pre test

A 1-year-old child is diagnosed with intussusception, and the mother of the child asks the student nurse to describe the disorder. Which statement by the student nurse indicates correct understanding of this disorder?

"It is an acute bowel obstruction." 2."It is a condition that causes an acute inflammatory process in the bowel." 3."It is a condition in which a distal segment of the bowel prolapses into a proximal segment of the bowel." *4."It is a condition in which a proximal segment of the bowel prolapses into a distal segment of the bowel." Intussusception occurs when a proximal segment of the bowel prolapses into a distal segment of the bowel. It is not an acute bowel obstruction, but it is a common cause of bowel obstruction in infants and young children. It is not an inflammatory process.

A client who is watching television in the dayroom shares with the nurse that he has begun seeing his mother being assaulted on the television screen. Which is the nurse's initial intervention?

*1.Turn off the television. 2.Walk with the client around the unit. 3.Discuss the possible hallucinatory triggers. 4.Help him call his mother so he can speak with her. Environmental factors such as a reflective television screen are often the trigger for hallucinations. Eliminating the trigger when possible is the priority. Options that intend to distract should be implemented after the client has been removed from the environmental stimulus. Discussing the hallucinatory trigger may be appropriate, but the priority is to eliminate the trigger.

Cyclobenzaprine is prescribed for a client for muscle spasms and the nurse is reviewing the client's record. Which disorder, if noted in the record, would indicate a need to contact the health care provider about the administration of this medication?

*Glaucoma 2.Emphysema 3.Hypothyroidism 4.Diabetes mellitus Because cyclobenzaprine has anticholinergic effects, it should be used with caution in clients with a history of urinary retention, glaucoma, and increased intraocular pressure. Cyclobenzaprine should be used only for a short time (2 to 3 weeks). The conditions in options 2, 3, and 4 are not a concern with this medication.

The nurse is reviewing the laboratory test results for a client seen in the clinic. The nurse determines that the urine specific gravity is normal if which value is noted on the laboratory results?

1.001 2.1.003 *3.1.019 4.1.036 The normal range for urine specific gravity is between 1.005 and 1.030. Values of 1.001 and 1.003 represent low values, and 1.036 reflects an elevated value.

When planning care for a postpartum client who plans to breast-feed her infant, which important piece of information should the nurse include in the teaching plan to prevent the development of mastitis?

1.Offer only 1 breast at each feeding. 82.Massage distended areas as the infant nurses. 3.Express and discard milk from the affected breast at the first signs of mastitis. 4.Cleanse the nipples with a mild antibacterial soap before and after infant feedings. Massaging the distended areas as the infant nurses will encourage complete emptying of the breast and prevent milk stasis. Each breast should be offered at each feeding to prevent milk stasis and ensure adequate milk supply. There is no need to discard breast milk. If early signs of mastitis occur, the client usually will be instructed to nurse the infant more frequently, because infant sucking is thought to empty the breast more completely. Soap should not be used on the nipples because of the risk of drying or cracking.

The nurse is caring for a client who has been prescribed intravenous metoclopramide. The nurse determines that the client likely is being treated for which condition?

1.Paralytic ileus 2.Diabetic gastroparesis 3.Gastroesophageal reflux disease *4.Postoperative nausea and vomiting Metoclopramide is given either orally or intravenously. Indications for intravenous metoclopramide include postoperative nausea and vomiting, facilitation of small bowel intubation, and facilitation of radiological exams of the gastrointestinal tract. Oral metoclopramide is given for paralytic ileus, diabetic gastroparesis, and gastroesophageal reflux disease.

The nurse is monitoring a hospitalized client who abuses alcohol. Which findings should alert the nurse to the potential for alcohol withdrawal delirium?

Hypotension, ataxia, hunger 2.Stupor, lethargy, muscular rigidity 3.Hypotension, coarse hand tremors, lethargy *4.Hypertension, changes in level of consciousness, hallucinations Symptoms associated with alcohol withdrawal delirium typically include anxiety, insomnia, anorexia, hypertension, disorientation, hallucinations, changes in level of consciousness, agitation, fever, and delusions.

