Passpoint Remediation

Pathophysiology of nephrotic syndrome

- Glomerular protein permeability increases. (See Pathophysiology of nephrotic syndrome.) - Urinary excretion of protein, especially albumin, increases. - Hypoalbuminemia develops and causes decreased colloidal oncotic pressure. - Leakage of fluid into interstitial spaces leads to acute generalized edema. - Vascular volume loss leads to increased blood viscosity and coagulation disorders. - The renin-angiotensin system is triggered, causing tubular reabsorption of sodium and water and contributing to edema.

Usually the second stage of labor (pushing) for a primigravid client lasts about __________ hours.

1-2 hours

Normal aPTT in heparinized clients is ___________ times normal

2-2.5

Therapeutic INR in in the range of _________ with warfarin?

2-3

The transition phase of the first stage of labor occurs when the client is ____ to ____ cm dilated.

8 to 10 cm

Place the five stages of death and dying in the order in which Elisabeth Kübler-Ross noted that they most often occur.

Denial and isolation Anger Bargaining Depression Acceptance

This STI in the female is characterized by mucopurulent vaginal discharge with cervical exudate

Chlamydia

The nurse is auscultating the lung sounds of a client with long-standing emphysema. The nurse is most likely to detect: You Selected: stridor. Correct response: diminished breath sounds.

In emphysema, the anteroposterior diameter of the chest wall is increased. As a result, the client's breath sounds may be diminished. Fine crackles are present when there is fluid in the lungs. Stridor occurs as a result of a partially obstructed larynx or trachea; stridor can be heard without auscultation. A pleural friction rub is present when pleural surfaces are inflamed and rub together.

Where do you adminster eye drops?

In the center of the lower lid

A child is receiving amoxicillin for otitis media. Which action should the nurse recommend the mother do when the child develops diarrhea?

Offer yogurt several times a day. Yogurt with live cultures helps restore the normal intestinal flora. Restricting the child to clear fluids will not help stop the diarrhea or recolonize the intestine.

A client is scheduled for electroconvulsive therapy (ECT). Before ECT begins, the nurse expects to administer which neuromuscular blocking agent?

Succinylcholine, a depolarizing blocking agent, is the drug of choice when short-term muscle relaxation is desired — for example, during ECT or intubation. Vecuronium, pancuronium, and atracurium are nondepolarizing blocking agents used for intermediate- or long-term muscle relaxation.

The nurse is making team assignments and is assigning tasks to the unlicensed assistive personnel (UAP). unit. What information should the nurse know before delegating tasks to the UAP? You Selected: Whether the UAP has previously completed and practiced the delegated activities. Correct response: The UAP's level of knowledge and comfort level in performing specific nursing activities should be considered.

The RN is responsible for providing, delegating, and at times supervising others to ensure safe nursing care. They remain responsible when delegating nursing tasks to other members of the health care team. The nurse should delegate tasks in collaboration with the UAP, considering their knowledge level and comfort when performing various aspects of care, regardless of whether the UAP has previously completed these activities.

What about a chest X-ray for a patient with tuberculosis?

The client will not have a clear chest X-ray for several months after starting treatment.

A client has received an infusion of antibiotics and is now experiencing an anaphylactic reaction. What is the most important intervention by the nurse? You Selected: Administer epinephrine Correct response: Maintain a patent airway

The first priority is to maintain a patent airway. The client will then require an epinephrine injection. If hypotension develops, a saline bolus may be given. The client's vital signs should be monitored, but not as the first action.

Where to end measurment for NG tube insertion? (Imagine the tube going from nose to earlobe, and then down toward the stomach.

When measuring for NG tube insertion, the nurse would end the measurement at the xiphoid process.

positive Ortolani's sign indicates

congenital hip dysplasia

Digoxin increases ____________________ of the heart and _______________ renal perfusion, resulting in a diuretic effect with increased loss of potassium and sodium.

contractility increases

A client whose cervix is 10 cm dilated has completed the ___________ stage of labor.

first The first stage of labor lasts from the beginning of cervical dilation to complete dilation (10 cm).

Levothyroxine is indicated for?

hypothyroidism

after an air-contrast study, position the patient

supine with the head lower than the trunk

antidote to heparin

protamine sulfate

A patient with emphysema is given aminophylline. How do you know when it is effective?

relaxation of smooth muscles in the bronchioles

INR relates to therapy with _______________.

warfarin

A nurse is administering a purified protein derivative (PPD) test to a client. Which statement concerning PPD testing is true? Correct answer: A positive reaction indicates that the client has been exposed to the disease.

A positive reaction means the client has been exposed to TB; it isn't conclusive for the presence of active disease. A positive reaction consists of palpable swelling and induration of 5 to 15 mm. It can be read 48 to 72 hours after the injection. In clients with positive reactions, further studies are usually done to rule out active disease. In immunosuppressed clients, a negative reaction doesn't exclude the presence of active disease.

A client who's receiving chemotherapy for breast cancer develops myelosuppression. Which instructions would the nurse include in the client's discharge teaching plan? Select all that apply. You Selected: Avoid crowded places such as shopping malls. Avoid activities that may cause bleeding. Increase intake of fresh fruits and vegetables. Wash hands frequently. Correct response: Avoid people who have recently received live vaccines. Avoid activities that may cause bleeding. Wash hands frequently. Avoid crowded places such as shopping malls.

Chemotherapy can cause myelosuppression, which is a decreased number of RBCs, white blood cells, and platelets. A client receiving chemotherapy needs to avoid people who have been vaccinated recently, especially by a live virus. Because platelet counts are reduced, the client also needs to avoid activities that could cause trauma and bleeding. The client would wash her hands frequently because hand washing is the best way to prevent the spread of infection. A client receiving chemotherapy would avoid crowded places as well as people with colds during flu season because she/he has a reduced ability to fight infection. Fresh fruits and vegetables would be avoided because they can harbor bacteria that cannot be removed easily by washing. Signs and symptoms of infection, such as a sore throat, fever, and a cough, are reported immediately to the health care provider.

