Spasticity and autonomic dysreflexia are seen in clients with upper motor injuries above T6. With an injury at L1-L2, ambulation may be possible with long leg braces but not with short leg braces.
A client is being discharged after undergoing abdominal surgery and colostomy formation to treat colon cancer. Which nursing action is most likely to promote continuity of care? notifying the American or Canadian Cancer Society of the client's diagnosis referring the client to home care for follow-up visits requesting Meals On Wheels to provide adequate nutritional intake asking an occupational therapist to evaluate the client at home
referring the client to home care for follow-up visits Explanation: Many clients are discharged from acute care settings so quickly that they don't receive complete instructions. Therefore, the first priority is to arrange for a home health nurse to make follow-up visits for colostomy care. The American or Canadian Cancer Society often sponsors support groups, which are helpful when the person is ready, but contacting this organization doesn't take precedence over ensuring follow-up visits by a home health nurse. Requesting Meals On Wheels and asking for an occupational therapy evaluation are important but can occur later in rehabilitation.
The nurse observes the unlicensed assistive personnel (UAP) delivering a food tray to the client prescribed a clear liquid diet. The nurse would intervene when which food product is seen on the food tray?
vanilla yogurt Explanation: Yogurt is found in full liquid diets. A clear liquid diet includes clear juices, such as cranberry juice, coffee, tea, water, and broth.
A nurse reviews the laboratory results for a client reporting right lower quadrant abdominal pain. Which laboratory finding should the nurse report to the health care provider immediately? red blood cell count of 5.4 million cells/mcL serum sodium level of 135 mEq/L white blood cell (WBC) count of 22.8/mm serum potassium level of 4.2 mEq/L
white blood cell (WBC) count of 22.8/mm Explanation: The nurse should report an elevated WBC count of 22.8/mm3 because it is a sign of infection, indicating that the client's appendix is inflamed or may have ruptured. The other laboratory values are within normal limits.
The nursing instructor asks the nursing student why shouldn't the nurse palpate both carotid arteries at the same time. Which response by the student is correct?
"Checking both carotid arteries at the same time may impair cerebral circulation." Explanation: The carotid arteries must be palpated one at a time to prevent severe bradycardia and impairment of cerebral circulation. The nurse must also remember to avoid massaging the carotid sinus, located at the bifurcation of the carotid arteries; the resulting bradycardia (not tachycardia) could lead to cardiac arrest. Palpating both carotid arteries at the same time doesn't cause hypertension.
A client with pneumonia has just finished dinner. The nurse must calculate the client's fluid intake before taking the tray from the room. The client had 6 oz of soup, 4 oz of milk, and 8 oz of juice. How many milliliters of fluid should the nurse record on the client's intake record? Record your answer using a whole number.
540 Explanation: The nurse should know that 1 oz equals 30 mL. Therefore, 18 oz multiplied by 30 equals 540 mL.
A client with a neurogenic bladder is beginning bladder training. Which nursing action is most important?
Set up specific times for the client to empty the bladder. Explanation: A client with a neurogenic bladder in bladder retraining should be taught to write down voiding patterns and to empty the bladder at the same times each day. Forcing fluids (more than 2 L/day) increases urine production and complicates the initial bladder-training process. Roughage is unnecessary for bladder training. An indwelling urinary catheter is used only when other methods of bladder control do not work.
When reinforcing education about fluid intake with the parents of a child with a urinary tract infection (UTI), which statement by a parent would indicate the need for further education? "I should encourage my child to drink about 50 mL per pound of body weight daily." "Clear liquids should be the primary liquids that my child drinks." "I should offer my child carbonated beverages about every 2 hours." "My child should avoid drinking caffeinated beverages."
"I should offer my child carbonated beverages about every 2 hours." Explanation: Carbonated or caffeinated beverages are avoided because of their potentially irritating effect on the bladder mucosa. Adequate fluid intake is always indicated during an acute UTI. It is recommended that a person drink approximately 50 mL/lb of body weight daily. The child should primarily drink clear liquids.
A nurse determines that an adolescent with a fractured left femur understands the instructions to perform only touch-down weight bearing when making what statement?
"I will allow my left leg to touch the floor without placing weight on it." Explanation: Touch-down weight bearing allows the child to put no weight on the extremity, but the child may touch the floor with the affected extremity. Full weight bearing allows the child to bear all of his weight on the affected extremity. Partial weight bearing allows for only 30% to 50% weight bearing on the affected extremity. Non-weight bearing means bearing no weight on the extremity, and it must remain elevated.
The school nurse is instructing high school students on prevention of infections in body tattooing. Which responses, if given by the students, would indicate to the nurse further teaching is needed?
"I will make sure the tattooist is certified by the American Medical Association." "I will make sure I put the antibacterial ointment on for 3 days after getting the tattoo." Explanation: The tattooist should be certified by the Alliance for Professional Tattooists. This group follows infection guidelines developed in conjunction with the Food and Drug Administration. Antibacterial ointment should be applied for 5 days, not 3, after obtaining a tattoo. The other responses are appropriate actions to decrease risk in developing an infection after getting a tattoo.