Trimethoprim-sulfamethoxazole is prescribed for a client. The nurse should instruct the client to report which symptom if it develops during the course of this medication therapy? . 1.Nausea 2.Diarrhea 3.Headache 4.Sore throat

sore throat Rationale: Clients taking trimethoprim-sulfamethoxazole should be informed about early signs and symptoms of blood disorders that can occur from this medication. These include sore throat, fever, and pallor, and the client should be instructed to notify the health care provider (HCP) if these occur. The other options do not require HCP notification.

The nurse is providing anticipatory guidance to the mother of a 10-month-old child. The mother asks how soon her daughter will be able to receive the chickenpox (varicella) vaccine. What is the best nursing response?

"She will receive it today." *2."She can receive it when she is 12 months old." 3."She can receive it any time before her first birthday." 4."She will receive it before entry into kindergarten, at 4 to 6 years of age." The varicella vaccination is recommended to be administered when the child is between 12 and 18 months of age; therefore, the remaining options are incorrect.

The nurse is reviewing the procedure for performance of an electrocardiogram (ECG). Which action by the nurse indicates understanding of the correct position for the V1lead when performing a 12-lead electrocardiogram?

"The lead should be placed on the fourth intercostal space left sternal border." ** 2."The lead should be placed on the fourth intercostal space right sternal border." 3."The lead should be placed on the fifth intercostal space left midaxillary line." 4."The lead should be placed on the fifth intercostal space left midclavicular line."

A client is diagnosed as having a bowel tumor. The nurse should monitor the client for which complications of this type of tumor? Select all that apply. .Flatulence 2.Peritonitis 3.Hemorrhage 4.Fistula formation 5.Bowel perforation 6.Lactose intolerance

2.Peritonitis 3.Hemorrhage 4.Fistula formation 5.Bowel perforation Complications of bowel tumors include bowel perforation, which can result in hemorrhage and peritonitis. Other complications include bowel obstruction and fistula formation. Flatulence can occur but is not a complication; lactose intolerance also is not a complication of intestinal tumor.

The nurse is reviewing laboratory test results for the client with liver disease and notes that the client's albumin level is low. Which nursing action is focused on the consequence of low albumin levels?

Evaluating for asterixis 2.Inspecting for petechiae *3.Palpating for peripheral edema 4.Evaluating for decreased level of consciousness Albumin is responsible for maintaining the osmolality of the blood. When there is a low albumin level, there is decreased osmotic pressure, which in turn can lead to peripheral edema. The remaining options are incorrect and are not associated with a low albumin level.

Carbamazepine has been prescribed for a client. The nurse should tell the client that which blood test will be done periodically while the client is taking this medication?

Lipase level 2. Amylase level 3. Ammonia level * 4. Complete blood cell (CBC) count Carbamazepine is classified as an iminostilbene derivative and is used as an anticonvulsant, antineuralgic, antimanic, and antipsychotic. The medication can cause blood dyscrasias as an adverse effect, and the client should have a CBC count done before therapy and periodically during therapy. Additional laboratory tests that should be done include a serum iron determination, urinalysis, blood urea nitrogen determination, and carbamazepine level. The tests identified in the remaining options are unnecessary.

The nurse assesses a client who is diagnosed with a stroke (brain attack). On assessment, the client is unable to understand the nurse's commands. Which condition should the nurse document?

Occipital lobe impairment * 2.Damage to the auditory association areas 3.Frontal lobe and optic nerve tracts damage 4.Difficulty with concept formation and abstraction areas Auditory association and storage areas are located in the temporal lobe and relate to understanding spoken language. The occipital lobe contains areas related to vision. The frontal lobe controls voluntary muscle activity, including speech, and an impairment can result in expressive aphasia. The parietal lobe contains association areas for concept formation, abstraction, spatial orientation, body and object size and shape, and tactile sensation.