Which information is important for a nurse to include in a teaching plan for a client with schizophrenia who is taking clozapine? You Selected: Monthly blood tests will be necessary. Correct response: Report a sore throat or fever to the physician immediately.

Explanation: A sore throat and fever are indications of an infection caused by agranulocytosis, a potentially life-threatening complication of clozapine therapy. Because of the risk of agranulocytosis, white blood cell (WBC) counts are necessary weekly, not monthly. If the client's WBC count drops below 3,000/μl, the medication must be discontinued. Clients taking this medication may experience hypotension. Warn the client to stand up slowly to avoid dizziness from orthostatic hypotension. The client should continue to take this medication even after his symptoms have been controlled. If the medication must be discontinued, it should be slowly tapered over 1 to 2 weeks under the supervision of a physician.

A 10-year-old with scoliosis has to wear a brace. The nurse should develop a teaching plan with the client to include which instruction? You Selected: Wear the brace during waking hours. Correct response: Wear a form-fitting t-shirt under the brace.

A form-fitting t-shirt can be worn under the brace to prevent skin irritation and collect perspiration. Braces are worn 23 hours each day. Lotions may cause irritation and should not be used. The skin under the brace should be bathed daily to help prevent irritation from the brace. The brace can be removed for bathing so all the skin can be bathed.

The nurse is caring for a client who is scheduled for an adrenalectomy. Which drug may be included in the preoperative prescriptions to prevent Addison's crisis following surgery?

A glucocorticoid preparation will be administered intravenously or intramuscularly in the immediate preoperative period to a client scheduled for an adrenalectomy. Methylprednisolone sodium succinate protects the client from developing acute adrenal insufficiency (Addison's crisis) that occurs as a result of the adrenalectomy.

The nurse advises the client who has had a femoral head prosthesis placement on the type of chair to sit in during the first 6 to 8 weeks after surgery. Which chair would be the correct type to recommend?

A high-backed straight chair with armrests is recommended to help keep the client in the best possible alignment after surgery for a femoral head prosthesis placement. Use of this type of chair helps to prevent dislocation of the prosthesis from the socket. A desk-type swivel chair, padded upholstered chair, or recliner should be avoided because it does not provide for good body alignment and can cause the overly flexed femoral head to dislocate.

Follwing a transsphenoidal hypophysectomy, the nurse should assess the client for: You Selected: fluctuating blood glucose levels. Correct response: cerebrospinal fluid (CSF) leak.

A major focus of nursing care after transsphenoidal hypophysectomy is the prevention of and monitoring for a CSF leak. CSF leakage can occur if the patch or incision is disrupted. The nurse should monitor for signs of infection, including elevated temperature, increased white blood cell count, rhinorrhea, nuchal rigidity, and persistent headache. Hypoglycemia and adrenocortical insufficiency may occur. Monitoring for fluctuating blood glucose levels is not related specifically to transsphenoidal hypophysectomy. The client will be given IV fluids postoperatively to supply carbohydrates. Cushing's disease results from adrenocortical excess, not insufficiency. Monitoring for cardiac arrhythmias is important, but arrhythmias are not anticipated following a transsphenoidal hypophysectomy.

A pregnant client asks the nurse whether she can take castor oil for her constipation. How should the nurse respond? You Selected: "Yes, it produces no adverse effects." Correct response: "No, it can initiate premature uterine contractions."

Castor oil can initiate premature uterine contractions and other adverse effects in pregnant women. Castor oil doesn't promote sodium retention and isn't known to increase absorption of fat-soluble vitamins.

During the initial assessment of a child admitted to the pediatric unit with osteomyelitis of the left tibia, when assessing the area over the tibia, which is an expected finding? You Selected: diffuse tenderness Correct response: increased warmth

Findings associated with osteomyelitis commonly include pain over the area, increased warmth, localized tenderness, and diffuse swelling over the involved bone. The area over the affected bone is red.

What electrolyte imbalance increases the risk of digoxin toxicity?

Hypokalemia

A client receiving a loop diuretic should be encouraged to eat which foods? Select all that apply. You Selected: banana dried fruit peppers orange juice Correct response: banana dried fruit orange juice

Hypokalemia is a side effect of loop diuretics. Bananas, dried fruit, and oranges are examples of food high in potassium. Angel food cake and peppers are low in potassium.

A child diagnosed with type 1 diabetes has the following order: Regular insulin 8 units to be administered subcutaneously before meals and at bedtime. Which of the following are priority actions for the nurse to take to administer the medication safely? Select all that apply. You Selected: Check the blood glucose level. Use a 22G needle on the syringe. Verify the insulin order. Correct response: Check the blood glucose level. Verify the insulin order.

Insulin is never administered without first checking the blood glucose level and verifying the order. These are always a nursing priority. Aspiration is not performed with the administration of insulin. Insulin is given subcutaneously, not in the muscle. A 22G needle is much too large for insulin administration.

What do night sweats indicate for a patient with tuberculosis?

Night sweats are a sign of tuberculosis, but they do not indicate whether the client is contagious.

Patient teaching for Selegiline

Selegiline transdermal system is the first transdermal monoamine oxidase inhibitor. The client needs to avoid exposing the application site to external sources of direct heat, such as saunas, heating lamps, electric blankets, heating pads, heated water beds, and prolonged direct sunlight because heat increases the amount of selegiline that is absorbed, resulting in elevated serum levels of selegiline. Selegiline is not associated with significant weight gain, although a weight gain of 1 to 2 lb (2.2 to 4.4 kg) is possible.

describe Moro's reflex

The Moro reflex is an infantile reflex normally present in all infants/newborns up to 3 or 4 months of age as a response to a sudden loss of support, when the infant feels as if it is falling. It involves three distinct components: 1. spreading out the arms (abduction) 2. unspreading the arms (adduction) 3. crying (usually)

The nurse should adjust a client's heparin dose according to a prescribed anticoagulation order based on maintaining which laboratory value at what therapeutic level for anticoagulant therapy? You Selected: International Normalized Ratio, 2 to 3 seconds. Correct response: Partial thromboplastin time, 1.5 to 2.5 times the normal control.

