physiological adaptation

The nurse is performing a newborn assessment on a neonate in the childbirth suite. The nurse notes epispadias. Which documentation of the defect would the nurse note?

C Explanation: Epispadias is characterized by the urethral opening at the top (dorsal) aspect of the penis. Though the child will be able to urinate, surgical repair will be completed. Option A is the normal opening of the urethra at the tip of the penis. Option B documents hypospadias with the urethral opening at the underside (ventral) aspect of the penis.

The nurse observes as a child with Duchenne muscular dystrophy attempts to rise from a sitting position on the floor. After attaining a kneeling position, the child "walks" his hands up his legs to stand. The nurse documents this as which sign? Goodell's sign Goodenough's sign Galeazzi's sign Gower's sign

Gower's sign Explanation: With Gower's sign, the child walks the hands up the legs in an attempt to stand, a common approach used by children with Duchenne muscular dystrophy when rising from a sitting to a standing position. Galeazzi's sign refers to the shortening of the affected limb in congenital hip dislocation. Goodell's sign refers to the softening of the cervix, considered a sign of probable pregnancy. Goodenough's sign refers to a test of mental age.

A client tells the nurse he is experiencing dyspnea. Which action by the nurse is most appropriate?

Placing the client in high Fowler's position Explanation: High Fowler's position — the posture assumed by the client when the head of the bed is elevated to 90 degrees — promotes breathing by allowing the thoracic cavity to expand. The Trendelenburg, Sims', and supine positions wouldn't facilitate breathing.

A male neonate born at 36 weeks' gestation is admitted to the neonatal intensive care nursery with a diagnosis of probable fetal alcohol syndrome (FAS). The mother visits the nursery soon after the neonate is admitted. Which instructions should the nurse expect to include when developing the teaching plan for the mother about FAS? Withdrawal symptoms usually do not occur until 7 days postpartum. Facial deformities associated with FAS can be corrected by plastic surgery. Symptoms of withdrawal include tremors, sleeplessness, and seizures. Large-for-gestational-age size is common with this condition.

Symptoms of withdrawal include tremors, sleeplessness, and seizures. Explanation: The long-term prognosis for neonates with FAS is poor. Symptoms of withdrawal include tremors, sleeplessness, seizures, abdominal distention, hyperactivity, and inconsolable crying. Symptoms of withdrawal commonly occur within 6 to 12 hours or, at the latest, within the first 3 days of life. The neonate with FAS is usually growth deficient at birth. Most neonates with FAS are mildly to severely mentally handicapped. The facial deformities, such as short palpebral fissures, epicanthal folds, broad nasal bridge, flattened midface, and short, upturned nose, are not easily corrected with plastic surgery.

A nurse performs cardiopulmonary resuscitation (CPR) for 2 minutes on an infant without calling for assistance. In reassessing the infant after 2 minutes of CPR, the nurse finds the infant still isn't breathing and has no pulse. The nurse should then:

call for assistance. Explanation: After 2 minutes of CPR, the nurse should call for assistance and then resume efforts. CPR shouldn't be stopped after it has been started unless the nurse is too exhausted to continue. A cycle usually ends with breaths, so the next beginning cycle after pulse check and summoning help would begin with chest compressions.

A client is recovering from abdominal surgery and has a nasogastric (NG) tube inserted. Which is the expected outcome of inserting the NG tube in the client's gastrointestinal tract? gavage compression decompression lavage

decompression Explanation: After abdominal surgery, the reason for inserting a NG tube is to decompress the gastrointestinal tract until peristaltic action returns. Compression may be used to control bleeding esophageal varices. Lavage is used to remove substances from the stomach or control bleeding. Gavage is used to provide enteral feedings

When teaching a group of pregnant adolescent clients about reproduction and conception, the nurse is correct when stating that fertilization occurs: in the uterus. when the ovum is released. in the first third of the fallopian tube. near the fimbriated end.

in the first third of the fallopian tube. Explanation: Fertilization occurs in the first third of the fallopian tube. After ovulation, an ovum is released by the ovary into the abdominopelvic cavity. It enters the fallopian tube at the fimbriated end and moves through the tube on the way to the uterus. Sperm cells "swim up" the tube and meet the ovum in the first third of the fallopian tube. The fertilized ovum then travels to the uterus and implants. Nurses must know where fertilization occurs because of the risk of an ectopic pregnancy.

After suctioning a client, a nurse should expect to find brisk capillary refill. clear breath sounds. a heart rate of 104 beats/minute. a respiratory rate of 28 breaths/minute.

clear breath sounds. Explanation: Clear breath sounds, which indicate that secretions have been removed, indicate effective suctioning. An above-normal respiratory rate, such as a rate of 28 breaths/minute, may indicate that the airway isn't clear of secretions and the client's respiratory rate has increased to compensate. A slightly increased heart rate, such as a rate of 104 beats/minute, may indicate health concerns unrelated to suctioning. Brisk capillary refill indicates adequate cardiovascular function and is unrelated to suctioning.

The nurse is assessing a client who has a history of peripheral artery disease. The nurse observes that the left great toe is black. The nurse determines that the black color is caused by which factor? gangrene atrophy contraction rubor

gangrene Explanation: The term gangrene refers to blackened, decomposing tissue that is devoid of circulation. Chronic ischemia and death of the tissue can lead to gangrene in the affected extremity. Injury, edema, and decreased circulation lead to infection, gangrene, and tissue death. Atrophy is the shrinking of tissue, and contraction is joint stiffening secondary to disuse. The term rubor denotes a reddish color of the skin.

While assessing a male neonate whose mother desires him to be circumcised, the nurse observes that the neonate's urinary meatus appears to be located on the ventral surface of the penis. The nurse notifies the healthcare provider because the nurse suspects which disorder? hypospadias epispadias hydrocele phimosis

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

A 9-year-old client is brought to the emergency department with a sutured wound with purulent drainage. The area around the wound is red and warm to the touch, and the child is febrile. The parents want to know the significance of the purulent drainage. What is the best response by the nurse? "If a wound heals on the surface but infection remains, it will open and drain." "The drainage contains enzymes that are necessary for wound healing." "The drainage is an indication that the sutures were not tight enough." "Antibiotics cause the cells of the tissues to produce purulent drainage."

"If a wound heals on the surface but infection remains, it will open and drain." Explanation: Purulent drainage indicates an infection in situ. A wound may heal over the top, but when infection remains, the wound may reopen at the base and drain the discharge. A wound will continually reopen and drain purulent discharge until the infection is eradicated. It is not related to antibiotics or the ineffectiveness of the sutures.

A 4-year-old child is having a sickle cell crisis. The initial nursing intervention should be to administer folic acid supplements. administer antibiotics. provide oral and I.V. fluids. place ice packs on the client's painful joints.

provide oral and I.V. fluids. Explanation: Initial nursing interventions for the child in a sickle cell crisis include providing hydration and oxygenation to prevent more sickling. Pain relief is also a concern. However, painful joints are treated with analgesics and warm packs because cold packs may increase sickling. Antibiotics will be given to treat a sickle cell crisis if it's thought to be bacterial but only after hydration and oxygenation have been addressed. Daily supplements of folic acid will help counteract anemia but aren't a priority during sickle cell crisis.

After the nurse teaches the mother of a child with atopic dermatitis how to bathe her child, which statement by the mother indicates effective teaching? "I let my child play in the tub for 30 minutes every night." "When my child gets out of the tub I just pat the skin dry." "I make sure my child has a bath every night." "My child loves the bubble bath I put in the tub."