The nursing instructor asks the nursing student to describe the anatomic position. How would the student correctly respond?
"The client's palms are turned forward." Explanation: In the anatomic position, the body is erect, facing forward with arms at the sides and palms turned forward.
A nurse is reinforcing education with parents on providing adequate nutrition for their toddler who has cerebral palsy. Which observation by the nurse indicates that the education has been effective? A. The child lies down to rest after eating. B. The toddler finishes the meal within a specified period of time. C. The child eats finger foods independently. D. The toddler stays neat while eating.
Answer: The child eats finger foods independently. Explanation: A child with cerebral palsy should be encouraged to be as independent as possible. Finger foods allow the toddler to self-feed. Because spasticity affects coordinated chewing and swallowing, as well as the ability to bring food to the mouth, it is difficult for a child with cerebral palsy to eat neatly. Independence in eating should take precedence over neatness. A child with cerebral palsy may require more time to bring food to the mouth; thus, chewing and swallowing should not be rushed to finish a meal by a specified time. A child with cerebral palsy may vomit after eating due to a hyperactive gag reflex. Therefore, the child should remain in an upright position after eating to prevent aspiration and choking.
A client is frustrated and embarrassed by urinary incontinence. Which of the following measures should the nurse include in a bladder retraining program? A. Encouraging the client to increase the time between voidings B. Assessing present elimination patterns C. Establishing a predetermined fluid intake pattern for the client D. Restricting fluid intake to reduce the need to void
B. Assessing present elimination patterns Explanation: The guidelines for initiating bladder retraining include assessing the client's intake patterns, voiding patterns, and reasons for each accidental voiding. Lowering the client's fluid intake won't reduce or prevent incontinence. The client should actually be encouraged to drink 1.5 to 2 L of water per day. A voiding schedule should be established after assessment.
Which food should be included in a client's diet during the first 6 to 8 weeks after ileostomy surgery?
Banana Explanation: Bananas are considered one of the most nutritious foods and are low in fiber. High-fiber foods such as fresh corn, celery, and bran cereal should be avoided during the first 6 to 8 weeks after placement of an ileostomy.
Following a liver transplant a client develops ascites. The nurse should teach the client to: A. perform 10 leg raises every waking hour. B. reduce requests for pain medicine. C. increase water intake. D. brace the abdomen with a pillow during coughing.
D. brace the abdomen with a pillow during coughing. Explanation: Bracing the abdomen during coughing will reduce the risk of wound dehiscence following liver transplantation. Ascites is fluid retention in the abdomen; therefore, increasing water ingestion isn't indicated. However, excessive ascites may lead to hypovolemia therefore the client should be assessed for fluid volume deficit. Leg raises will put unwanted tension on the abdominal wound. Pain control is important after surgery to provide for client comfort. It wouldn't be appropriate to suggest that the client reduce his requests.
The nurse is caring for a client who was admitted with a stroke. The client has left-sided paralysis. How should the nurse document this finding?
Hemiplegia Explanation: Hemiplegia refers to paralysis of one side of the body. Monoplegia refers to paralysis of one extremity; paraplegia, to paralysis of both lower limbs; and quadriplegia, to paralysis of all four extremities and usually also the trunk
A 4-year-old client has just returned from surgery. He has a nasogastric (NG) tube in place and is attached to intermittent suction. The child says to the nurse, "I'm going to throw up." What should the nurse do first?
Irrigate the NG tube to ensure patency. Explanation: If the NG tube isn't draining properly or is kinked, the child will experience nausea. Therefore, the nurse should check the tube's patency and irrigate it as ordered. There is no reason to notify the physician immediately because a nurse should be able to handle the situation. Giving the child an antiemetic doesn't really address the problem. Encouraging the mother to calm the child is always a good intervention but isn't the first thing to do in this case.
A client diagnosed with renal calculi is experiencing severe pain despite having received pain medication. A nurse pages a physician. Which intervention can the nurse perform while awaiting the physician's response?
Perform non-pharmacologic pain interventions. Explanation: The nurse should institute non-pharmacologic pain measures to help control the client's pain until the physician responds. These include repositioning, massage, and distraction. A client experiencing severe pain will most likely be able to tolerate a higher dose of pain medication. Although ambulation is sometimes effective in mobilizing renal calculi, the client is most likely experiencing too much pain to ambulate at this time. The nurse can't apply a heating pad without a physician's order.
A client who is paralyzed on the left side has been receiving physical therapy and attending teaching sessions about safety. Which behavior indicates that the client accurately understands safety measures related to paralysis?
The client uses a mirror to inspect skin. Explanation: Using a mirror enables the client to inspect all areas of skin for signs of breakdown without the help of staff or family members. The client should keep the side rails up to help with repositioning and to prevent falls. The client should take responsibility for repositioning, or for reminding the staff to assist him, if needed. A client with left-side paralysis may not realize that the left arm is hanging over the side of the wheelchair. However, the nurse should call this to the client's attention because the arm could get caught in the wheel spokes or develop impaired circulation from being in a dependent position for too long.