The nurse should adjust the heparin dose to maintain the client's partial thromboplastin time between 1.5 and 2.5 times the normal control. The prothrombin time and International Normalized Ratio are used to maintain therapeutic levels of warfarin, oral anticoagulation therapy. The thrombin clotting time is used to confirm disseminated intravascular coagulation.

A client with preeclampsia is prescribed magnesium sulfate to prevent seizure activity. The nurse is reviewing the results of the client's serum magnesium level and determines that the client's level is therapeutic based on which result? You Selected: 16 mEq/L (8 mmol/L) Correct response: 6.8 mEq/L (3.4 mmol/L)

The therapeutic level of magnesium for clients with preeclampsia ranges 4 to 8 mEq/L (2 to 4 mmol/L). A serum magnesium level of 8 to 10 mEq/L (4 to 5 mmol/L) may cause the absence of reflexes in the client. Serum levels of 10 to 12 mEq/L (5 to 6 mmol/L) may cause respiratory depression, and a serum level of magnesium greater than 15 mEq/L (7.5 mmol/L) may result in respiratory paralysis.

A client with a bleeding peptic ulcer is admitted to an acute care facility. As part of therapy, the physician orders cimetidine I.V. Infusing this medication too rapidly may cause: You Selected: tetany. Correct response: hypotension.

When given by rapid I.V. infusion, cimetidine may cause profound hypotension and other cardiotoxic effects. Tetany and bronchospasms aren't associated with cimetidine. Although the drug may cause hallucinations, this adverse reaction doesn't result simply from rapid administration.

When a child vomits, it is suggested to

Withhold food and fluids for 2 hours

What assessment finding would support the administration of protamine sulfate?

aPTT 3.5-5 times normal

A client with nonresistant tuberculosis is no longer considered contagious when he/she shows clinical evidence of

decreased infection, such as significantly decreased coughing and fewer organisms on sputum smears.

Which laboratory finding is present in nephrotic syndrome?

decreased total serum protein A decreased total serum protein occurs as extensive amounts of protein are excreted from the body through the urine. Clients may develop hypocalcemia.

A client with drug-resistant tuberculosis is not contagious when?

the client has had a negative acid-fast test. The medication may not produce a negative acid-fast test results for several days.

Patient teaching Re CRF: dietary instruction to increase intake of carbohydrates. Why does a patient with CRF (chronic renal failure) require extra carbohydrates?

to prevent protein catabolism In a client with CRF, unrestricted intake of sodium, protein, potassium, and fluid may lead to a dangerous accumulation of electrolytes and protein metabolic products, such as amino acids and ammonia. Therefore, the client must limit intake of sodium; meat, which is high in protein; bananas, which are high in potassium; and fluid, because the failing kidneys can't secrete adequate urine. Salt substitutes are high in potassium and should be avoided.

Which type of restraint is best for the nurse to use for a child in the immediate postoperative period after cleft palate repair? You Selected: wrist restraints Correct response: elbow restraints

Recommended restraints for a child who has had palate surgery are elbow restraints. They minimize the limitation placed on the child but still prevent the child from injuring the repair with fingers and hands. A safety jacket or wrist or body restraints restrict the child unnecessarily.

What should be readily available at the bedside of a client with a chest tube in place? You Selected: another sterile chest tube Correct response: a bottle of sterile water

A bottle of sterile water should be readily available and in view when a client has a chest tube so that the tube can be immediately submersed in the water if the chest tube system becomes disconnected. The chest tube should be reconnected to the water-seal system as soon as a sterile functioning system can be reestablished. There is no need for a tracheostomy tray, another chest tube, or a spirometer to be placed at the bedside for emergency use.

Describe retinal detachment

A client with retinal detachment frequently reports flashing lights in the affected eye followed by a loss of vision commonly described as a curtain being slowly drawn across the eye. The detachment is painless, and the client will not report pain. Retinal detachment does not involve the eye muscles. Retinal detachment does not cause lacrimation.

A primigravida in active labor is about 10 days postterm. The client desires a pudendal block anesthetic before childbirth. After the nurse explains this type of anesthesia to the client, which location if identified by the client as the area of relief would indicate to the nurse that the teaching was effective?

A pudendal block is used for vaginal births to relieve pain primarily in the perineum and vagina. Pudendal block anesthesia is adequate for episiotomy and its repair. A pudendal block relieves pain in the perineum and vagina. It does not relieve discomfort in the back, abdomen, or fundus.

The client with an abdominal perineal resection and colostomy had a nasogastric (NG) tube inserted during surgery. The NG tube will most likely be removed when the client demonstrates:

A sign indicating that a client's colostomy is ready to function is the passage of flatus. The nurse will auscultate for the presence of bowel sounds. When this occurs, gastric suction is discontinued, and the client is started on fluids and food orally. Neither gastric drainage nor a decrease in nausea and vomiting is a criterion for determining whether or not the gastric suction should be discontinued. A soft, flat abdomen is an indication that abdominal distention has not developed. It is not an indicator for removal of the NG tube.

A client who's being admitted to labor and delivery has these assessment findings: gravida 2 para 1, estimated 40 weeks' gestation, contractions 2 minutes apart, lasting 45 seconds, vertex +4 station. Which nursing intervention would be the priority at this time? You Selected: Placing the client in bed to begin fetal monitoring Correct response: Preparing for immediate delivery

Based on the client's assessment findings, this client is ready for delivery, which is the nurse's top priority. Although placing the client in bed, checking for ruptured membranes, and providing comfort measures are applicable interventions, the priority is immediate delivery for this client.