"When my child gets out of the tub I just pat the skin dry." Explanation: Atopic dermatitis is a chronic pruritic dermatitis that usually begins in infancy. Many of the children diagnosed with it have a family history of eczema, allergies, or asthma. Atopic dermatitis is best treated with hydrating the skin, controlling the pruritus, and preventing secondary infection. Patting the skin dry removes less natural skin moisturizer and thus maintains skin hydration. Water has a drying effect on the skin. Playing in the tub for 30 minutes each night would deplete the skin of its natural moisturizers, thereby leading to increased pruritus and dry skin. Bubble baths are to be avoided in children with atopic dermatitis because they may act as an irritant, possibly exacerbating the condition. Also, bubble baths deplete the skin of its natural moisturizers. The issue is not whether the child bathes every night. Rather, the goal is to decrease dryness and itching.

Just after delivery, a nurse measures a neonate's axillary temperature at 94.1°F (34.5°C). What should the nurse do? Rewarm the neonate gradually. Observe the neonate hourly. Notify the healthcare provider when the neonate's temperature is normal. Give the neonate a bath.

Rewarm the neonate gradually. Explanation: A neonate with a temperature of 94.1°F(34.5°C) is experiencing cold stress. To correct cold stress while avoiding hyperthermia and its complications, the nurse should rewarm the neonate gradually, observing closely and checking vital signs every 15 to 30 minutes. Rapid rewarming may cause hyperthermia. Bathing the baby will further cause the baby to lose heat. Hourly observation is not frequent enough because cold stress increases oxygen, calorie, and fat expenditure, putting the neonate at risk for anabolic metabolism and possibly metabolic acidosis. A neonate with cold stress requires intervention; the nurse should notify the healthcare provider of the problem as soon as it is identified.

The nurse on a medical unit is providing discharge instructions to a 52-year-old male client, diagnosed with Clostridioides difficile (C. diff), about preventing the spread of this infection at home.

wash hands with soap and water before eating or preparing food, wash hands with soap water for 15 seconds, use bleach to clean surfaces in the home Explanation: The spread of Clostridioides difficile (C. diff.) can be reduced with good hand hygiene. Chlorine bleach should be used to disinfect surfaces, such as counters and toilets. Hands should be washed with soap and water, for at least 20 seconds, before preparing food or eating. Hands should also be washed with soap and water, for at least 20 seconds, after using the toilet. Alcohol-based sanitizers are not effective for handwashing to prevent the transmission of C. diff.To prevent the spread of C. diff, the hands should be washed with soap and water for a minimum of 20 seconds. To prevent the transmission of C. diff, hands should be washed often, such as after using the bathroom, before eating or handling food, and after coughing and sneezing. Washing the hands once each day is not sufficient to prevent the spread of C. diff.

The nurse is assessing a client's activity tolerance. Which report from a treadmill test indicates an abnormal response? pulse rate increased by 20 bpm immediately after the activity pulse rate within 6 bpm of resting pulse after 3 minutes of rest diastolic blood pressure increased by 7 mm Hg respiratory rate decreased by 5 breaths/minute

respiratory rate decreased by 5 breaths/minute Explanation: The normal physiologic response to activity is an increased metabolic rate over the resting basal rate. The decrease in respiratory rate indicates that the client is not strong enough to complete the mechanical cycle of respiration needed for gas exchange. The postactivity pulse is expected to increase immediately after activity but by no more than 50 bpm if it is strenuous activity. The diastolic blood pressure is expected to rise but by no more than 15 mm Hg. The pulse returns to within 6 bpm of the resting pulse after 3 minutes of rest.

Which finding would the nurse most expect to find in a neonate born at 28 weeks' gestation who is diagnosed with intraventricular hemorrhage (IVH)? hyperbilirubinemia hyperactivity bulging fontanels increased muscle tone

bulging fontanels Explanation: A common finding of IVH is a bulging fontanel. The most common site of hemorrhage is the periventricular subependymal germinal matrix, where there is a rich blood supply and where the capillary walls are thin and fragile. Rapid volume expansion, hypercarbia, and hypoglycemia contribute to the development of IVH. Other common manifestations include neurologic signs such as hypotonia, lethargy, temperature instability, nystagmus, apnea, bradycardia, decreased hematocrit, and increasing hypoxia. Seizures also may occur. Hyperbilirubinemia refers to an increase in bilirubin in the blood and may be seen if bleeding was severe.

Which assessment is most supportive of the nursing diagnosis, impaired skin integrity related to purulent inflammation of dermal layers as evidenced by purulent drainage and erythema? dry and intact wound dressing oral temperature of 101° F (38.3° C) wound healing by primary intention a heart rate of 88 beats/minute

oral temperature of 101° F (38.3° C) Explanation: The nursing diagnosis indicates that the client's wound, which has purulent drainage, is infected. In response to the infection, the client's temperature would be elevated. A heart rate of 88 beats/minute, healing by primary intention, and a dry, intact dressing demonstrate normal assessment findings.

A nurse is teaching a client about the importance of increasing fluids when experiencing the early stages of dehydration. Which statement by the client would express understanding? "If my skin becomes dry and itchy I can apply extra lotion." "Dehydration is only a problem in the summer months when it's hot outside." "Vitamin hydration drinks would be good when I feel my heart pounding and become lightheaded." "I should drink more water when feeling thirsty or becoming irritabl

"I should drink more water when feeling thirsty or becoming irritable." Explanation: Early signs and symptoms of dehydration include thirst, irritability, dry mucous membranes, and dizziness. Coma, seizures, sunken eyeballs, poor skin turgor, and increased heart rate with hypotension are all later signs. Dehydration is a problem at all times, not just when it's hot outside. Lotion helps dry skin, but will not help hydration.

A nurse should expect to find which defining characteristics in a client with a nursing diagnosis of Ineffective tissue perfusion (peripheral)? Select all that apply. skin pink in color normal sensation skin temperature changes skin discoloration edema strong, bounding pulses

Edema skin discoloration skin temperature changes Explanation: Lack of oxygen to nourish tissues at the capillary level causes edema, discoloration, and changes in skin temperature. Pulses will be weak or absent, and the client will experience altered sensation. Pink skin color; strong, bounding pulses; and normal sensation are signs of adequate perfusion.

A 30-month-old toddler is being evaluated for a ventricular septal defect (VSD). Identify the area where a VSD occurs.

Explanation: A VSD is a small hole between the right and left ventricles that allows blood to shunt between them, causing right ventricular hypertrophy and, if left untreated, biventricular heart failure. It is a common congenital heart defect and accounts for approximately 20% to 30% of all heart lesions.

The nurse is assessing a client who is restless and agitated, has dry mucous membranes, and has intense thirst. The nurse should assess the client further for which electrolyte imbalance? hypercalcemia hypokalemia hypernatremia hypomagnesemia

hypernatremia Explanation: Restlessness, agitation, dry mucous membranes, and thirst are indicative of fluid loss and hypernatremia.Hypokalemia causes such symptoms as fatigue, muscle weakness, and cardiac irregularities.Clinical manifestations of hypercalcemia include lethargy, weakness, depressed reflexes, constipation, polyuria, and bone pain.Hypomagnesemia is manifested by confusion, tremors, hyperactive reflexes, and seizures.