A client asks the reason for being placed in traction prior to surgery. Which response by the nurse is most appropriate?
Traction helps to prevent trauma and overcome muscle spasms. Explanation: Traction prevents trauma and overcomes muscle spasms. Traction doesn't help in preventing skin breakdown, repositioning the client, or allowing the client to become active.
The nurse is collecting data from a postoperative client. The nurse documents which subjective data?
client's description of pain client's nausea Explanation: Subjective data come directly from the client and usually are recorded as direct quotations that reflect the client's opinions or feelings about a situation. Vital signs, laboratory test results, and ECG waveforms are examples of objective data
When plotting height and weight on a growth chart, which observation by the nurse would indicate that a 4-year-old child has a growth hormone deficiency?
downward shift of 2 percentiles or more Explanation: When the health care provider evaluates the results of plotting height and weight, upward or downward shifts of 2 percentiles or more in children older than age 3 may indicate a growth abnormality.
The nurse is caring for a child with acute rheumatic fever. Which data does the nurse anticipate in this child? leukocytosis normal electrocardiogram normal red blood cell count normal erythrocyte sedimentation rate
leukocytosis Explanation: Leukocytosis can be seen as an immune response triggered by colonization of the pharynx with group A streptococci. The electrocardiogram will show a prolonged PR interval as a result of carditis. A low-grade fever is a minor manifestation. There should be no change in red blood cell count. The inflammatory response will cause an elevated erythrocyte sedimentation rate.
An adolescent is diagnosed with iron deficiency anemia. After emphasizing the importance of consuming dietary iron, the nurse asks the child to select iron-rich breakfast items from a sample menu. Which selection demonstrates knowledge of dietary iron sources? A. Pancakes and a banana B. Grapefruit and white toast C.Ham and eggs D. Bagel and cream cheese
C. Ham and eggs Explanation: Good sources of dietary iron include red meat, egg yolks, whole wheat breads, seafood, nuts, legumes, iron-fortified cereals, and green, leafy vegetables. Fresh fruits and milk products contain only small amounts of iron. Breads (except for whole wheat and iron-fortified breads) aren't good iron sources.
Which intervention has the highest priority when providing skin care to a bedridden client? A. Gently massaging the skin around the pressure areas B. Rubbing moisturizing lotion around the pressure areas C. Keeping the skin clean and dry without using harsh soaps D. Changing the bed linens frequently for an incontinent client
C. Keeping the skin clean and dry without using harsh soaps Explanation: Keeping the skin clean is always the highest priority. The other measures are also important but only after the skin is cleaned.
When the nurse turns a client, who has undergone a colon resection, wound dehiscence with evisceration occurs. What is the priority action by the nurse?
apply a sterile saline dressing Explanation: The nurse should first place a saline-soaked sterile dressing on the open wound to prevent tissue drying and possible infection. The nurse should then call the healthcare provider and take the vital signs of the client who has experienced wound dehiscence with evisceration after a colon resection. Gentle support to the area should be provided to prevent further dehiscence of the wound. Dehiscence requires surgically closure; the nurse should never try to close it.
A nurse is reinforcing discharge instructions to the parents of a child who had a tonsillectomy. Which instruction is the most important? A. Orange juice should be given to provide pain control. B. The child should drink extra milk. C. The child shouldn't drink from straws. D. The mouth should be rinsed with salt water to provide pain relief.
C. The child shouldn't drink from straws. Explanation: Straws and other sharp objects inserted into the mouth could disrupt the clot at the operative site. Extra milk wouldn't promote healing and may encourage mucus production. Although drinking orange juice and rinsing with salt water will irritate the tissue at the operative site, irritation doesn't pose the same level of danger as clot disruption.
The nurse is caring for a child with acute rheumatic fever. Which data does the nurse anticipate in this child? A. normal erythrocyte sedimentation rate B. normal red blood cell count C. leukocytosis D. normal electrocardiogram
C. leukocytosis Explanation: Leukocytosis can be seen as an immune response triggered by colonization of the pharynx with group A streptococci. The electrocardiogram will show a prolonged PR interval as a result of carditis. A low-grade fever is a minor manifestation. There should be no change in red blood cell count. The inflammatory response will cause an elevated erythrocyte sedimentation rate.
A client with a knee-to-toe cast applied informs the nurse that they are having severe itching in the ankle area and need something to scratch it with. What is the priority nursing action?
A. Encourage the client to avoid scratching, and confer with the health care provider if severe itching persists. Explanation: Clients should not scratch inside casts because of the risk of skin breakdown and potential damage to the cast. The nurse should consider notifying the health care provider if itching persists. The health care provider may prescribe an antihistamine, such as diphenhydramine, to relieve itching. Sedatives are not generally indicated for itching. A blow dryer on the heat setting could cause burns and increase itching due to vasodilation. Using it on the cool setting may be of some relief.