The client with human immunodeficiency virus (HIV) infection has been started on therapy with zidovudine. The nurse reviews the laboratory results and determines that the client is experiencing an adverse effect of the medication if which is noted? 1.Phosphorus 4.5 mg/dL (1.45 mmol/L) 2.Hemoglobin of 10 g/dL (100 mmol/L) 3.Blood glucose level 70 mg/dL (4 mmol/L) 4.Blood urea nitrogen (BUN) 10 mg/dL (3.6 mmol/L)

hemoglobin An adverse effect of this medication therapy is agranulocytopenia and anemia. The nurse carefully monitors the CBC count for these changes. With early HIV infection or in the client who is asymptomatic, CBC counts are monitored monthly for 3 months and then every 3 months thereafter. In clients with advanced disease, these counts are monitored every 2 weeks for the first 2 months and then once a month if the medication is tolerated well. The normal hemoglobin level is 14 to18 g/dL (140 to180 mmol/L); thus this client is experiencing anemia. The remaining options identify normal values. The normal phosphorus 3.0 to4.5 mg/dL (0.97 to 1.45 mmol/L). The normal blood glucose level is 70 to110 mg/dL (4 to 6 mmol/L). The normal BUN is 10 to 20 mg/dL (3.6 to 7.1 mmol/L).

The nurse is instructing the caregiver of a child about reprimanding the child. The nurse recognizes that additional teaching is neededif the caregiver makes which statement to the child?

."I like it when you obey." 2."I need you to listen to me." *3."You need to stop hitting your sister." 4."I don't like it when you hit your sister." When reprimanding children, the person reprimanding should focus only on the misbehavior, not on the child. "I" messages rather than "you" messages should be used to express personal feelings without accusation. An "I" message attacks the behavior, not the child.

The nurse is explaining an upper gastrointestinal series to a client and provides the client with the preprocedure and postprocedure instructions. The nurse informs the client that after this procedure, the stools can be expected to remain white for what time period? 1.1 week 2.6 hours 3.8 hours 4.1 to 2 days

1 to 2 days It takes at least 12 to 24 hours for a substance to pass through the colon. One week is too long a period, and 6 to 8 hours is too short a period because of residual barium and decreased peristalsis.

The nurse is preparing to administer an MMR (measles, mumps, and rubella) vaccine to a 15-month-old child. Before administering the vaccine, which question should the nurse ask the mother of the child?

1."Has the child had any sore throats?" 2."Has the child been eating properly?" *3."Is the child allergic to any antibiotics?" 4."Has the child been exposed to any infections?" Before the administration of MMR vaccine, a thorough health history needs to be obtained. MMR is used with caution in a child with a history of an allergy to gelatin, eggs, or neomycin because the live measles vaccine is produced by chick embryo cell culture and because MMR also contains a small amount of the antibiotic neomycin. The questions in the remaining options are not directed at addressing contraindications to administering immunizations.

A client sustained a burn injury at 7:00 a.m. The client's spouse states that before the burn, the client's body weight was 198 lbs. The health care provider has estimated that the total body surface area (BSA) burned is 83%. Using the Parkland (Baxter) formula (4 mL × kilograms of body mass × percent total BSA), the nurse determines that the total amount of intravenous lactated Ringer's solution that the client will receive by 3 p.m. of the same day on which the burn occurred is which value?

14,940mL Rationale: The Parkland (Baxter) formula for estimating fluid requirements is 4 mL × kilograms of body mass × percent total BSA. Half of this total is administered in the first 8 hours after the burn. First, convert pounds to kilograms by dividing 198 lbs by 2.2, which equals 90. Therefore, 4 × 90 × 83 = 29,880 mL, divided by 2 = 14,940 mL

The nurse preceptor and the orientee note that the reticulocyte count for a client is increased. The preceptor determines that the orientee understands the significance of reticulocytes if the orientee makes which statement with regard to red blood cells (RBCs)? "A reticulocyte is a mature RBC." 2."A reticulocyte is an immature RBC." 3."A reticulocyte is decreased whenever there is accelerated production of RBCs." 4."A reticulocyte is increased when the bone marrow has slowed production of RBCs."

2."A reticulocyte is an immature RBC." The reticulocyte is an immature RBC. The reticulocyte count is increased any time there is an accelerated production of RBCs. It is decreased when the bone marrow has slowed production of RBCs.`

A client is being weaned from parenteral nutrition (PN) and is expected to begin taking solid food today. The ongoing solution rate has been 100 mL/hour. The nurse anticipates that which prescription regarding the PN solution will accompany the diet prescription? 1.Discontinue the PN. 2.Decrease PN rate to 50 mL/hour. 3.Start 0.9% normal saline at 25 mL/hour. 4.Continue current infusion rate prescriptions for PN.