A child with type 1 diabetes develops diabetic ketoacidosis and receives a continuous insulin infusion. Which condition represents the greatest risk to this child? hypercalcemia hyperphosphatemia hypokalemia hypernatremia

hypokalemia Explanation: Hypokalemia occurs when insulin administration causes glucose and potassium to move into the cells. Insulin administration doesn't directly affect calcium levels. Hypophosphatemia — not hyperphosphatemia — may occur with insulin administration because phosphorus enters the cells with insulin and potassium. Insulin administration doesn't directly affect sodium level

A neonate is admitted to the neonatal intensive care unit for observation with a diagnosis of probable meconium aspiration syndrome (MAS). The neonate weighs 10 lb, 4 oz (4,650 g) and is at 41 weeks' gestation. What would be the priority problem for this neonate? impaired skin integrity impaired gas exchange hyperglycemia risk for impaired patent-infant-child attachment

impaired gas exchange Explanation: The priority problem for the neonate with probable MAS is impaired gas exchange related to the effects of respiratory distress. Obstruction of the airways may be complete or partial. Meconium aspiration may lead to pneumonia or pneumothorax. Establishing adequate respirations is the primary goal. Impaired skin integrity is a concern, but establishing and maintaining an airway and gas exchange is always the priority. Hypoglycemia tends to be a problem for large-for-gestational-age babies, not hyperglycemia. If the parents do not express interest or concern for the neonate, then risk for impaired parent-infant-child attachment may be appropriate once the airway is established.

A client was brought to the emergency department following a motor vehicle accident and has phrenic nerve involvement. The nurse should assess the client for which nursing problem? altered cardiac functioning ineffective breathing pattern alteration in urinary elimination alteration in level of consciousness

ineffective breathing pattern Explanation: The diaphragm is the major muscle of respiration; it is made up of two hemidiaphragms, each innervated by the right and left phrenic nerves. Injury to the phrenic nerve results in hemidiaphragm paralysis on the side of the injury and an ineffective breathing pattern. Consciousness, cardiac function, and urinary elimination are not affected by the phrenic nerve.

A child with a cardiac defect assumes a squatting position. The nurse should determine that the position is effective for the child by noting which finding? relief of abdominal pressure less energy required to play with toys on the floor less dyspnea improved muscle tone

less dyspnea Explanation: A child with a cardiac defect finds that squatting decreases venous return and workload to the heart and increases comfort and blood flow to the lungs. Squatting traps blood in the lower extremities so less blood is returned to the right atrium. Squatting does not make it easier for the child to play with toys. Squatting does not relieve abdominal pressure; it may even increase it slightly. Squatting has no effect on muscle tone. When done by a child with a cardiac defect, it is not meant as an exercise but is a compensatory process used to reduce dyspnea.

A nurse is caring for a client with acute pulmonary edema. To immediately promote oxygenation and relieve dyspnea, the nurse should have the client take deep breaths and cough. perform chest physiotherapy. administer oxygen. place the client in high Fowler's position.

place the client in high Fowler's position. Explanation: The high Fowler's position will initially promote oxygenation in the client and relieve shortness of breath. Additional measures include administering oxygen to increase oxygen content in the blood. Deep breathing and coughing will improve oxygenation postoperatively but may not immediately relieve shortness of breath. Chest physiotherapy results in expectoration of secretions, which isn't the primary problem in pulmonary edema.

A client has arterial blood gas results of pH 7.32; PaCO2 50; HCO3 23; and SaO2 80%. These results indicate: metabolic acidosis. respiratory acidosis. respiratory alkalosis. metabolic alkalosis.

respiratory acidosis. Explanation: Respiratory acidosis is correct because the pH is decreased and the PCO2 is increased. All of the other choices are incorrect.

The nurse is completing an initial assessment of a client admitted with chronic kidney disease. Which finding indicates the client has fluid volume excess? cool, dry skin dry cough poor tissue turgor weight gain

weight gain Explanation: When the kidneys are not functioning, fluid volume excess presents. Signs of fluid excess are indicated by weight gain, hypertension, jugular vein distention, adventitious breath sounds (including crackles), and a wet cough. Cool, dry skin and poor tissue turgor are signs of fluid volume deficit.

A toddler is receiving an infusion of total parenteral nutrition via a Broviac catheter. As the child plays, the I.V. tubing becomes disconnected from the catheter. What should the nurse do first? Clamp the catheter. Flush the catheter with heparin. Turn off the infusion pump. Position the child on the side.

Clamp the catheter. Explanation: First, the nurse must clamp the catheter to prevent air entry, which could lead to air embolism. If an air embolism occurs, the nurse should position the child on the side after clamping the catheter. The nurse may turn off the infusion pump after ensuring the child's safety. If blood has backed up in the catheter, the nurse may need to flush the catheter with heparin; however, this isn't the initial priority.

While assessing a male neonate whose mother desires him to be circumcised, the nurse observes that the neonate's urinary meatus appears to be located on the ventral surface of the penis. The nurse notifies the healthcare provider because the nurse suspects which disorder? epispadias hydrocele phimosis hypospadias

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

The nurse is caring for a client at 36 weeks' gestation with a temperature of 101.2°F (38.4°C). Examination indicates that the client is leaking amniotic fluid. What is the nurse's priority concern based on these findings? group B Streptococcus colonization intrauterine infection stress response to labor urinary tract infection

intrauterine infection Explanation: Premature membrane rupture creates an open port for intrauterine infection, indicated by an elevated temperature. The client doesn't exhibit common symptoms that would indicate a urinary tract infection. Fever and premature rupture of membranes aren't normal findings in labor. Group B strep colonization has no outward symptoms.

A 2-year-old child is being examined in the emergency department for epiglottitis. Which assessment finding supports this diagnosis? clear speech gradual onset of symptoms tripod position mild fever

tripod position Explanation: The child being in the tripod position (sitting up and leaning forward) supports the diagnosis of epiglottitis because this position facilitates breathing. Epiglottitis presents with a sudden onset of signs and symptoms, such as high fever, muffled speech, inspiratory stridor, and drooling.

A client is brought to the emergency department in respiratory distress caused by acute epiglottitis. Which assessment finding is most concerning for the nurse?

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

The nurse is caring for a 12-hour-old neonate born to a mother with diabetes mellitus. The neonate's respiratory rate is 70 breaths/minute, heart rate 162 beats/minute, oxygen saturation is 92% on room air, and the blood glucose 30 mg/dL (1.7 mmol/L). What is the priority intervention for the nurse to implement? Start an IV. Administer oxygen. Assess the temperature. Administer glucose.

Administer glucose. Explanation: Hypoglycemia is the most common metabolic disorder in infants. It is especially true for those infants born to type 1 diabetic mothers. In infants, blood glucose levels fall to a low point during the first few hours of life because the source of the maternal glucose is removed when the placenta is expelled. Hypoglycemia is defined as < 30 mg/dL (1.7 mmol/L) in the first 24 hours of life and < 45 mg/dL (2.6 mmol/L) thereafter, but this is qualified further by whether or not the infant is symptomatic. The symptoms of hypoglycemia include jitteriness, tachycardia, lethargy, cyanosis, a weak cry, and apnea. Early feeding helps prevent hypoglycemia. The treatment for hypoglycemia is a rapid-acting source of glucose. This can be given via a bottle or, if needed, an IV infusion. It is important to treat the infant early to prevent permanent neurological damage and seizures. The symptoms this infant is exhibiting are related to hypoglycemia, so correcting the blood glucose would be the priority.

The nurse is caring for a lethargic but arousable preschooler who is a victim of a near-drowning accident. What should the nurse do first? Institute rewarming. Administer oxygen. Start an IV infusion. Prepare for intubation.

Administer oxygen. Explanation: Near-drowning victims typically suffer hypoxia and mixed acidosis. The priority is to restore oxygenation and prevent further hypoxia. Here, the client has blunted sensorium, but is not unconscious; therefore, delivery of supplemental oxygen with a mask is appropriate. Warming protocols and fluid resuscitation will most likely be needed to help correct acidosis, but these interventions are secondary to oxygen administration. Intubation is required if the child is comatose, shows signs of airway compromise, or does not respond adequately to more conservative therapies.