A client in the early stages of labor who is admitted to the labor and delivery unit is noted to have not recently bathed or changed her clothes. Which action should the nurse take to help this client?
Help the client to undress and suggest a quick bath to freshen up. Explanation: The nurse should respectfully address the client's hygiene needs by helping the client to undress and offering her a quick bath. It's unsafe for the client to get into a shower at this point. Allowing the client to remain in soiled clothes may place the neonate at risk for infection. Giving the client a clean gown and offering her deodorant doesn't address the client's hygiene needs.
The nurse is caring for a client who was admitted with a stroke. The client has left-sided paralysis. How should the nurse document this finding? Monoplegia Hemiplegia Paraplegia Quadriplegia
Hemiplegia Explanation: Hemiplegia refers to paralysis of one side of the body. Monoplegia refers to paralysis of one extremity; paraplegia, to paralysis of both lower limbs; and quadriplegia, to paralysis of all four extremities and usually also the trunk.
The nurse is performing vital signs on a client. What should the nurse do to avoid recording an erroneously low systolic blood pressure because of failure to recognize an auscultatory gap? A. Have the client lie down while taking his or her blood pressure. B. Inflate the cuff to at least 200 mm Hg. C. Take blood pressure readings in both arms. D. Inflate the cuff at least another 30 mm Hg after the radial pulse becomes impalpable.
Inflate the cuff at least another 30 mm Hg after the radial pulse becomes impalpable. Explanation: The nurse should wrap an appropriately sized cuff around the client's upper arm and then place the diaphragm of the stethoscope over the brachial artery. The nurse should then rapidly inflate the cuff until she can no longer palpate or auscultate the pulse and continue inflating until the pressure rises another 30 mm Hg. The other options aren't appropriate measures.
The nurse is performing vital signs on a client. What should the nurse do to avoid recording an erroneously low systolic blood pressure because of failure to recognize an auscultatory gap? Have the client lie down while taking his or her blood pressure. Inflate the cuff to at least 200 mm Hg. Take blood pressure readings in both arms. Inflate the cuff at least another 30 mm Hg after the radial pulse becomes impalpable.
Inflate the cuff at least another 30 mm Hg after the radial pulse becomes impalpable. Explanation: The nurse should wrap an appropriately sized cuff around the client's upper arm and then place the diaphragm of the stethoscope over the brachial artery. The nurse should then rapidly inflate the cuff until she can no longer palpate or auscultate the pulse and continue inflating until the pressure rises another 30 mm Hg. The other options aren't appropriate measures.
A client who experienced a stroke has left-sided facial droop. During mouth care, the client begins to cough violently. What should the nurse do? Avoid providing mouth care. Maintain the client on nothing-by-mouth status. Make sure a tonsil suction device is readily available while providing mouth care. Continue providing mouth care because the client's gag reflex is intact.
Make sure a tonsil suction device is readily available while providing mouth care. Explanation: The client with facial droop has difficulty swallowing secretions during mouth care. Therefore, the nurse should have a tonsil suction device available to suction the client's mouth to avoid further coughing episodes and prevent aspiration. The client should undergo swallowing studies before a decision is made on whether to maintain nothing-by- mouth status. Continuing mouth care without the tonsil suction device places the client at risk for aspiration.
To verify the placement of a nasogastric feeding tube, what action should the nurse perform?
Obtain a chest X-ray. Explanation: The gold standard for identification of placement of a nasogastric feeding tube is a chest X-ray. The cessation of reflex gagging that occurs during placement indicates the oropharynx is no longer being stimulated. Exact measurement of the distance between the nares and the stomach is impossible prior to insertion but should be estimated and marked. Instillation of any fluid prior to checking appropriate placement may induce aspiration pneumonia.
A client with metastatic cancer is experiencing neuropathic pain. Which alternative therapy is most beneficial in treating this type of pain?
Transcutaneous electrical nerve stimulation (TENS) Explanation: TENS alters the client's perception of pain by blocking painful stimuli traveling over nerve fibers. This treatment is believed to help treat cancer pain because it reduces muscle spasm, decreases edema, and raises the pain threshold. This therapy appears to be the most effective in treating neuropathic pain. Cryotherapy is used for acute injuries, such as an ankle sprain, because it reduces inflammation. Biofeedback has been found to reduce cancer pain through the client's learned conscious control of the body's responses to pain. However, this method of pain control isn't the most beneficial in treating neuropathic pain. Herbal therapy isn't the most effective alternative therapy for treating neuropathic pain.
A female client with a history of four urinary tract infections (UTIs) in the past 3 months comes to the urology clinic reporting of burning and urinary urgency and frequency. A health care provider makes the diagnosis of UTI. Which instructions should the nurse give the client to help prevent recurring infections? Select all that apply. "Increase the intake of carbonated beverages." "Avoid using irritating substances such as bubble bath and scented toilet paper." "Change laundry detergents frequently." "Take antibiotics until symptoms abate." "Clean the perineal area from front to back."