2.Decrease PN rate to 50 mL/hour. When a client begins eating a regular diet after a period of receiving PN, the PN is decreased gradually. PN that is discontinued abruptly can cause hypoglycemia. Clients often have anorexia after being without food for some time, and the digestive tract also is not used to producing the digestive enzymes that will be needed. Gradually decreasing the infusion rate allows the client to remain adequately nourished during the transition to a normal diet and prevents the occurrence of hypoglycemia. Even before clients are started on a solid diet, they are given clear liquids followed by full liquids to further ease the transition. A solution of normal saline does not provide the glucose needed during the transition of discontinuing the PN and could cause the client to experience hypoglycemia.

The clinic nurse prepares instructions for a client who developed stomatitis after the administration of a course of antineoplastic medications. The nurse should provide the client with which instruction? 1.Avoid foods and fluids for the next 12 to 24 hours. 2.Swab the mouth with lemon and glycerin 4 times a day. 3.Rinse the mouth with a diluted solution of baking soda or saline. 4.Brush the teeth with a stiff-bristled toothbrush, and use dental floss 3 times a day.

3.Rinse the mouth with a diluted solution of baking soda or saline. Stomatitis (ulceration in the mouth) can result from the administration of antineoplastic medications. The client should be instructed to examine the mouth daily and report any signs of ulceration. If stomatitis occurs, the client should be instructed to rinse the mouth with a diluted solution of baking soda or saline. Food and fluid are important and should not be restricted. If chewing and swallowing are painful, the client may switch to a liquid diet that includes milkshakes and ice cream. Instruct the client to avoid spicy foods and foods with hard crusts or edges. Lemon and glycerin swabs may cause pain and further irritation. The client should avoid brushing the teeth, particularly with a stiff-bristled toothbrush, and flossing when stomatitis is severe.

The nursing student enrolled in an anatomy and physiology course is studying the immune system. The nursing instructor determines that the student understands the chemical barriers against a nonspecific immune response if which statement is made? 1."The skin is considered a chemical barrier." 2."The mucous membranes act as chemical barriers." 3."The cilia lining the respiratory tract are chemical barriers." 4."Acids and enzymes found in body fluids function as chemical barriers."

4 Chemical barriers include various acids and enzymes found in body fluids. The skin, the mucous membranes, and the action of cilia lining the respiratory tract are physical barriers.

The nurse presents a seminar on sexually transmitted infections. Which information about syphilis should the nurse include in this presentation? Select all that apply. 1.A blood test will confirm the diagnosis. 2.Syphilis signs and symptoms are divided into stages. 3.Syphilis can be spread through vaginal, anal, or oral sex. 4.Having syphilis once provides lifelong immunity from repeat infection. 5.Syphilis will always be present in a chronic state, as there is no cure for this illness.

A blood test will confirm the diagnosis. 2.Syphilis signs and symptoms are divided into stages. 3.Syphilis can be spread through vaginal, anal, or oral sex. Syphilis can be cured with the initiation of prompt treatment. A blood test can confirm this diagnosis. Syphilis is staged in relation to signs and symptoms and the length of the infection. Syphilis may be transmitted via vaginal, anal, or oral sex. An individual may be positive for syphilis more than once. Syphilis can be cured by early treatment.

During the assessment, what is the nurse's primary goal for a confused and disoriented client diagnosed with posttraumatic stress disorder? 1.Explaining the unit rules 2.Making the client feel safe 3.Orienting the client to the unit 4.Stabilizing the client's psychiatric needs

making the client feel safe It is important to make a confused client feel safe. Explaining the unit rules and orienting the client to the unit are part of any admission process. Stabilizing psychiatric needs is a long-term goal.

A registered nurse (RN) has instructed an unlicensed assistive personnel (UAP) to administer soapsuds enemas until clear to a client. The UAP reports that three enemas have been administered and the client is still passing brown, liquid stool. What should the RN instruct the UAP to do?

Administer a Fleet enema. 2.Administer an oil retention enema. 3.Wait 30 minutes and then administer another enema. **4.Stop administering the enemas until the health care provider (HCP) is notified. Up to three enemas may be given when there is a prescription for enemas until clear. If more than three are necessary, the nurse should call the HCP (or act according to agency policy). Excessive enemas could cause fluid and electrolyte depletion. Options 1 and 3 are incorrect for these reasons. An oil retention enema is an enema that is used to soften dry, hard stool and would have no use in this situation.