A client gave birth vaginally 2 hours ago and has a third-degree laceration. There is ice in place on her perineum. However, her perineum is slightly edematous, and the client is reporting pain rated 6 on a scale of 1 to 10. Which nursing intervention would be the most appropriate at this time? Initiate anesthetic sprays to the perineum. Replace ice packs to the perineum. Begin sitz baths. Administer pain medication per prescription.

Administer pain medication per prescription. Explanation: Pain medication is the first strategy to initiate at this pain level. When trauma has occurred to any area, the usual intervention is ice for the first 24 hours and heat after the first 24 hours. Sitz baths are initiated at the conclusion of ice therapy. Ice has already been initiated and will prevent further edema to the rectal sphincter and perineum and continue to reduce some of the pain. Anesthetic sprays can also be utilized for the perineal area when pain is involved but would not lower the pain to a level that the client considers tolerable.

While assessing the incision of a client who had surgery 2 weeks ago, a nurse observes that the suture line has a shiny, light pink appearance. Which step should the nurse take next? Prepare the client for debridement of the suture line. Continue to monitor the suture line, and document findings. Notify the physician that the wound may be infected. Apply normal saline solution to keep the wound moist.

Continue to monitor the suture line, and document findings. Explanation: During the fibroplastic stage of healing, granulation tissue, which has a characteristic pink shiny appearance, fills in the wound. This normal occurrence requires the nurse to continue to monitor the suture line. There is no evidence of wound dehiscence or necrotic tissue. There is also no indication that the wound is open or needs to be kept moist.

While assessing a child experiencing respiratory distress, the nurse notes subcostal retractions. Which graphic highlights the area where subcostal retractions are seen?

Explanation: Subcostal retractions are retractions seen below the lower costal margin of the rib cage. Option B highlights the area where subcostal retractions are seen. Option A shows the areas where intercostal retractions would be seen. Option C shows the area for suprasternal retraction. Option D shows the areas for clavicular retractions.

During assessment, a nurse measures a client's respiratory rate at 32 breaths/minute with a regular rhythm. When documenting this pattern, the nurse should use which term? Eupnea Apnea Bradypnea Tachypnea

Tachypnea Explanation: A respiratory rate of 32 breaths/minute with a regular rhythm is faster than normal and should be documented as tachypnea. Eupnea is a respiratory rate of 12 to 20 breaths/minute with a regular rhythm. Bradypnea refers to a respiratory rate below 12 breaths/minute with a regular rhythm. Apnea refers to absence of breathing.

A nurse is assessing a full-term neonate and discovers a heart rate of 100 beats/minute and an axillary temperature of 97.3°F (36.3°C). What action should the nurse take? Perform a thorough physical assessment including checking rectal temperature. Place a cap on the neonate's head, and offer the neonate to the mother for skin-to-skin contact. Place the neonate in an incubator, and notify the healthcare provider of the neonate's temperature. Encourage the mother to breastfeed the infant as soon as possible.

Place a cap on the neonate's head, and offer the neonate to the mother for skin-to-skin contact. Explanation: The normal axillary temperature range for a neonate is 97.7 to 99.5°F (36.5 to 37.5°C). A temperature of 97.3°F (36.3°C) is slightly below normal. Because the neonate is full-term, it is safe to warm the neonate using conservative measures such as placing a cap on the head and trying skin-to-skin contact. There is no need to encourage feeding. Performing an assessment would require exposing the neonate and is not indicated. If this were an unstable or preterm neonate, an incubator may be recommended due to the underdeveloped thermoregulation in these neonates. Neonates with hypothermia experience bradycardia, which is defined as a heart rate less than 100 beats/minute.

A parent calls the Poison Control Center because her 3-year-old has eaten 10 to 12 chewable acetaminophen tablets. What should the nurse instruct the parent to do? Give the child a large glass of milk. Induce vomiting. Monitor the child's respirations for 24 hours. Take the child to the emergency department.

Take the child to the emergency department. Explanation: Acetaminophen ingestion can cause severe liver disease. The child should be evaluated in the emergency department. The child should not be offered any fluids, and the parents should not attempt to induce vomiting. Assessing the child's respirations for 24 hours will delay needed emergency treatment.

A 19-year-old primigravida at 38 weeks' gestation, in active labor for the past 8 hours, is admitted to the hospital accompanied by her mother. On admission, the client's cervix is 5 cm dilated, her blood pressure is 120/84 mm Hg, and she is breathing rapidly, feeling dizzy and light-headed. The nurse determines that the client is most likely experiencing effects of which factor? hyperventilation rapid cervical dilation elevated blood pressure excitement about labor

hyperventilation Explanation: When a client is hyperventilating during labor, she is eliminating more carbon dioxide than usual. As a result, she becomes light-headed or dizzy.Being light-headed or dizzy is not correlated with rapid cervical dilation.The client's problems are not related to an elevated blood pressure.Being light-headed or dizzy is not correlated to excitement about the labor process.

During assessment of a child with celiac disease, the nurse should most likely note which physical finding? periorbital edema tender inguinal lymph nodes enlarged liver protuberant abdomen

protuberant abdomen Explanation: The intestines of a child with celiac disease fill with accumulated undigested food and flatus, causing the characteristic protuberant abdomen. Celiac disease is not usually associated with any liver dysfunction, including poor liver functioning leading to liver enlargement. Tender inguinal lymph nodes are often associated with an infection. Periorbital edema, swelling around the eyes, is associated with nephritis.

The parents of an infant with a colostomy are concerned that their child's colostomy bag is filling up frequently with gas. What is the most appropriate response by the nurse? "Don't worry. This is a normal occurrence." "Restrict the intake of bottled formula." "Place a few pin pricks in the bag." "Open the bag slightly whenever this happens."

"Open the bag slightly whenever this happens." Explanation: Gently expelling the gas will relieve the risk of the bag disconnecting from the appliance. Placing pin pricks in the bag compromises the integrity of the appliance. It is not necessary to restrict the intake of bottled formula. While expelling gas is normal, doing nothing would not be the best option for relieving the situation.

What would be an appropriate action for the nurse prior to performing deep tracheal suctioning due to increased secretions? Apply negative pressure as the catheter is being inserted. Deflate the cuff of the tracheotomy during suctioning. Instill acetylcysteine into the tracheotomy before suctioning. Hyperoxygenate the client before suctioning.

Hyperoxygenate the client before suctioning. Explanation: Preoxygenation and deep breathing assist in reducing suction-induced hypoxemia because it decreases the risk of atelectasis caused by negative pressure of suctioning. Deflating the cuff is not necessary and there is no reason to instill acetylcysteine into the tracheotomy before suctioning. Pressure is applied only with the removal of the catheter.

A 10-year-old child falls, injures the left shoulder, and is taken to the emergency department. While the client waits to be seen by the physician, what intervention should the nurse perform first? Keep the child in a comfortable position and apply ice to the injured shoulder. Apply a warm compress to the injured shoulder. Give the child a nonopioid analgesic for pain. Ask the child to demonstrate full range of motion of the left arm.

Keep the child in a comfortable position and apply ice to the injured shoulder. Explanation: Ice should be applied first to reduce swelling and pain. The client should also be helped into a comfortable position. The nurse shouldn't apply warm compresses because it may increase swelling and cause bleeding into the injured tissue. Demonstrating full range of motion of the left arm may cause further damage to the injured area. In the emergency department, the nurse must have a physician's order to administer an analgesic.