"Avoid using irritating substances such as bubble bath and scented toilet paper." "Clean the perineal area from front to back." Explanation: The nurse should reinforce the importance of good hygiene practices, such as cleaning the perineal area from front to back and avoiding the use of irritating substances such as bubble bath and scented toilet paper for a client with a UTI. Consuming carbonated beverages should be discouraged. Instead, the client should be encouraged to drink plenty of water to maintain adequate hydration. Drinking cranberry juice should also be encouraged because it helps promote urine acidity, which inhibits bacterial growth. The client should also be cautioned against changing laundry detergents frequently. Some laundry detergents cause irritation, which might place the client at risk for a UTI. The client should be instructed to complete the entire course of antibiotics, even after symptoms abate, to prevent another infection.
A 9-month-old admitted with pneumonia cries when his parents aren't holding him. He's also unable to sleep. The parents have two other young children at home and can't stay with the infant continually. Which suggestion by the nurse might help the infant sleep?
"Can one of you stay and the other one go home and care for your other children?" Explanation: The nurse can best help the infant and his parents by suggesting that one parent stay with the infant and the other one go home to care for the other children. The other children need to have contact with the parents so they don't feel abandoned during the hospitalization of the infant. It may also be impossible for the parents to get childcare for the other children. Encouraging the parents to leave and allow the infant to cry expends energy and doesn't promote rest, which is needed to recover from pneumonia. It isn't appropriate to give an infant medicine to aid sleep.
A 9-month-old admitted with pneumonia cries when his parents aren't holding him. He's also unable to sleep. The parents have two other young children at home and can't stay with the infant continually. Which suggestion by the nurse might help the infant sleep? "You should find childcare for your other children so you can stay with your baby." "Can one of you stay and the other one go home and care for your other children?" "It's fine for you leave; he'll eventually tire and fall to sleep." "After you leave, I'll give him some medicine to make him sleep."
"Can one of you stay and the other one go home and care for your other children?" Explanation: The nurse can best help the infant and his parents by suggesting that one parent stay with the infant and the other one go home to care for the other children. The other children need to have contact with the parents so they don't feel abandoned during the hospitalization of the infant. It may also be impossible for the parents to get childcare for the other children. Encouraging the parents to leave and allow the infant to cry expends energy and doesn't promote rest, which is needed to recover from pneumonia. It isn't appropriate to give an infant medicine to aid sleep.
A client with multiple sclerosis who is unable to bathe herself complains that other staff members haven't been bathing her. How should the nurse respond to this client's complaint?
"I'm sorry you haven't been bathed. I'm available to bathe you now." Explanation: The nurse should attempt to rectify the situation by offering to bathe the client. Option 1 will most likely cause the client to become defensive. Option 2 is not a good response because it places blame on other staff members. Option 4 also places blame on other staff members and doesn't address the client's concerns.
During chemotherapy, a boy, age 10, loses his appetite. When teaching the parents about his food intake, the nurse should include which instruction?
"Let your child eat any food he wants." Explanation: The nurse should instruct the parents to let the child eat any food he wants because any form of intake is better than none. Dry crackers would be appropriate for a child experiencing nausea. Withholding all foods and fluids or ignoring lack of food intake would be inappropriate.
A 40-year-old client with mild dementia related to end-stage acquired immunodeficiency syndrome (AIDS) is preparing for discharge. She has decided against further curative treatment. Before discharge, she develops ocular cytomegalovirus (CMV). Her physician recommends treatment with a ganciclovir-impregnated implant, which requires a surgical procedure. The client's husband feels the implant won't help the client and asks the nurse if the implant will cure CMV. Which response best answers the husband's question while promoting client advocacy?
"The implant won't cure the virus, but it may help preserve her vision. If she can't see you or her surroundings, it may worsen her dementia and make caring for her at home more difficult." Explanation: By explaining the client's wishes while also promoting improved quality of life and safety for the client, the nurse is being the client's advocate. The other responses don't advocate for the client and may be considered confrontational
A nurse is reinforcing preoperative instructions for a client scheduled for an appendectomy. Which statement regarding postoperative pain control is most appropriate?
"To manage your pain well you should take the pain medication before pain becomes intense." Explanation: When an analgesic is taken before pain becomes severe, less medication is required to control the pain, thus minimizing the risk of adverse effects. The client should not be told to wait for the scheduled analgesic. Pain medication should be taken before walking or other activities that are expected to cause pain. The client should not be discouraged from using pain medication because of possible addiction; a client with no history of substance abuse has a very minimal risk of addiction when using pain medication for postoperative pain relief.
When assisting to plan nursing care to maintain skin integrity for an adult female bed-bound client, which interventions should the nurse include?