A child is receiving succimer for the treatment of lead poisoning. The nurse should monitor which most important laboratory result? Iron level 2.Calcium level 3.Red blood cell count 4.Blood urea nitrogen level

BUN level Succimer is a medication that is used to treat lead poisoning. Renal function (blood urea nitrogen and creatinine) is monitored closely during the administration of chelation therapy because the medication is excreted via the kidneys. Although it is important to monitor the iron level, calcium level, and red blood cell count, these results are not specific to chelation therapy, so they are not the most important lab values to monitor.

A client has a prescription to begin an infusion of 1000 mL of 5% dextrose in lactated Ringer's solution. The client has an intravenous (IV) cannula inserted, and the nurse prepares the solution and IV tubing. Arrange the actions in the order that they should be performed. All options must be used.

Close the roller clamp on the IV tubing. Spike the IV bag and half-fill the drip chamber. Open the roller clamp and fill the tubing. Uncap the distal end of the tubing. Attach the distal end of the tubing to the client.

The mother of a 6-year-old child who has type 1 diabetes mellitus calls a clinic nurse and tells the nurse that the child has been sick. The mother reports that she checked the child's urine and it was positive for ketones. The nurse should instruct the mother to take which action? 1.Hold the next dose of insulin. 2.Come to the clinic immediately. 3.Encourage the child to drink liquids. 4.Administer an additional dose of regular insulin.

Encourage the child to drink fluids When the child is sick, the mother should test for urinary ketones with each voiding. If ketones are present, liquids are essential to aid in clearing the ketones. The child should be encouraged to drink liquids. Bringing the child to the clinic immediately is unnecessary. Insulin doses should not be adjusted or changed.

A client who is taking phenytoin for a seizure disorder is being admitted to the hospital because of an increase in seizure activity. The client reports severe vomiting for the last 24 hours and an inability to take phenytoin during that time. The nurse anticipates that the health care provider will most likely prescribe which medication? Clonazepam 2.Phenobarbital 3.Carbamazepine 4.Fosphenytoin sodium

Fosphenytoin sodium Fosphenytoin sodium is used for short-term parenteral (intravenous) infusion. A client who is not tolerating medications orally and has a seizure disorder would need an anticonvulsant administered by the parenteral route. Phenobarbital is an antiseizure medication that is given orally or parenterally. However, the medication of choice in this case would be fosphenytoin since its use is short term. Carbamazepine and clonazepam usually are administered orally.

The nurse is supervising the postmortem care of a client. Which action by the unlicensed assistive personnel (UAP) performing the care is appropriate?

Keeps the client's body in a flat, supine position 2.Closes the client's eyes by taping the eyelids shut *3.Elevates the head of the bed 30 degrees as soon as possible after death 4.Removes the client's dentures and places them in a denture cup with the client's name on the lid The nurse may delegate postmortem care to UAPs, but the nurse must supervise the postmortem care. The care given must protect the client's body from damage or disfigurement. Elevating the head of bed immediately after the client's death can help reduce facial discoloring from livor mortis. Using tape may damage the delicate eyelid tissues; dentures should be placed inside the client's mouth during postmortem care to maintain facial structure.

A client seen in an ambulatory clinic has a facial rash that is present on both cheeks and across the bridge of the nose. The nurse interprets that this finding is consistent with manifestations of which disorder? 1.Hyperthyroidism 2.Pernicious anemia 3.Cardiopulmonary disorders 4.Systemic lupus erythematosus (SLE)

Lupus Systemic lupus erythematosus is a chronic, progressive, inflammatory connective tissue disorder that can cause major body organs and systems to fail. A major skin manifestation of SLE is the appearance of a rash on both cheeks and across the nose. It is known as a "butterfly rash." Hyperthyroidism is associated with moist skin and increased perspiration. Pernicious anemia causes pallor of the skin. Cardiopulmonary disorders may lead to clubbing of the fingers.

A nurse is caring for a client recently diagnosed with type 2 diabetes mellitus who has been prescribed sustained-release glipizide. What is the most important point for the nurse to include in teaching this client about this medication?