What is the most important goal of nursing care for a client who is in shock? Manage increased cardiac output. Manage vasoconstriction of vascular beds. Manage fluid overload. Manage inadequate tissue perfusion.

Manage inadequate tissue perfusion. Explanation: Nursing interventions and collaborative management are focused on correcting and maintaining adequate tissue perfusion. Inadequate tissue perfusion may be caused by hemorrhage, as in hypovolemic shock; by decreased cardiac output, as in cardiogenic shock; or by massive vasodilation of the vascular bed, as in neurogenic, anaphylactic, and septic shock. Fluid deficit, not fluid overload, occurs in shock.

The nurse in an outpatient clinic is conducting a follow-up assessment on a child who had a severe streptococcal infection 1 week ago. The client is doing better, and the nurse is providing teaching to the parents about continuing to monitor the client for possible complications of the infection. Which information is most important for the nurse to discuss with the parents? "Expect the child's weight to decrease over the next 2 weeks." "The infection may cause the child to have some burning with urination." "Fevers may continue to occur as the body recovers from the infection." "Return immediately if acute flank or mid-abdominal pain occurs."

Return immediately if acute flank or mid-abdominal pain occurs." Explanation: Acute glomerulonephritis is a major complication of streptococcal infections in children. The onset is often marked by a sudden occurrence of acute flank or mid-abdominal pain. The child may show signs of fluid retention, such as weight gain and edema. Hypertension also commonly occurs

A nurse is caring for a child with intussusception. What is an expected outcome for a goal to relieve acute pain from abdominal cramping? The child exhibits no manifestations of discomfort. The child has a normal bowel movement. The child is very still. The child has not vomited in 3 hours

The child exhibits no manifestations of discomfort. Explanation: An expected client outcome for a goal to reduce acute pain related to cramping is that the client exhibits no manifestations of discomfort, such as crying or drawing the legs to the abdomen. Being very still may indicate either a pain state or a state of relaxation, and the nurse would need to assess the client further. Having normal bowel movements and not vomiting are desired outcomes, but the goal here is to relieve the pain. Remediation:

The nurse caring for a client admitted with a deep vein thrombosis is reviewing the client's prepackaged medications delivered by the pharmacy. The nurse suspects a pharmacy omission when medication from which classification is missing? antihyperglycemic anticoagulant antihypertensive antibiotic

anticoagulant Explanation: The nurse should anticipate the use of an anticoagulant for this medical condition. The other options would be used for other conditions such as an infection, hypertension, or an elevated cholesterol level. The client may receive these medications, but the classification related to deep vein thrombosis is the anticoagulant.

Which documentation would indicate nursing actions were effective in reducing breathing problems for a client? Select all that apply. edema of the extremities, labored respirations, color normal anxiety decreased, oxygen saturation levels at 94%, nonproductive cough, respirations at 22 breaths/min lung sounds clear bilaterally with non-labored respirations noted respirations at 26 breaths/min, circumoral cyanosis present, orthopneic disoriented; oxygen saturation levels at 85%; coughing large amount thick, white sputum; dyspnea on exertion

anxiety decreased, oxygen saturation levels at 94%, nonproductive cough, respirations at 22 breaths/min lung sounds clear bilaterally with non-labored respirations noted Explanation: A decrease in anxiety with an increase in oxygen saturation and clear lung sounds with non-labored respirations show documentation that breathing has improved. The other answers indicate abnormal data of the respiratory status.

While assessing a term neonate on a home visit to a primiparous client 2 weeks after a vaginal birth, the nurse observes that the neonate is slightly jaundiced and the stool is a pale, light color. The nurse notifies the health care provider because these findings indicate which problem?

biliary atresia Explanation: Jaundice that persists past the third or fourth day of life and pale, light stools are associated with biliary atresia. Alkaline phosphatase levels will also be elevated. Surgical intervention is necessary to remove the blockage. Rh isoimmunization and ABO incompatibility are associated with neonatal anemia as the red blood cells are hemolyzed by the antibodies. Esophageal varices are associated with cirrhosis of the liver and large amounts of bleeding when the vessels rupture. The child with esophageal varices will exhibit manifestations of anemia such as pallor and may experience hemorrhage and shock.

Which clinical manifestation would be most indicative of complete arterial obstruction in the lower extremities?

coldness Explanation: Coldness is the assessment finding most consistent with complete arterial obstruction. Other expected findings would include paralysis and pallor.Aching pain, burning sensations, numbness, and tingling are all earlier signs of tissue hypoxia and ischemia and are associated with incomplete obstruction.

When assessing a client's pain, which is the most reliable indicator of the existence and intensity of acute pain? the severity of the condition causing the pain the nurse's assessment the client's vital signs the client's self-report

the client's self-report Explanation: The client's self-report of pain is the single most reliable indicator of the amount of pain the client is experiencing. Pain tolerance and the expression of pain can vary a great deal among clients.The nurse cannot determine the intensity of pain by measuring the client's blood pressure, pulse, or respiratory rate.It is essential that the nurse listen to the client. The nurse cannot rely on the nurse's own assessment to determine the extent of the pain.The severity of the client's condition does not determine the client's pain response.

When assessing a client with hemophilia, the nurse identifies which condition as an early sign of hemarthrosis? decreased peripheral pulses active bleeding joint stiffness hematuria

joint stiffness Explanation: Joint stiffness is an early sign of hemarthrosis. Hemarthrosis doesn't affect pulses and bleeding into the joints can't be observed directly. Hematuria is incorrect because this sign indicates bleeding in the urinary tract.

A neonate born 2 hours ago has just arrived in the nursery. Which nursing measure will prevent the neonate from losing heat by evaporation? putting a blanket between the neonate and cold surfaces keeping the neonate away from drafts putting a cap on the neonate's head drying the neonate thoroughly after a bath

drying the neonate thoroughly after a bath Explanation: Neonates lose heat through evaporation as liquid is converted to a vapor. Drying a neonate after birth and following a bath prevents heat loss by evaporation. Keeping a neonate away from drafts prevents heat loss through convection. Keeping a neonate off a cold surface, such as a scale, prevents the loss of heat through conduction. Placing a cap on the neonate's head preserves heat and prevents heat loss from radiation.

When assessing a client with hemophilia, the nurse identifies which condition as an early sign of hemarthrosis? hematuria decreased peripheral pulses joint stiffness active bleeding

joint stiffness Explanation: Joint stiffness is an early sign of hemarthrosis. Hemarthrosis doesn't affect pulses and bleeding into the joints can't be observed directly. Hematuria is incorrect because this sign indicates bleeding in the urinary tract.

A student nurse requires additional teaching when identifying what factor as contributing to a client's increased risk for infection? impairment of primary body system defenses proper nutrient intake inadequate secondary defenses chronic disease

proper nutrient intake Explanation: Malnutrition, rather than proper nutrient intake, would put the client at risk for infection. Inadequate secondary defenses, impaired primary defenses, and chronic disease put the client at risk by lowering the body's ability to fight infection.

When determining the effectiveness of teaching a child's mother about sickle cell disease, which statement by the mother indicates the need for additional teaching? "I've told the child's father that both he and I are carriers of the disease." "I've started to give him some extra fluids with and between meals." "I'm concerned about how the hospital staff will manage his pain." "He's going to be playing on a soccer team when he's feeling better."