1. Monitor the skin for breakdown daily during the client's bath. 2. Keep skin clean and dry to prevent breakdown. 3. Turn and reposition the client every two hours. Explanation: Because healthy skin is the body's first line of defense, a key nursing goal is to keep the skin intact. The nurse can accomplish this goal by keeping the skin clean and dry to prevent breakdown. To reduce moisture, the nurse can apply a nonirritating dusting powder, such as cornstarch, to the client's axillae and groin, beneath the breasts, and between the toes after those areas are dry. However, scented powder should not be used because it can irritate the skin. Deodorants and antiperspirants should not be applied to the skin immediately after shaving because they can cause irritation. The nurse should use lotion for backrubs because rubbing alcohol dries the skin and can irritate it. Daily inspection of the skin will catch any problems early. Turning the client every two hours will prevent the development of pressure areas over the bony prominences
A 54-year-old client who was admitted to the psychiatric unit during an acute phase of schizophrenia has hardly eaten and hasn't bathed or changed his clothes for 3 weeks. He undergoes 4 weeks of psychotherapy and medication adjustment. Which statement by the client indicates that he's ready for discharge? A. "I know a sign of my disease is not bathing and maintaining my personal appearance." B. "God tells me that I only need to bathe during the full moon." C. "I bathe and brush my teeth daily just like that voice tells me to." D. "I'll make sure I change my clothes every 3 days when I return home."
A. "I know a sign of my disease is not bathing and maintaining my personal appearance." Explanation: The client shows understanding that not being able to perform activities of daily living is a sign of an acute phase of his schizophrenia. As he improves, he resumes personal hygiene. That the client is listening to auditory hallucinations indicates that further management is required. Part of standard grooming is brushing one's teeth twice a day. Although the client is cognitively aware of the relationship between personal hygiene and psychological wellness, he's unable to apply this knowledge to day-to-day living (as indicated by the client's response in option 4).
A client who was transferred from a long-term care facility is admitted with dehydration and pneumonia. Which nursing interventions can help prevent pressure ulcer formation in this client? Select all that apply. A. Reposition the client every 2 hours. B. Use commercial soaps to keep the skin dry. C. Perform range-of-motion exercises. D. Encourage the client to eat a well-balanced diet. E. Tuck bed covers tightly in the foot of the bed.
A. Reposition the client every 2 hours. Perform range-of-motion exercises. Encourage the client to eat a well-balanced diet. Explanation: To prevent pressure ulcer formation, the nurse should turn and reposition the client every 2 hours, perform range-of-motion exercises, avoid using commercial soaps that dry or irritate skin, avoid tucking covers tightly into the foot of the bed, and encourage the client to eat a well-balanced diet.
One day after an appendectomy, a 9-year-old client rates his pain at 4 out of 5 on the pain scale but is playing video games and laughing with his friend. Which of the following would the nurse document on the child's chart? A. The child rates pain at 4 out of 5. Pain medication administered as prescribed. B. The child doesn't understand the pain scale. Performed teaching to help child match his pain rating to how he appears to be feeling. C. The child rates his pain at 4 out of 5; however, he appears to be in no distress. Reassess when he's visibly showing signs of pain. D. The child is in no apparent distress, and no pain medication is needed at this time.
A. The child rates pain at 4 out of 5. Pain medication administered as prescribed. Explanation: Pain is what the child says it is, and the nurse must document what the child reports. If a child's behavior appears to differ from the child's rating of pain, believe the pain rating. A child who uses a passive coping behavior (such as distraction) may rate pain as more intense than children who use active coping behavior (such as crying). Making judgments about pain based on behavior can result in children being inadequately medicated for pain.
A client comes to the emergency department complaining of severe pain in the right flank, nausea, and vomiting. The physician tentatively diagnoses right ureterolithiasis (renal calculi). When planning this client's care, the nurse should assign highest priority to which nursing diagnosis?
Acute pain Explanation: Ureterolithiasis typically causes such acute, severe pain that the client can't rest and becomes increasingly anxious. Therefore, the nursing diagnosis of Acute pain takes highest priority. Diagnoses of Risk for infection and Deficient knowledge related to medication regimen are appropriate when the client's pain is controlled. A diagnosis of Imbalanced nutrition: Less than body requirements isn't pertinent at this time.
A 2-year-old is brought to the clinic by his mother for his annual examination. Which statement by the mother alerts the nurse to the toddler's risk for malnutrition? A. "He's so busy at meal time so I give him frequent snacks of a variety of foods throughout the day." B. "He drinks a bottle of whole milk several times a day." C. "He loves cheese, crackers, and all kinds of fruit." D. "He eats peanut butter and jelly sandwiches every day."
B. "He drinks a bottle of whole milk several times a day." Explanation: A 2-year-old should consume 2% milk with meals from a cup, not a bottle. Drinking whole milk several times per day prevents the toddler from consuming other foods that are essential to his diet, leaving him at risk for malnutrition. Toddlers commonly develop preferences for foods that they consume on a regular basis, such as peanut butter and jelly sandwiches. This food preference doesn't place the toddler at risk for malnutrition. Toddlers are typically unable to sit still for meals; therefore, small, frequent feedings are recommended. Cheese, crackers, and fruit are good food choices for toddlers.