Take the medication at least 1 hour after eating. 2.Make sure to take the medication every 12 hours. 3.Take measures to prevent and treat hyperglycemia. *4.Swallow the medication whole and never crush or chew it. Sustained-release glipizide is designed to be slowly absorbed form the gastrointestinal tract. Crushing or chewing the tablet alters absorption of the medication. It must be taken 30 minutes before eating because absorption is delayed by food. Hypoglycemia may occur when taking this medication, especially with insufficient caloric intake. Sustained-release glipizide has a duration of action of 24 hours and is taken once a day.

The pediatric nurse clinician is discussing the pathophysiology related to childhood leukemia with a class of nursing students. Which statement made by a nursing student indicates a need for further teaching of the pathophysiology of this disease?

The platelet count is decreased. 2.Red blood cell production is affected. *3.Reed-Sternberg cells are found on biopsy. 4.Normal bone marrow is replaced by blast cells. In leukemia, normal bone marrow is replaced by malignant blast cells. As the blast cells take over the bone marrow, eventually red blood cell and platelet production is affected, and the child becomes anemic and thrombocytopenic. The Reed-Sternberg cell is found in Hodgkin's disease.

A client receives a dose of scopolamine. The nurse determines that which sign or symptom later displayed by the client is a result of medication side and adverse effects? 1.Dry mouth 2.Diaphoresis 3.Excessive urination 4.Pupillary constriction

dry mouth Side and adverse effects of scopolamine, an anticholinergic medication, are dry mouth, urinary retention, decreased sweating, and dilation of the pupils. Each of the incorrect options states the opposite of a side effect of this medication.

The nurse has completed medication administration that included a nitroglycerin. Within minutes, the client is complaining of a headache. Which is the priority nursing action at this time? 1.Evaluate pupil response. 2.Place the client on the left side. 3.Administer the prescribed analgesic. 4.Notify the health care provider (HCP) immediately.

administer the prescribed analgesic Nitroglycerin causes vasodilation. The major side effect of nitroglycerin is a headache that can be alleviated by an analgesic. It is an expected response to the medication, and the HCP does not need to be notified. Placing the client on the left side will not alleviate the headache. There is no indication for the need to evaluate pupil response

The nurse is providing directions to a client about how to test a stool for occult blood. The nurse cautions the client that which could cause a false-negative result? 1.Iodine 2.Colchicine 3.Ascorbic acid 4.Acetylsalicylic acid

ascorbic acid Ascorbic acid can interfere with results of occult blood testing, yielding a false-negative result. Colchicine and iodine can cause false-positive results. Acetylsalicylic acid would have no effect or could cause a positive result by inducing bleeding from the gastrointestinal tract.

A child is admitted to the pediatric unit with a diagnosis of acute stage Kawasaki disease. Which assessment findings by the nurse are characteristic of this disorder? Select all that apply. 1.Red throat 2.Cracking lips 3.Conjunctival hyperemia 4.Desquamation of the skin 5.Enlargement of the cervical lymph nodes

red throat conjunctival hyperemia enlargement of cervical lymph nodes Kawasaki disease is known as mucocutaneous lymph node syndrome and is an acute systemic inflammatory disease. Assessment findings in the acute stage include fever, conjunctival hyperemia, red throat, swollen hands, rash, and enlargement of the cervical lymph nodes. Desquamation of the skin, cracking lips, joint pain, cardiac manifestations, and thrombocytosis are characteristics of the subacute stage.

A nursing student who is researching a medication at the nurses' station asks the registered nurse (RN) what the function of an alpha-adrenergic receptor is, and where the receptors are primarily found. The RN educates the nursing student. Which statement by the nursing student indicates that teaching has been effective? "The peripheral arteries and veins; when stimulated they cause vasoconstriction." 2."Arterial and bronchial walls; when stimulated they cause vasodilation and bronchodilation." 3."The heart; when stimulated it causes an increase in heart rate, atrioventricular node conduction, and contractility." 4."Several tissues; when stimulated they cause contraction of smooth muscle, inhibition of lipolysis, and promotion of platelet aggregation."

"The peripheral arteries and veins; when stimulated they cause vasoconstriction." Found in the peripheral arteries and veins, alpha-adrenergic receptors cause a powerful vasoconstriction when stimulated. The remaining options are incorrect statements.