"He's going to be playing on a soccer team when he's feeling better." Explanation: Physical and emotional stress can precipitate a sickle cell crisis. Physical exercise such as running involved in soccer would increase the child's risk for a crisis. Thus, the mother needs additional instruction about this area.Providing extra fluids with and in between meals is appropriate because it is important for the child with sickle cell disease to keep well hydrated. In addition, these children commonly have nephritis related to sickle cell disease and have difficulty conserving fluids. Therefore, they need up to 150% of normal fluid intake.Pain control is an issue in sickle cell crisis. The mother is showing concern for her child by asking how pain will be managed.Sickle cell disease is an autosomal recessive disease. For the child to have the disease, both parents must carry the recessive gene.

The parents of a child with a serious head injury ask the nurse if the child is going to be all right. Which response by the nurse would be most appropriate? "Children usually recover rapidly from head injuries." "Children usually do not do very well after head injuries like this." "That is something you'll have to talk to the health care provider about." "It is hard to tell this early, but we will keep you informed of the progress."

"It is hard to tell this early, but we will keep you informed of the progress." Explanation: As a rule, children demonstrate more rapid and more complete recovery from coma than do adults. However, it is extremely difficult to predict a specific outcome. Reassuring the parents that they will be kept informed helps open lines of communication and establish trust. Telling the parents that children do not do well would be extremely negative, destroying any hope that the parents might have. Telling the parents that children recover rapidly may give the parents false hopes. Telling the parents to talk to the HCP ignores the parents' concerns and interferes with trust building.

A nurse is providing health teaching to a group of adolescent girls. The focus is on urinary tract infections. One of the girls tells the nurse that she wants to know more about cystitis. Which statement by the nurse is the most appropriate response?

"This condition can result from irritation and inflammation from sexual activity." Explanation: Cystitis is a lower urinary tract infection. One cause seen in young adolescent women is after their first sexual intercourse. The urinary tract infections occur because of inflammation and local irritation caused by sexual activity. Bladder infections can lead to complications, and therefore are not minor or harmless. A bladder or urethral infection is not the result of vaginal cleanses such as douches.

A nurse is caring for an infant who is in critical condition. The nurse notes that the child weighs 11 lb (5 kg) and has had a blood loss of 100 mL. Assessment reveals a decreased urine output, mild tachycardia, and restlessness. Which of the following should be the priority action for the nurse to take? application of telemetry monitoring IV administration of lactated Ringer's insertion of a Foley indwelling catheter neurologic assessment with the Glasgow Coma Scale

IV administration of lactated Ringer's Explanation: The loss of small volumes of blood in children is significant and can lead to hypovolemic shock. In this situation, the blood loss represents approximately 10% of the child's total blood volume. Because the child is exhibiting signs of early hypovolemic shock, the priority action should be the administration of Ringer's lactate for fluid resuscitation. The remaining options may need to be implemented, but the priority is to correct the fluid deficit.

A nurse is caring for an infant who is in critical condition. The nurse notes that the child weighs 11 lb (5 kg) and has had a blood loss of 100 mL. Assessment reveals a decreased urine output, mild tachycardia, and restlessness. Which of the following should be the priority action for the nurse to take? insertion of a Foley indwelling catheter application of telemetry monitoring IV administration of lactated Ringer's neurologic assessment with the Glasgow Coma Scale

IV administration of lactated Ringer's Explanation: The loss of small volumes of blood in children is significant and can lead to hypovolemic shock. In this situation, the blood loss represents approximately 10% of the child's total blood volume. Because the child is exhibiting signs of early hypovolemic shock, the priority action should be the administration of Ringer's lactate for fluid resuscitation. The remaining options may need to be implemented, but the priority is to correct the fluid deficit.

An obese, malnourished client has undergone abdominal surgery. While ambulating on the fourth postoperative day, she complains to the nurse that her dressing is saturated with drainage. Before this activity, the dressing was dry and intact. Which is the best initial action for the nurse to take?

Lift the dressing to assess the wound. Explanation: The client probably has a wound evisceration or dehiscence. The first step is to assess the wound; then the nurse can implement appropriate measures. Splinting the abdomen, applying an abdominal binder, or reinforcing the existing dressing would delay treatment.

A client with peripheral artery disease has femoral-popliteal bypass surgery. What goal should the nurse establish with the client immediately after surgery? Prevent infection. Maintain circulation. Provide education. Relieve pain.

Maintain circulation. Explanation: Maintaining circulation in the affected extremity after surgery is the focus of care. The graft can become occluded, and the client must be assessed frequently to determine whether the graft is patent. Preventing infection and relieving pain are important but are secondary to maintaining graft patency. Education should have taken place in the preoperative phase and then continued during the recovery phase.

After receiving large doses of an ovulatory stimulant such as menotropins, a client comes in for her office visit. Assessment reveals the following: 6-lb (3-kg) weight gain, ascites, and pedal edema. Based on this assessment, what should the nurse do next? Prepare for a paracentesis. Notify the healthcare provider. Prepare the woman for hospitalization. Place the woman on bed rest.

Notify the healthcare provider. Explanation: Ovarian hyperstimulation syndrome is caused by an excessive response to the medications used to produce eggs and make them grow. With the increased number of growing follicles, the estradiol levels are increased, leading to fluid leaks in the abdomen. There is increased vascular permeability that causes rapid accumulation of fluid in the peritoneal cavity, thorax, and pericardium. Some symptoms of the problem are an increased weight gain of 3 pounds or more over a 2-day period, shortness of breath, abdominal pain, dehydration, vomiting, and the production of blood clots. The healthcare provider should be notified as soon as possible. The woman may require hospitalization and a paracentesis. If the woman is not admitted to the hospital, the woman should be instructed to stop the medication, rest, and drink large amounts of electrolyte fluids.

The nurse discovers that a young client has been given a dose of morphine four times the dose prescribed. What is the priority action of the nurse? Monitor the client's respiratory rate for 5 minutes. Bring emergency resuscitation equipment to the child's room. Follow the facility policy for reporting of the error. Obtain naloxone and assess the need for administration.

Obtain naloxone and assess the need for administration. Explanation: Naloxone is an opioid antagonist that is given as an antidote for morphine. An antidote is an agent that neutralizes a poison or counteracts its effects. This would be an immediate priority for the nurse. Respiratory depression is a common side effect of opioids, and with a dosage error of this magnitude, it would be the priority to have naloxone ready to administer. Documentation of the error would happen after the client is treated and deemed stable. Emergency resuscitation equipment should be obtained after treating the client if indicated.

After gathering all necessary equipment and setting up the supplies, what should be the first step in performing endotracheal (ET) or tracheal suctioning in an infant? Put on clean gloves. Insert a few drops of sterile saline solution. Provide extra oxygen by using a ventilator or through manual bagging. Insert a suction catheter to the appropriate measured length.

Provide extra oxygen by using a ventilator or through manual bagging. Explanation: Providing extra oxygen before suctioning is the first step because it helps prevent hypoxemia. Insertion of a suction catheter is performed after preoxygenation. Instilling a few drops of sterile saline solution is no longer part of routine suctioning. ET and tracheal suctioning require sterile technique and sterile gloves, not just clean gloves.

While assessing a term neonate on a home visit to a primiparous client 2 weeks after a vaginal birth, the nurse observes that the neonate is slightly jaundiced and the stool is a pale, light color. The nurse notifies the health care provider because these findings indicate which problem? biliary atresia ABO incompatibility Rh isoimmunization esophageal varices

biliary atresia Explanation: Jaundice that persists past the third or fourth day of life and pale, light stools are associated with biliary atresia. Alkaline phosphatase levels will also be elevated. Surgical intervention is necessary to remove the blockage. Rh isoimmunization and ABO incompatibility are associated with neonatal anemia as the red blood cells are hemolyzed by the antibodies. Esophageal varices are associated with cirrhosis of the liver and large amounts of bleeding when the vessels rupture. The child with esophageal varices will exhibit manifestations of anemia such as pallor and may experience hemorrhage and shock.