When caring for a client during the second stage of labor, which action would be most appropriate? A. Encouraging the client to void every 2 hours B. Assisting the mother with pushing C. Allowing the client clear liquids D. Assisting the client with ambulation
B. Assisting the mother with pushing Explanation: Nursing care for the client during the second stage of labor should include assisting the mother with pushing, helping position her legs for maximum pushing effectiveness, and monitoring the fetal heart rate. During this time, the client is usually offered ice chips rather than clear liquids. The client should be encouraged to ambulate and void every 2 hours during the first stage of labor, not the second.
The nurse is caring for a child undergoing cardiac surgery? Which home care instruction is most appropriate? A. Immunizations are delayed indefinitely. B. Maintain the prescribed medication regimen until the health care provider makes a change. C. Routine dental care can be resumed. D. Maintain a sodium-restricted diet.
B. Maintain the prescribed medication regimen until the health care provider makes a change. Explanation: Drugs such as digoxin and furosemide shouldn't be stopped abruptly. There are no diet restrictions, so the child may resume a regular diet. Routine dental care is usually delayed 4 to 5 months after surgery. Immunizations may be delayed 6 to 8 weeks after surgery.
A client with a recent history of a stroke has been discharged from the rehabilitation facility with a walker. On a return visit to the health care provider, the nurse observes the gait. Which observation indicates the need to reinforce client education about walker use? A. The client moves his weak leg forward with the walker. B. The client's arms are fully extended when using the walker. C. The client backs up to the chair until his legs touch the chair, and then sits down. D. The client moves his hands to the chair armrests before lowering himself into the chair
B. The client's arms are fully extended when using the walker. Explanation: When using a walker, the client's arms should be slightly bent at the elbow, allowing maximum support from the arms while ambulating. The weak leg is always moved forward first with the walker to provide the maximum support. When sitting, the client should always back up to the chair and feel the chair with his legs before sitting. The client should use the armrests of the chair for support because the armrests are more stable than the walker.
A client asks the reason for being placed in traction prior to surgery. Which response by the nurse is most appropriate? A. Traction allows for more activity. B. Traction helps to prevent trauma and overcome muscle spasms. C. Traction helps with repositioning while in bed. D. Traction will help prevent skin breakdown.
B. Traction helps to prevent trauma and overcome muscle spasms. Explanation: Traction prevents trauma and overcomes muscle spasms. Traction doesn't help in preventing skin breakdown, repositioning the client, or allowing the client to become active.
A client is in the manic phase of bipolar disorder. To help the client effectively maintain adequate nutrition, the nurse should plan to: A. provide large, attractive meals. B. offer finger foods and sandwiches. C. provide a stimulating mealtime environment. D. let the client choose favorite foods.
B. offer finger foods and sandwiches. Explanation: Finger foods and sandwiches help maintain adequate nutrition and provide calories for this client's high energy level. During the manic phase, the client can't sit still for the large meals specified in option 1. Option 3 is incorrect because a quiet mealtime environment is more beneficial than a stimulating one. Option 4 is inappropriate because this client has a short attention span and has trouble making choices.
A client with a history of colon cancer has a permanent colostomy. The nurse must irrigate the colostomy to prepare the client for diagnostic testing. When irrigating, how far into the stoma should the nurse insert the lubricated catheter? A. 1" to 1.5" B. 5" to 7" C. 2" to 4" D. 0.25" to 0.5"
C. 2" to 4" Explanation: When irrigating a colostomy, the nurse should insert the catheter 2" to 4" into the stoma. Inserting it less than 2" may cause leakage. Inserting it more than 4" may cause trauma to the intestinal mucosa.
When explaining to the parents the optimal time for repair of hypospadias, the nurse should indicate which as the age of choice? A. 2 years B. 4 years C. 6 to 18 months D. 1 week
C. 6 to 18 months Explanation: The preferred time for surgical repair is ages 6 to 18 months, before the child has developed body image and castration anxiety. Surgical repair of hypospadias as early as age 3 months has been successful, but with a high incidence of complications.
Which nursing action should be included in the care plan to promote comfort in a 4-year-old child hospitalized with meningitis? A. Let the child's 2-year-old sibling stay in the room. B. Rock the child frequently. C. Avoid making noise when in the child's room. D. Keep the lights on brightly so that the child can see the parent.
C. Avoid making noise when in the child's room. Explanation: Meningeal irritation may cause seizures and heightens a child's sensitivity to all stimuli, including noise, lights, movement, and touch. Frequent rocking, presence of a younger sibling, and bright lights would increase stimulation
The nurse explains to a client with thyroid disease that the thyroid gland normally produces: A. TSH, T3, and calcitonin. B. iodine and thyroid-stimulating hormone (TSH). C. T3, T4, and calcitonin. D. thyrotropin-releasing hormone (TRH) and TSH.
C. T3, T4, and calcitonin. Explanation: The thyroid gland normally produces thyroid hormone (T3 and T4) and calcitonin. TSH is produced by the pituitary gland to regulate the thyroid gland. TRH is produced by the hypothalamus gland to regulate the pituitary gland.