Which instruction should the nurse expect to include in the discharge teaching plan for the parent of an infant who has had an inguinal herniorrhaphy? You Selected: Keep the incision covered with a sterile dressing. Correct response: Change diapers as soon as they become soiled.

Changing a diaper as soon as it becomes soiled helps prevent wound infection, the most common complication after inguinal hernia repair in an infant secondary to possible wound contamination with urine and stool. Because the surgical wound is unlikely to separate, an abdominal binder is unnecessary. The incision may or may not be covered with a dressing. If a dressing is not used, the health care provider (HCP may apply a topical spray to protect the wound. Restraining the infant's hands is unnecessary if the diaper is applied snugly. The infant would be unable to get the hands into the diaper close to the surgical site.

A client with chronic obstructive pulmonary disease has a new prescription for theophylline. Which of the following information obtained from the client would prompt the nurse to consult with the healthcare provider? You Selected: The client is coughing up thick mucus. Correct response: The client takes cimetidine 150 mg daily.

Cimetidine interferes with the metabolism of theophylline and may cause theophylline toxicity. Theophylline should be taken as prescribed even if the client is not experiencing any symptoms of shortness of breath. An elevated heart rate is an expected side effect of theophylline and moderate exercise in a client with COPD. Thick mucus production is also an expected symptom of COPD.

What type of isolation precautions would the nurse request for a child diagnosed with group-A beta-hemolytic streptococcus?

Droplet precautions Streptococcal group A disease, including pharyngitis (in infants and young children), pneumonia, serious invasive wounds, and scarlet fever (in infants and young children)

A client with bipolar disorder has been receiving lithium for two weeks. He also takes chemotherapeutic drugs that cause him to feel nauseated and anorexic. It is most important for the nurse to assess this client for: You Selected: oliguria and cardiac dysrhythmias. Correct response: hypotonic reflexes with muscle weakness.

Lithium alters sodium transport in nerve and muscle cells, slowing the speed of impulse transmission. Hypotonic reflexes and muscle weakness can be an adverse effect of lithium. Lithium has no known effect on body temperature, does not cause double vision or arthritis with joint tenderness. Oliguria and symptoms of cardiac dysrhythmias occur late in severe lithium toxicity.

What medication is a human brain natriuretic peptide (BNP) preparation?

Nesiritide (Natrecor) is a preparation of human BNP that mimics the action of endogenous BNP, causing dieresis and vasodilation, reducing blood pressure, and improving cardiac output. It is a preload and afterload reducer. Chapter 29: Management of Patients With Complications from Heart Disease - Page 803

signs indicating levothyroxine overdose

Sweating, insomnia, rapid pulse, dyspnea, irritability, fever, and weight loss

The nurse is caring for an infant with pyloric stenosis. Which manifestation requires priority attention? You Selected: Coffee ground emesis Correct response: Projectile vomiting

The obstruction doesn't allow food to pass through the pyloris to the duodenum. When the stomach becomes full, the infant forcefully vomits for pressure relief. Chronic hunger is commonly seen. There's no diarrhea because food doesn't pass the stomach. Coffee ground emesis is a result of partially digested blood in the stomach, and not an expected finding with pyloric stenosis.

Which safeguard is necessary when administering I.V. fluid to an infant?

Use of an infusion pump to regulate the flow rate is the appropriate safeguard, because infants and children with compromised cardiopulmonary status are particularly vulnerable to I.V. fluid overload. Administering fluid at the slowest possible rate may not benefit the infant. Using a gravity infusion set or a micro drop infusion set will not protect against fluid overload when I.V. administration is too rapid.

When teaching parents about fifth disease (erythema infectiosum) and its transmission, the nurse should provide which information? You Selected: Fifth disease is transmitted by stool. Correct response: Fifth disease is transmitted by respiratory secretions.

Fifth disease is transmitted by respiratory secretions. The transmission mode for roseola is unknown. Rubella is transmitted by respiratory secretions, stool, and urine. Intestinal parasitic conditions, such as giardiasis and pinworm infection, are transmitted by stool.

Nursing interventions for digoxin toxicity Symptoms of digoxin toxicity include severe sinus bradycardia, colorful halos around lights, nausea, anorexia, and vomiting.

1. discontinue administration of drug; 2. begin continuous electrocardiographic monitoring for cardiac dysrhythmias; 3. administer any appropriate antidysrhythmic drugs as ordered; 4. determine serum digoxin and electrolyte levels; 5. administer potassium supplements for hypokalemia if indicated, as ordered; 6. institute supportive therapy for gastrointestinal symptoms (nausea, vomiting, or diarrhea); 7. and administer digoxin antidote (digoxin immune fab) if indicated, as ordered. Inserting a nasogastric tube or administering oxygen is not appropriate for digoxin toxicity.

Which assessment in a client that has just returned from having a modified radical neck dissection with skin flap would require a nurse to take immediate action? You Selected: The client's voice is hoarse. Correct response: The skin flap appears white.

A white skin flap indicates lack of perfusion and the healthcare provider should be notified immediately. Hoarseness may be due to trauma from the endotracheal tube that is inserted during surgery. Sutures may be visible after this surgery. An absence of bowel sounds is a normal finding immediately post surgery with general anesthesia.

A client admitted for treatment of a gastric ulcer is being prepared for discharge on antacid therapy. Discharge teaching should include which instruction? You Selected: "Avoid taking antacids containing magnesium if you develop a heart problem." Correct response: "Continue to take antacids even if your symptoms subside."

Antacids decrease gastric acidity and should be continued even if the client's symptoms subside. Because other medications may interfere with antacid action, the client should avoid taking antacids concomitantly with other drugs. If cardiac problems arise, the client should avoid antacids containing sodium, not magnesium. For optimal results, the client should take an antacid 1 hour before or 2 hours after meals.