An adolescent who is immobilized in a cast to stabilize a recent fractured femur suddenly develops chest pain, dyspnea, diaphoresis, and tachycardia. The nurse should further assess the client for what condition?

pulmonary emboli Explanation: Chest pain and dyspnea in an immobilized adolescent with a large bone fracture suggest a fat embolus. With this condition, fat droplets, rather than a thrombus, are transferred from the marrow into the general blood stream by the venous-arterial route, possibly reaching the lung or brain. Atelectasis may develop; however, the onset of signs and symptoms is usually more gradual and subtler. Pneumonia can occur; however, the signs and symptoms usually do not develop suddenly. Pulmonary edema should not be a problem in a healthy adolescent who has sustained a fracture.

A client is hospitalized with fractures of the right femur and right humerus sustained in a motorcycle accident. Laboratory tests reveal a blood alcohol level of 0.2% (200 mg/dL; 43.2 mmol/dL). The client later admits to drinking heavily for years. The client periodically reports tingling and numbness in the hands and feet. Which finding does the nurse expect based on these symptoms?

thiamine deficiency Explanation: Numbness and tingling in the hands and feet are symptoms of peripheral polyneuritis, which results from inadequate intake of vitamin B1 (thiamine) secondary to prolonged and excessive alcohol intake. Treatment includes reducing alcohol intake, correcting nutritional deficiencies through diet and vitamin supplements, and preventing such residual disabilities as foot and wrist drop. Acetate accumulation is unrelated to the client's symptoms. The triglyceride level indicates buildup, but this is not related to the client's symptoms. The serum potassium level is below normal, but it is unrelated to the client's symptoms.

During a home visit, the public health nurse assesses the peritoneal catheter exit site of a child with chronic renal failure. Which finding should lead the nurse to determine a client has a risk for infection? granulation tissue tissue swelling increased time for drainage dialysate leakage

tissue swelling Explanation: Tissue swelling, pain, redness, and exudate indicate infection. Dialysate leakage is associated with improper catheter function, incomplete healing at the insertion site, or excessive instillation of dialysate. Granulation tissue indicates healing around the exit site, not infection. Increased time for drainage may indicate that the tube is kinked, suggesting an obstruction.

A newborn is diagnosed with fetal alcohol syndrome. The nurse is teaching this mother what to expect when she goes home with her baby. The nurse determines the mother needs further instruction when she makes which statement? "The way my baby's face looks now will stay that way." "I may need some help coping with my newborn." "My baby may be irritable as a newborn." "My baby will be fine soon after we are home."

"My baby will be fine soon after we are home." Explanation: Changes seen in the facial features of newborns with fetal alcohol syndrome remain that way. These include epicanthal folds, whorls, irregular hair, cleft lip or palate, small teeth, and lack of philtrum. Newborns with fetal alcohol syndrome are usually difficult to calm and frequently cry for long periods of time. Parents do need assistance with caring for themselves and their infants, particularly with continued alcohol use. A supportive family or support systems are essential. The problems seen with this newborn do not go away and remain with the infant throughout life and are compounded when the child begins to develop mentally.

The nurse is caring for an adolescent client after an overdose on barbiturate drugs and alcohol. The client is hypotensive with a mean arterial pressure below 30 mm Hg and a urine output of 5 mL/hr. Serum creatinine and potassium are elevated. The parents of the client ask why there is so little urine in the indwelling catheter drainage bag. What is the best response by the nurse?

"There is not enough blood circulating to the kidneys." Explanation: The best answer directly and simply explains to the parents that the kidneys are not getting perfused and therefore cannot function. Acute renal failure is often caused by ischemic tubular necrosis. The hypotensive state with a dangerously low mean arterial pressure means the vital organs are not being perfused adequately and are ischemic. Barbiturates are cleared renally and do commonly cause oliguria after an overdose. It is also common to require hemodialysis after a severe overdose.

A child who was intubated after a craniotomy now shows signs of decreased level of consciousness. The health care provider (HCP) prescribes manual hyperventilation to keep the PaCO2 between 25 and 29 mm Hg and the PaO2 between 80 and 100 mm Hg. The nurse interprets this prescription based on the understanding that this action will accomplish which goal? Decrease intracranial pressure. Produce hypoxia. Lower the arousal level. Ensure a patent airway.

Decrease intracranial pressure. Explanation: Hypercapnia, hypoxia, and acidosis are potent cerebral vasodilating mechanisms that can cause increased intracranial pressure. Lowering the carbon dioxide level and increasing the oxygen level through hyperventilation is the most effective short-term method of reducing intracranial pressure. Although ensuring a patent airway is important, this is not accomplished by manual hyperventilation. Manual hyperventilation does not lower the arousal level; in fact, the arousal level may increase. Manual hyperventilation is used to reduce hypoxia, not produce it.

After staying several hours with her 9-year-old daughter who is admitted to the hospital with an asthma attack, the mother leaves to attend to her other children. The child exhibits continued signs and symptoms of respiratory distress. Which finding should lead the nurse to believe the child is experiencing anxiety? frequent requests for someone to stay in the room verbalization of a feeling of tightness in her chest not able to get comfortable inability to remember her exact address

frequent requests for someone to stay in the room Explanation: A 9-year-old child should be able to tolerate being alone. Frequently asking for someone to be in the room indicates a degree of psychological distress that, at this age, suggests anxiety.The inability to get comfortable is more characteristic of a child in pain. Inability to answer questions correctly may reflect a state of anoxia or a lack of knowledge.Tightness in the chest occurs as a result of bronchial spasms.

While assessing a male neonate whose mother desires him to be circumcised, the nurse observes that the neonate's urinary meatus appears to be located on the ventral surface of the penis. The nurse notifies the healthcare provider because the nurse suspects which disorder? hydrocele epispadias hypospadias phimosis

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

When assessing a pregnant client with diabetes mellitus, the nurse stays alert for signs and symptoms of a vaginal or urinary tract infection (UTI). Which laboratory value makes this client more susceptible to such infections? hemoglobin A1C of 6.8% potassium level of 3.0 mEq/L (3.0 mmol/L) +3 urine glucose blood glucose level of 60 mg/dL (3.3mmol/L)

+3 urine glucose Explanation: Glycosuria, evidenced by a +3 urine glucose level, predisposes the pregnant diabetic client to vaginal infections (especially Candida vaginitis) and UTIs, because the hormonal changes of pregnancy affect vaginal pH and the bladder. Electrolyte imbalances, such as a potassium level of 3.0 mEq/L and hypoglycemia, evidenced by a blood glucose level of 60 mg/dl (3.3 mmol/L), aren't associated with vaginal infections or UTIs. Hemoglobin A1C of 6.8% is within normal range for a client with diabetes and doesn't increase the client's risk for infection.

A client in a general hospital is to undergo surgery in 2 days and is experiencing moderate anxiety about the procedure and its outcome. What should the nurse do to help the client reduce anxiety? Distract the client with games and television. Explain the surgical procedure to the client and what happens before and after surgery. Provide reassurance that the client that will come through surgery without incident. Ask the surgeon to refer the client to a psychiatrist who can work with the client to diminish anxiety.

Explain the surgical procedure to the client and what happens before and after surgery. Explanation: An explanation of what to expect decreases anxiety about upcoming events that could be seen as traumatic by the client. Distraction, such as with games or television, only decreases anxiety temporarily and does not fulfill the client's need for information about the procedure. Reassurance about an uncomplicated outcome is not appropriate; the nurse cannot guarantee that the client will come through surgery without problems. Referring the client to a psychiatrist is not indicated for moderate, expected preoperative anxiety.