A 10-year-old referred for evaluation after drawing sexually explicit scenes says to the psychiatric nurse, "I just felt like it." Which response by the nurse is focused on assessing for abuse-related symptoms?

"Well, a picture paints a thousand words." 2."You just felt like destroying your textbooks?" 3."Your parents and teachers are very concerned about your drawings." *4."I am concerned about you. Are you now or have you ever been abused?" The behaviors that this child engaged in are a warning signal of distress. The correct option is the only one that specifically addresses abuse. The remaining options are insensitive, not focused on the possible sexual abuse, or too indirect to be useful.

The nurse is collecting data from an African American client scheduled for surgery. Which questions would be most appropriate for the nurse to ask on initial assessment? Select all that apply.

*"Do you ever experience chest pain?" *2."Do you have any difficulty breathing?" 3."How many people live in your house?" 4."Do you have a close family relationship?" * 5."Do you frequently have episodes of headache?" In the African American culture, it is considered to be intrusive to ask personal questions on the initial contact or meeting. African Americans are highly verbal and express feelings openly to family or friends, but what transpires within the family is viewed as private. Psychosocial data are the least priority during the initial data collection. Additionally, cardiovascular, neurological, and respiratory data include physiological assessments that would be the priority.

The nurse is teaching the client about his prescribed prednisone. Which statement, if made by the client, indicates that further teaching is necessary? I can take aspirin or my antihistamine if I need it." 2."I need to take the medication every day at the same time." 3."I need to avoid coffee, tea, cola, and chocolate in my diet." 4."If I gain more than 5 pounds (2.25 kg) a week, I will call my health care provider (HCP)."

*"I can take aspirin or my antihistamine if I need it." Aspirin and other over-the-counter medications should not be taken unless the client consults with the HCP. The client needs to take the medication at the same time every day and should be instructed not to stop the medication. A slight weight gain as a result of an improved appetite is expected; however, after the dosage is stabilized, a weight gain of 5 pounds (2.25 kg) or more weekly should be reported to the HCP. Caffeine-containing foods and fluids need to be avoided because they may contribute to steroid-ulcer development.

The nurse is caring for a client who is mechanically ventilated, and the high-pressure ventilator alarm is sounding. The nurse understands that which complications may cause this alarm? Select all that apply.

*.Water or a kink in the tubing *2.Biting on the endotracheal tube *3.Increased secretions in the airway 4.Disconnection or leak in the system 5.The client ceasing spontaneous breathing Causes of high-pressure ventilator alarms include water or a kink in the tubing, biting on the endotracheal tube, increased secretions in the airway, wheezing or bronchospasm, displacement of the endotracheal tube, or the client fighting the ventilator. A disconnection or leak in the system and the client ceasing to spontaneously breathe are causes of a low-pressure ventilator alarm.

A client with diabetes mellitus is told that amputation of the leg is necessary to sustain life. The client is very upset and tells the nurse, "This is all my health care provider's fault. I have done everything I've been asked to do!" Which nursing interpretation is best for this situation?

*1. An expected coping mechanism 2.An ineffective defense mechanism 3.A need to notify the hospital lawyer 4.An expression of guilt on the part of the client The nurse needs to be aware of the effective and ineffective coping mechanisms that can occur in a client when loss is anticipated. The expression of anger is known to be a normal response to impending loss, and the anger may be directed toward the self, God or other spiritual being, or caregivers. Notifying the hospital lawyer is inappropriate. Guilt may or may not be a component of the client's feelings, and the data in the question do not indicate that guilt is present.

A client with muscle aches and a diagnosis of rheumatism has been given a prescription for capsaicin topical cream. The nurse determines that the client understands the use of the medication if the client makes which statement?

*1."The medication will act as a local analgesic." 2."The medication acts by decreasing muscle spasms." 3."The medication will cause redness, flaking, and the skin to peel." 4."A heating pad should be put on the area after applying the medication." Rationale: Capsaicin is used for the temporary relief of muscular aches, rheumatism, arthritis, sprains, and neuralgia. It is one of a group of products known as rubs or liniments, which contain combinations of antiseptics, local anesthetics, analgesics, and counterirritants. The skin should not become red, flaky, or peel; if this occurs, the health care provider should be notified. The medication does not act systemically. A heating pad should not be applied because it could cause skin irritation or burning.