A 15-year-old girl is sent to the school nurse with reports of dizziness and nausea. While assessing the girl, who denies any health problems, the nurse smells alcohol on her breath. Which response by the nurse is most appropriate?

Asking the client to report everything that she has had to eat and drink yesterday and today is the least judgmental approach and also provides helpful information. Confronting the client about drinking alcohol or asking her to admit the real reason for feeling sick can put the client on the defensive and block further communication. The nurse should avoid putting the client on the defensive to facilitate communication that may eventually enable the nurse to get the truth and identify interventions.

A client is 12 hours post abdominal inguinal hernia repair done under general anesthesia. The practitioner orders to progress diet as tolerated. Which tray should the nurse choose for this client?

Broth, gelatin cubes, and tea To begin the patient's transition to eating a regular diet, the nurse will first choose a clear-liquid diet. This includes transparent liquids, such as apple juice, ginger ale, and chicken broth. When clear liquids are tolerated, the client can then transition to a full-liquid diet consisting of fluids and foods that are liquid at room temperature. Some examples are milk, custard, ice cream, puddings, vegetable and fruit juices, refined or strained cereals, and egg substitutes. Although milk, custard, and vanilla ice cream may be included in a bland diet, it may also include semi-solid and solid foods that are not spicy. The BRAT diet is commonly used to combat diarrhea and limits intake to bananas, rice, applesauce, and toast.

The nurse is assessing a 10-month-old infant during a checkup. Which developmental milestones would the nurse expect the infant to display? Select all that apply. You Selected: Sitting on a firm surface without support Holding head erect Correct response: Holding head erect Sitting on a firm surface without support Bearing majority of weight on legs

By age 4 months, an infant would be able to hold the head erect. By age 9 months, the infant would be able to sit on a firm surface without support and bear the majority of weight on the legs (for example, walking while holding onto furniture). Self-feeding and bowel and bladder control are developmental milestones of toddlers. By age 12 months, the infant would be able to stand alone and may take the first steps.

The nurse is documenting in the client's health record. Which information is most appropriate for the nurse to record as objective data? Select all that apply. You Selected: Client's dressing is intact with scant amount of serous drainage. Client ambulated to end of hallway. Client's blood pressure is 120/80 mm Hg; pulse 76 bpm; respirations 14 breaths/min. Client appeared angry and belligerent all shift. Correct response: Client's blood pressure is 120/80 mm Hg; pulse 76 bpm; respirations 14 breaths/min. Client's dressing is intact with scant amount of serous drainage. Client ambulated to end of hallway.

Client vital signs, observation of a dressing, and documentation of the activity of a patient represent objective data. Using words such as "seems" or "appears" implies subjectivity on the part of the nurse.

For which of the following clients is the nursing assessment of pain most likely to result in undertreatment? You Selected: Asian American who requests medication for pain following abdominal surgery Correct response: Older adult who grimaces and states there is no pain after a gastrostomy tube placement

Clients at risk for insufficient pain control are older adults and those of ethnic origins that hold the tradition of stoicism, such as many Asian and Hispanic cultures. The nurse must assess carefully to provide culturally appropriate care. Clients who request medication, or are allowed to regulate their own medications, are more likely to have their pain controlled.

The nurse is assessing a client with multiple sclerosis who is experiencing mobility problems. What question about diagnostic studies would the nurse ask the client while obtaining the client's history? You Selected: Did you have a computerized axial tomography (CAT) scan of the legs? Correct response: Have you had a recent dual-energy x-ray absorptiometry (DEXA) scan?

Clients with multiple sclerosis who have mobility problems may experience bone loss and an early onset of osteoporosis. Therefore, a DEXA scan would be performed to determine the likelihood of bone loss, and the nurse would ask the client if a recent DEXA scan was performed. Asking about the other diagnostic studies is not directly related to the client's recent experience of mobility problems.

A client who recently experienced a stroke tells the nurse that he has double vision. Which nursing intervention is the most appropriate? You Selected: Encourage the client to close his eyes. Correct response: Alternatively patch one eye every 2 hours.

Explanation: Patching one eye at a time relieves diplopia (double vision). Closing the eyes and making the room dark aren't the most appropriate options because they deprive the client of sensory input. Artificial tears relieve eye dryness but don't treat diplopia.

A client who is positive for human immunodeficiency virus (HIV) tells the nurse that her significant other is the only family member who knows her health status. What should the nurse do to keep the client's health status confidential? Select all that apply. You Selected: Ask all family members, except the client's significant other, to wait outside when she's educating the client. Correct response: Use the hospital code for HIV when documenting care. Ask all family members, except the client's significant other, to wait outside when she's educating the client.

Every facility uses a specific code to designate HIV-positive clients. To protect confidentiality, the nurse should speak about the diagnosis only with the client and any person the client designates. A nurse should never discuss a client with anyone who is not directly involved in that client's care. For instance, if the client does not give the nurse permission to speak with the client's mother, the nurse may not give the mother information about the client. Keeping a log of all HIV-positive clients violates client confidentiality.

The nurse is caring for a neonate at 38 weeks' gestation when the nurse observes marked peristaltic waves on the neonate's abdomen. After this observation, the neonate exhibits projectile vomiting. The nurse notifies the health care provider (HCP) because these signs are indicative of which problem? You Selected: diaphragmatic hernia Correct response: pyloric stenosis

Marked visible peristaltic waves in the abdomen and projectile vomiting are signs of pyloric stenosis. If the condition progresses without surgical intervention, the neonate will become dehydrated and develop metabolic alkalosis. Signs of esophageal atresia include coughing and regurgitation with feedings. Diaphragmatic hernia, a life-threatening event in which the abdominal contents herniate into the thoracic cavity, may be evidenced by breath sounds being heard over the abdomen and significant respiratory distress with cyanosis. Signs of hiatal hernia include vomiting, failure to thrive, and short periods of apnea.