A client in a general hospital is to undergo surgery in 2 days and is experiencing moderate anxiety about the procedure and its outcome. What should the nurse do to help the client reduce anxiety? Provide reassurance that the client that will come through surgery without incident. Explain the surgical procedure to the client and what happens before and after surgery. Distract the client with games and television. Ask the surgeon to refer the client to a psychiatrist who can work with the client to diminish anxiety.

Explain the surgical procedure to the client and what happens before and after surgery. Explanation: An explanation of what to expect decreases anxiety about upcoming events that could be seen as traumatic by the client. Distraction, such as with games or television, only decreases anxiety temporarily and does not fulfill the client's need for information about the procedure. Reassurance about an uncomplicated outcome is not appropriate; the nurse cannot guarantee that the client will come through surgery without problems. Referring the client to a psychiatrist is not indicated for moderate, expected preoperative anxiety.

A 30-year-old multigravida with prolonged rupture of membranes is diagnosed with endometritis 36 hours after birth of a viable neonate. While assessing the client after intravenous antibiotic therapy is initiated, the nurse notes that the client's temperature is 100° F (37.8° C), pulse rate is 124 bpm, and respirations are 24 breaths/minute. The nurse should: Monitor the vital signs every 4 hours. Provide the client with clear liquids. Administer an analgesic as prescribed. Contact the primary care provider.

Explanation: The nurse should contact the primary care provider immediately because the client is demonstrating danger signals of septic shock. Tachycardia, or a pulse rate greater than 120 bpm, and tachypnea, or respirations of 24 breaths/minute or higher, are both danger signs of septic shock. Hypotension, changes in the level of consciousness, and decreased urine output are later signs.Analgesics can assist the client's comfort but are not critical at this time.Providing the client with clear liquids does not address the life-threatening problem of septic shock.The vital signs should be monitored more frequently than every 4 hours if the client is developing septic shock.

The nurse discovers that a young client has been given a dose of morphine four times the dose prescribed. What is the priority action of the nurse? Follow the facility policy for reporting of the error. Obtain naloxone and assess the need for administration. Monitor the client's respiratory rate for 5 minutes. Bring emergency resuscitation equipment to the child's room.

Obtain naloxone and assess the need for administration. Explanation: Naloxone is an opioid antagonist that is given as an antidote for morphine. An antidote is an agent that neutralizes a poison or counteracts its effects. This would be an immediate priority for the nurse. Respiratory depression is a common side effect of opioids, and with a dosage error of this magnitude, it would be the priority to have naloxone ready to administer. Documentation of the error would happen after the client is treated and deemed stable. Emergency resuscitation equipment should be obtained after treating the client if indicated.

The nurse assesses an adolescent client with lethargy, retractions of the intercostal spaces, a persistent expiratory wheeze, diminished breath sounds, tachycardia, and tachypnea. Arterial blood gas results are pH 7.10; PCO2 80 mm Hg (10.64 kPa); PO2 35 mm Hg (4.66 kPa), HCO3 29 mEq/l (29 mmol/l). What is the priority condition the nurse must address? respiratory acidosis change in mental status breathing pattern increased heart rate

respiratory acidosis Explanation: Based on the results of the arterial blood gases, this client is in respiratory acidosis. The nurse must address this quickly because it could lead to respiratory failure. If the nurse addresses the respiratory acidosis quickly, which means also addressing the cause of the imbalance, the client may not experience respiratory failure. Additionally, assessment data, vital signs, and laboratory work will begin to normalize.

A nurse offers to meet with the mother and teacher of a 9-year-old child with insulin dependent diabetes before school to discuss the teacher's responsibilities in relation to the child's diabetes. What should the nurse discuss at the meeting? how to give an insulin injection signs and symptoms of hypoglycemia the child's dietary requirements how to perform a glucometer test

signs and symptoms of hypoglycemia Explanation: Because an insulin reaction can be life threatening and may occur while the child is in school, the nurse and mother should discuss hypoglycemia's seriousness and how to evaluate it in the child with the child's teacher. The teacher also needs to know what measures to take if an insulin reaction occurs. There is no reason why a teacher would need to be able to give an insulin injection. If the child needs to take insulin during school hours, the school nurse would be responsible for monitoring this aspect. The child should be responsible for insulin injections. The child should also be responsible for diet and testing blood glucose levels. Additional help could be obtained from the nurse. The teacher does not need to understand the American or Canadian Diabetes Association diet plan.

A child, age 15 months, is admitted to the health care facility. During the initial nursing assessment, which statement by the mother most strongly suggests that the child has a Wilms' tumor? "My child's appetite has increased so much lately." "My child's abdomen seems bigger, and his diapers are much tighter." "My child has grown 3" in the past 6 months." "My child seems to be napping for longer periods."

"My child's abdomen seems bigger, and his diapers are much tighter." Explanation: The most common presenting sign of a Wilms' tumor is abdominal swelling or an abdominal mass. Therefore, the mother's observation that her child's abdomen seems bigger suggests a Wilms' tumor. A rapid increase in length (height) isn't associated with this type of tumor. Although lethargy may accompany a Wilms' tumor, abdominal swelling is a more specific sign. Children with a Wilms' tumor usually have a decreased, not increased, appetite.

A client has chest pain rated at 8 on a 10-point visual analog scale. The 12-lead electrocardiogram reveals ST elevation in the inferior leads and troponin levels are elevated. What should the nurse do first? Monitor daily weights and urine output. Limit visitation by family and friends. Reduce pain and myocardial oxygen demand. Provide client education on medications and diet.

Reduce pain and myocardial oxygen demand. Explanation: Nursing management for a client with a myocardial infarction should focus on pain management and decreasing myocardial oxygen demand. Fluid status should be closely monitored. Client education should begin once the client is stable and amenable to teaching. Visitation should be based on client comfort and maintaining a calm environmen

A client who underwent a mastectomy has been admitted to the surgical care unit after discharge from the postanesthesia care unit. What is the nurse's priority assessment? Monitor for urinary retention. Ask about the client's level of pain. Assess the dressing, drain, and amount of drainage. Assess the vital signs and oxygen saturation levels.

Assess the vital signs and oxygen saturation levels. Explanation: The correct response is based on the principle of prioritizing assessment of airway, breathing, and circulation (ABC) for every client. Assessing vital signs and oxygen saturation, therefore, is the priority. The return of urinary function after anesthesia usually takes 6 or more hours, so this assessment is not a priority upon return from the postanesthesia care unit. Checking the dressing and level of pain are both important but not the priority.

A 9-month-old, well-nourished boy who lives with his extensive extended family tests positive for tuberculosis. What is a risk factor for tuberculosis in this child? having a mother who did not receive prenatal care until the second trimester of her pregnancy being male being an infant being in the 95th percentile for height and weight

being an infant Explanation: Infants are more susceptible to tuberculosis because of a diminished resistance to infection due to an immature immune system.In later childhood and adolescence, morbidity and mortality are higher in females than males.A higher-than-average weight and height would indicate that the child has had good nutrition. Poor nutrition is a risk factor for tuberculosis.Prenatal care is unrelated to tuberculosis.

A 10-month-old child with recurrent otitis media is brought to the clinic for evaluation. What is most important for the nurse to ask the family about the baby's symptoms? "Do you give the baby a bottle to take to bed?" "Have you noticed a lot of wax in the baby's ears?" "Can the baby combine two words when speaking?" "Does water ever get into the baby's ears during shampooing?"

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