A client expressed interest in using complementary alternate modalities for health benefits and asks the nurse to provide information about meditation. The nurse would provide which appropriate response to this client
It consists of deep personal thoughts and breath control to help decrease anxiety. Explanation: Meditation strives to clear the mind with deep breathing and personal thoughts. Herbalists use herbs and plants to promote health. Therapeutic touch teaches that each person is surrounded by an energy field. In acupressure, the client applies external pressure to the energy points for pain control.
A nurse is caring for a client who is awaiting surgery for a hip fracture. Which nursing intervention has the highest priority when providing skin care for this client? Change the bed linens frequently for an incontinent client. Keep the skin clean and dry without using harsh soaps. Gently massage the skin around pressure areas. Rub moisturizing lotion over pressure areas.
Keep the skin clean and dry without using harsh soaps. Explanation: Keeping the skin clean is always the highest priority when providing skin care to a bedridden client. The other measures are also important, but the nurse should rub around, not directly over, pressure areas to avoid skin breakdown.
A client who experienced a stroke has left-sided facial droop. During mouth care, the client begins to cough violently. What should the nurse do?
Make sure a tonsil suction device is readily available while providing mouth care. Explanation: The client with facial droop has difficulty swallowing secretions during mouth care. Therefore, the nurse should have a tonsil suction device available to suction the client's mouth to avoid further coughing episodes and prevent aspiration. The client should undergo swallowing studies before a decision is made on whether to maintain nothing-by- mouth status. Continuing mouth care without the tonsil suction device places the client at risk for aspiration.
A nurse is caring for a bedridden older adult client. Which nursing intervention should the nurse include in this client's care? Vigorously massage areas of redness. Apply lotion to the bony prominences. Post an every 2 hour turn schedule at the bedside. Slide the client onto either side when turning.
Post an every 2 hour turn schedule at the bedside. Explanation: A turning schedule with a signature sheet helps ensure that the client is turned, thus helping to prevent pressure ulcers. Turning should occur every 1 to 2 hours for clients who are in bed for prolonged periods. The nurse should apply lotion to keep the skin moist but should avoid vigorous massage of bony prominences, which could damage capillaries. When moving the client, the nurse should lift, rather than slide, the client to avoid shearing.
x A nurse is caring for a bedridden older adult client. Which nursing intervention should the nurse include in this client's care? Vigorously massage areas of redness. Apply lotion to the bony prominences. Post an every 2 hour turn schedule at the bedside. Slide the client onto either side when turning.
Post an every 2 hour turn schedule at the bedside. Explanation: A turning schedule with a signature sheet helps ensure that the client is turned, thus helping to prevent pressure ulcers. Turning should occur every 1 to 2 hours for clients who are in bed for prolonged periods. The nurse should apply lotion to keep the skin moist but should avoid vigorous massage of bony prominences, which could damage capillaries. When moving the client, the nurse should lift, rather than slide, the client to avoid shearing.
A nurse demonstrates how to clean dentures to an unlicensed assistive personnel (UAP). Which action should the nurse make sure to teach the UAP?
Put a washcloth in the sink to prevent damage the dentures. Explanation: When cleaning dentures over a sink, the UAP should place a paper towel or washcloth in the sink to prevent damage in case the dentures are dropped. The UAP should rinse dentures under tepid (not hot) running water because hot water could change their shape. The UAP should scrub dentures with a cleaning agent and tepid (not cold) water to make cleaning and denture reinsertion easier.
A client has followed an antipsychotic medication regimen for a number of years. The health care provider treats a urinary tract infection with antibiotic therapy. Which action would be most appropriate? Arrange for possible hospitalization so that the client adheres to the new therapy. Let a visiting nurse give the medication to reduce the risk for nonadherence. Develop a psychoeducational program to address the client's emotional and physical problems arising from physiological problems. Reinforce instruction on the medication, possible adverse effects, and a return demonstration for teaching effectiveness.
Reinforce instruction on the medication, possible adverse effects, and a return demonstration for teaching effectiveness. Explanation: The client has been successful and reliable in carrying out current medication regimen. The nurse should assume the competency includes self-administration of antibiotics if the instructions are understood. No evidence exists that the client is having a relapse as a result of the infection, so the client wouldn't need a psychoeducational program or hospitalization. Arranging for a community nurse to give the medication encourages dependency as opposed to self-care.
A nurse is caring for a client with a pressure ulcer on the sacrum. When educating the client about dietary intake, which foods should the nurse plan to emphasize? legumes and cheese whole-grain products fruits and vegetables lean meats and low-fat milk
lean meats and low-fat milk Explanation: Although the client should eat a balanced diet with foods from all food groups, the diet should emphasize foods that supply complete protein, such as lean meats and low-fat milk. Protein helps build and repair body tissue, which promotes healing. Legumes provide incomplete protein. Cheese contains complete protein but also fat, which should be limited to 30% or less of caloric intake. Whole-grain products supply incomplete proteins and carbohydrates. Fruits and vegetables provide mainly carbohydrates.