Which action would be most appropriate for a neonate whose hemoglobin is 16 g/dL (160 g/L) immediately after birth? You Selected: Assess for symptoms of polycythemia. Correct response: Document this as a normal finding.

Normal neonatal hemoglobin level ranges from 15 to 20 g/dL (150 to 200 g/L) blood. After birth, the hemoglobin level gradually decreases. The nurse should document this as a normal finding. The neonate does not demonstrate symptoms of polycythemia, such as red, ruddy skin color, a hematocrit level greater than 65% (0.65), or a hemoglobin level greater than 20 g/dL (200 g/L).

Which client should receive a shingles vaccine? A client who: You Selected: has never had chickenpox. Correct response: is older than 60 years.

People older than 60 years should receive shingles vaccine to prevent the disease. The vaccine is not effective for genital herpes. The vaccine can be given to persons who have or have not had chickenpox. The vaccine is not advised for persons with a compromised immune system, for example those receiving chemotherapy or radiation therapy.

A nurse working in a pediatric cardiac unit is teaching the parents of a child with a cardiac disorder about cardiac arrest among children. Which statement by the parents informs the nurse that the teaching has been successful? You Selected: "We will decrease the risk of cardiac arrest by limiting exercise for our child." Correct response: "We will be alert to respiratory problems to decrease the risk of cardiac arrest."

Respiratory failure is the leading cause of cardiac arrest among infants and children. Cardiac arrest is typically caused by the progressive tissue hypoxia and acidosis associated with respiratory failure. Although medication incompatibilities and hypovolemia from dehydration have the potential to deteriorate into serious situations, more common cardiac event situations arise from respiratory failure in this population.

A client is to have a nasogastric (NG) tube inserted. When inserting the tube, the nurse should: You Selected: lubricate the tube with petroleum-based lubricant. Correct response: have the client flex the head when the tube is above the oropharynx.

The nurse should have the client tilt the head toward the ceiling as the NG tube is inserted. When the tube is above the oropharynx, the client should be instructed to bring the head forward a bit by flexing the neck. This technique closes the trachea and opens the esophagus to receive the tube. Correct technique includes lubricating the tube with a water-soluble lubricant and having the client swallow as the tube is passed into the stomach. The client should not be instructed to hold the breath. The client should be placed in a sitting position.

A parent asks the nurse how to care for a child with chickenpox. What should the nurse include in the plan of care? Select all that apply. You Selected: Do not return to school until all lesions have crusted over. Keep finger nails short. Avoid overheating. Correct response: Encourage oatmeal baths. Keep finger nails short. Avoid overheating. Do not return to school until all lesions have crusted over.

The care of a child with chickenpox focuses keeping the child comfortable and preventing infection in the lesions. Oatmeal baths may ease severe itching. Keeping finger nails short reduces trauma from scratching and helps prevent skin infections. Overheating can make itching worse. Children may return to school once all lesions have crusted over. The use of aspirin in children with chicken pox is contraindicated because it has been linked to Reye syndrome.

The home health nurse is visiting a client newly diagnosed with type 1 diabetes mellitus. The client reports nausea and abdominal pain. The nurse observes dehydration and dry skin. What question should the nurse ask the client? You Selected: "What did you drink today?" Correct response: "Are you taking your insulin daily?"

The nurse should ask if the client is taking their insulin, as a common cause of DKA is missed insulin. Classic symptoms of diabetic ketoacidosis (DKA) include polyuria, weight loss, nausea and vomiting, altered mental status, abdominal pain, and Kussmaul's respirations. The nurse should also check a blood glucose level. Asking the client what he drank, if he weighed himself, and when he had a check-up will not help identify the cause of the current symptoms.

The nurse is monitoring a client, who is six hours post embolectomy, for an acute arterial occlusion of the left leg. When a Doppler ultrasound fails to detect a pedal pulse, the nurse notifies the surgeon who requests that the client be prepared for immediate surgery. The client refuses to consider additional surgery. What is the nurse's initial intervention? You Selected: Reinforce the risks of not having the surgery Correct response: Notify the provider immediately

The nurse should notify the health care provider. The health care provider is responsible for providing information regarding the procedure, risks, benefits and expected outcomes. After notifying the provider, the nurse should document the situation and client response in the client's record.

The nurse is preparing a client for a cardiac catheterization. Which of the following client statements would the nurse need to report to the healthcare provider immediately? You Selected: "I am allergic to penicillin and midazolam (Versed)." Correct response: "I took my metformin this morning."

The priority would be to notify the healthcare provider of the metformin because it cannot be taken 48 hours before or after contrast, as there is an increased risk of lactic acidosis and acute renal failure with iodinated contrast material. It would be appropriate for the client to take nothing by mouth. It is important to determine the client's allergies; however, it is not the priority. Claustrophobia would not be an issue during a cardiac catheterization.

The nurse is instructing the spouse of a client who had an incision and drainage procedure for an abscess how to care for the wound at home. The nurse should instruct the spouse to: You Selected: clean from the incision site to the drainage site. Correct response: clean both sites independently.

The sites should be treated as separate sites to avoid cross contamination. This adheres to the principle of cleaning from the least contaminated area to the most contaminated area. Each site is considered a separate area for wound care.

After a myelogram, positioning depends on the dye injected. When a water-soluble dye such as metrizamide is 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.

Nephrotic syndrome Overview

- Kidney disorder characterized by marked proteinuria, hypoalbuminemia, and edema - Results from a glomerular defect that affects permeability, indicating renal damage - Some forms possibly progressing to end-stage kidney failure

describe primary, secondary, and tertiary stages of syphilis

- Primary syphilis is characterized by a single painless lesion or chancre at the site of infection in the genital area. - Secondary syphilis is characterized by a rash on the palms of hands and the soles of feet and may involve the trunk. - Tertiary syphilis is slow and progressive and involves multiple organs, but is characterized by neurologic symptoms, including dementia and psychosis.

The nurse is caring for a client post myocardial infarction (MI). Orders include strict bed rest and a clear, liquid diet. What is the nurse's best response to the client when inquiring about the purpose of the new diet? You Selected: To reduce the amount of fecal elimination Correct response: To reduce the metabolic workload of digestion

Acute care of the client with an MI is aimed at reducing the cardiac workload. Clear liquids are easily digested to help reduce this workload. Sympathetic nervous system involvement causes decreased peristalsis and gastric secretion, so limiting food intake helps prevent gastric distension and cardiac workload. A clear diet will not reduce gastric acidity or blood glucose, and fecal elimination will still occur, so these are incorrect choices.

A client complains that he experiences pain and numbness in his fingers when he types on a computer keyboard. Which action will help the nurse assess for Phalen's sign? You Selected: Tapping gently over the median nerve in the wrist Correct response: Having the client hold both wrists in acute flexion with the dorsal surfaces touching for 60 seconds

Acute wrist flexion places pressure on the inflamed median nerve, causing the pain and numbness of carpal tunnel syndrome (Phalen's sign). Holding the hands above the head with arms straight for 30 seconds isn't an assessment technique. Tapping gently over the median nerve in the wrist tests for Tinel's sign, another sign of carpal tunnel syndrome. Placing the wrists in extension against resistance tests strength.

The nurse is preparing to administer vasopressin to a client who has undergone a hypophysectomy. What is the purpose of the medication? You Selected: To reduce cerebral edema and lower intracranial pressure Correct response: To replace antidiuretic hormone (ADH) normally secreted from the pituitary

After hypophysectomy, or removal of the pituitary gland, the body can't synthesize ADH; therefore, vasopressin is administered. Somatropin or growth hormone is used to treat growth failure. SIADH results from excessive ADH secretion. Vasopressin is not used to treat cerebral edema.

While making rounds, the nurse enters a client's room and finds the client on the floor between the bed and the bathroom. In which order of priority from first to last should the nurse take the actions? All options must be used. You Selected: Assess the client's current condition and vital signs. If no acute injury, get help, and carefully assist the client back to bed. Document as required by the facility. Notify the client's health care provider (HCP) and family. Correct response: Assess the client's current condition and vital signs. If no acute injury, get help, and carefully assist the client back to bed. Notify the client's health care provider (HCP) and family. Document as required by the facility.

The nurse should first assess the client and then, if there is no acute injury, help the client get back into bed. The nurse must notify the HCP and the family of the fall, and finally, document the event on the client's health record.

The nurse is caring for a homeless client with pneumonia. Laboratory testing reveals the following results: blood urea nitrogen (BUN) 180 mg/dl, creatinine 30 mg/dl (2652 mmol/L), potassium 6.2 mEq/L (6.2 mmol/L), and hemoglobin 6.2% (62 g/L). Based on the health care provider's order below, which drug order would the nurse question? You Selected: Ferrous sulfate Correct response: Gentamicin sulfate

Based on the high BUN, creatinine, and potassium levels, the client is in renal failure. Gentamicin sulfate is nephrotoxic and can exacerbate the renal failure. Ferrous sulfate and erythropoietin would be given to treat the client's anemia. Aluminum hydroxide gel would also be appropriate because it binds with phosphate, which is elevated in renal failure.

Following an epidural and placement of internal monitors, a client's labor is augmented. Contractions are lasting greater than 90 seconds and occurring every 1½ minutes. The uterine resting tone is greater than 20 mm Hg with an atypical fetal heart rate and pattern. Which action should the nurse take first? You Selected: Turn the client to her left side. Correct response: Turn off the oxytocin infusion.

The client is experiencing uterine hyperstimulation from the oxytocin. The first intervention should be to stop the oxytocin infusion, which may be the cause of the long, frequent contractions, elevated resting tone, and abnormal fetal heart patterns. Only after turning off the oxytocin should the nurse turn the client to her left side to better perfuse the mother and fetus. Then she should increase the maintenance IV fluids to allow available oxygen to be carried to the mother and fetus. When all other interventions are initiated, she should notify the HCP.

The nurse is caring for a client diagnosed with an anterior myocardial infarction 2 days ago. Upon assessment, the nurse identifies a systolic murmur at the apex. The nurse should first: You Selected: evaluate heart sounds with the client leaning forward. Correct response: assess for changes in vital signs.

The nurse should first obtain vital signs as changes in the vital signs will reflect the severity of the sudden drop in cardiac output: decrease in blood pressure, increase in heart rate, and increase in respirations. Infarction of the papillary muscles is a potential complication of an MI causing ineffective closure of the mitral valve during systole. Mitral regurgitation results when the left ventricle contracts and blood flows backward into the left atrium, which is heard at the fifth intercostal space, left midclavicular line. The murmur worsens during expiration and in the supine or left-side position, and can best be heard when the client is in these positions, not with the client learning forward. A 12-lead ECG views the electrical activity of the heart; an echocardiogram views valve function.

A client is brought to the emergency department having been involved in a fire while putting lighter fluid on a grill. The client sustained burns to both arms. The nurse assesses the burns to be dry and pale white with some areas that are brown and leathery. Which of the following types of burns does the nurse determine are present? You Selected: Second degree (partial thickness) Correct response: Third degree (full thickness)

Third-degree burns involve the epidermis, dermis, and sometimes subcutaneous tissue. They are insensate and usually present as dry, pale, white, red brown, leathery, or charred. First degree or superficial burns involve the outer layer of the skin and are similar to sunburn, reddened without blisters. Second degree burns or partial thickness burns involve the dermis and have a reddened, blistered appearance. Fourth degree burns involve the dermal layers as well as the fat, fascia, muscle, and may also include bone.

When restraining an infant

Using restraints requires a primary care provider's prescription; 1. document the reason for use and effectiveness of the restraint. 2. inspect the skin for areas of pressure caused by the restraint and remove the restraint periodically to provide skin care and range of motion. 3. The ties should be secured so they can be released quickly if needed; 4. the ties should be fastened to the bed springs, not the rails of the crib or the mattress. 5. The belt restraint is positioned correctly; the restraint will limit the infant's movement yet allow for changing the diaper. 6. The restraint should limit the infant's movement and not enable the infant to move from side to side. Reapply the restraint to cover the hip to 1 inch above the umbilicus. = INCORRECT

An infant needs a one time gavage feeding. After inserting a the nasogastric tube what should the nurse do next? You Selected: Obtain a prescription for a chest radiograph. Correct response: Aspirate stomach contents through the catheter.

After inserting a gavage feeding catheter, the nurse should next check that the catheter is in the stomach before instilling nourishment. One way is to aspirate stomach contents. Another method is to inject a few millimeters of air into the catheter while auscultating over the stomach with a stethoscope to listen for the sound of air entering the stomach. Clamping the catheter momentarily is unnecessary and does not indicate the proper placement of the catheter. Routine chest radiograph to check for placement of the feeding tube usually is not done if the feeding tube will not be left in for a long-term basis because of the increased cost and exposure of the neonate to radiation.

The nurse prepares the client for a lumbar puncture (LP) (see client chart below) to rule out a subarachnoid hemorrhage. Which assessment finding would require intervention before the procedure? 2/10/2017 1900 56-year-old, right-handed female presents with severe onset of headache and projectile vomiting that started 45 minutes prior to admission. Physical examination findings include nuchal rigidity. You Selected: Client requires mechanical ventilation Correct response: Suspected increased intracranial pressure (ICP)

Sudden removal of CSF result in a lowered pressure in the lumbar area than in the brain which can cause brain herniation, especially in the presence of increased ICP. Therefore a LP is contraindicated when increased ICP is suspected. Vomiting may be caused by reasons other than increased ICP; therefore, LP isn't strictly contraindicated. A LP may be performed on clients requiring mechanical ventilation. Blood in the CSF is diagnostic for subarachnoid hemorrhage.

A client who was involved in a motor vehicle accident has a fractured femur. The nurse caring for the client documents "acute pain" as a nursing diagnosis in the care plan. Which nursing interventions are appropriate? Select all that apply. You Selected: Explain that pain management should leave the client pain-free. Assess the client's perception of pain. Ask the client about the methods used previously to alleviate pain. Correct response: Assess the client's perception of pain. Ask the client about the methods used previously to alleviate pain.

The nurse should begin by assessing the client's perception of pain, including its characteristics, and the methods previously found effective in managing pain. These interventions provide a baseline from which the nurse can plan interventions and evaluate their success. The nurse should allow the client to decide which pain control management techniques to use to help feel in control of his situation. Analgesics should be administered as needed to relieve pain. Addiction should not be a concern at this time. After receiving analgesics, the client should indicate increased comfort, by reporting pain as a score of 3 or less on a scale of 0 to 10 (0 being without pain). Being completely pain-free is not a realistic expectation. The nurse should teach the client alternative and supplementary pain control techniques, such as imagery, distraction, and heat and cold application. These techniques provide the client with options for dealing with pain.

On the first postpartum day, a neonate diagnosed with an ABO incompatibility has a bilirubin level of 10 mg/dL (170 µmol/L). After teaching the parents about this condition, which statement by the parents about the neonate indicates the need for additional teaching? You Selected: "Breastfeeding may need to be stopped temporarily." Correct response: "The baby will need an exchange transfusion with type A blood."

ABO incompatibility occurs when the mother has type O blood, and the neonate is A, B, or AB. This condition is not as serious as Rh incompatibility. The mother needs further instructions when she says the neonate will require an exchange transfusion with type A blood. Unless the bilirubin concentration reaches the dangerous level (~20 mg/dL or 342 umol/L), an exchange transfusion is not usually performed. If an exchange transfusion does become necessary, type O blood is used. Phototherapy is the common treatment for ABO incompatibility. The neonate may have bright green stools as bilirubin is broken down and excreted in the stool. The mother may need to temporarily halt breastfeeding, but she may pump the breasts and continue feeding after the first 48 hours. The destruction of the neonate's red blood cells occurs after birth, so the neonate may become anemic until the hemolysis ceases, usually within 2 weeks.

Before starting treatment for leukemia, a client receives IV fluids and allopurinol. These interventions reduce the risk for: You Selected: pancytopenia. Correct response: tumor lysis syndrome.

During chemotherapy for leukemia, tumor lysis syndrome may occur as cell destruction releases intracellular components, resulting in hyperuricemia. Large fluid quantities and allopurinol therapy help reduce the amount of uric acid that result from tumor lysis syndrome but don't stop the cell lysis. Although DIC, pancytopenia, and mucositis are possible chemotherapy complications, they're not treated with IV fluids and allopurinol.

A client admitted with a diagnosis of schizoaffective disorder, manic phase, who is currently taking fluoxetine, valproic acid, and olanzapine as prescribed, has had an increase in manic symptoms in the past week. The health care provider (HCP) prescribes a valproic acid blood level to be drawn at once. What does the nurse understand is the rationale for this prescription? You Selected: All clients taking valproic acid need periodic valproic acid levels drawn. Correct response: A decrease in the level of valproic acid could explain the increase in manic symptoms.

Valproic acid is commonly used to treat manic symptoms. Therefore, a decrease in the valproic acid level could explain the increase in manic symptoms. Periodic determinations of the valproic acid level are necessary to determine the effectiveness of the drug. However, the stat nature of the specimen to be drawn indicates an immediate problem. Fluoxetine is not known to decrease the effectiveness of valproic acid. The valproic acid level is not needed before beginning a short course of therapy with lorazepam.