A stillborn baby was delivered in the birthing suite a few hours ago. After the delivery, the family remained together, holding and touching the baby. Which statement by the nurse would assist the family in their period of grief?

*1."What can I do for you?" 2."Now you have an angel in heaven." 3."Don't worry, there is nothing you could have done to prevent this from happening." 4."We will see to it that you have an early discharge so that you don't have to be reminded of this experience." When a loss or death occurs, the nurse should ensure that parents have been honestly told about the situation by their health care provider or others on the health care team. It is important for the nurse to be with the parents at this time and to use therapeutic communication techniques. The nurse must also consider cultural and religious practices and beliefs. The correct option provides a supportive, giving, and caring response. Options 2, 3, and 4 are blocks to communication and devalue the parents' feelings.

The nurse is performing an assessment on a client who suspects that she is pregnant and is checking the client for probable signs of pregnancy. The nurse should assess for which probable signs of pregnancy? Select all that apply.

*1.Ballottement *2.Chadwick's sign *3.Uterine enlargement *4.Positive pregnancy test 5.Fetal heart rate detected by a nonelectronic device 6.Outline of fetus via radiography or ultrasonography The probable signs of pregnancy include uterine enlargement, Hegar's sign (compressibility and softening of the lower uterine segment that occurs at about week 6), Goodell's sign (softening of the cervix that occurs at the beginning of the second month), Chadwick's sign (violet coloration of the mucous membranes of the cervix, vagina, and vulva that occurs at about week 4), ballottement (rebounding of the fetus against the examiner's fingers on palpation), Braxton Hicks contractions, and a positive pregnancy test for the presence of human chorionic gonadotropin. Positive signs of pregnancy include fetal heart rate detected by electronic device (Doppler transducer) at 10 to 12 weeks and by nonelectronic device (fetoscope) at 20 weeks of gestation, active fetal movements palpable by the examiner, and an outline of the fetus by radiography or ultrasonography.

An infant returns to the nursing unit following surgery for a diagnosis of esophageal atresia with tracheoesophageal fistula (TEF). The infant is receiving intravenous fluids and a gastrostomy tube is in place. Following assessment, the nurse positions the infant and performs which action?

*1.Elevates the gastrostomy tube 2.Tapes the gastrostomy tube to the bed linens 3.Attaches the gastrostomy tube to low suction 4.Connects the gastrostomy tube to the feeding pump In the immediate postoperative period, the gastrostomy tube is elevated, allowing gastric contents to pass into the small intestine and air to escape. This promotes comfort and decreases the risk of leakage at the anastomosis. The remaining options are incorrect. Taping the tube to the bed linens presents a risk of accidental removal. Attaching the tube to suction could disrupt the surgical repair site. Feedings are not initiated in the immediate postoperative period.

The nurse is creating a plan of care for a client with a diagnosis of nephrotic syndrome whose glomerular filtration rate (GFR) is normal. Which interventions should the nurse include in the plan of care? Select all that apply.

*1.Monitor daily weight. *2.Maintain sodium restrictions. 3.Maintain a diet low in protein. *4.Monitor intake and output (I&O). *5.Maintain bed rest when edema is severe. Controlling edema is a critical aspect of therapeutic management of nephrotic syndrome. If the GFR is normal, dietary intake of proteins is needed to restore normal plasma oncotic pressure and thereby decrease edema. Daily measurement of weight and abdominal girth, and careful monitoring of I&O will determine whether weight loss is caused by diuresis or protein loss. Dietary modifications may include salt restriction and fluid restriction and are based on the client's symptoms. Bed rest is prescribed to promote diuresis when edema is severe.

The nurse is completing an assessment on a client who is being admitted for a diagnostic workup for primary hyperparathyroidism. Which client complaint would be characteristic of this disorder? Select all that apply.

*1.Polyuria 2.Headache *3.Bone pain 4.Nervousness 5.Weight gain The role of parathyroid hormone (PTH) in the body is to maintain serum calcium homeostasis. In hyperparathyroidism, PTH levels are high, which causes bone resorption (calcium is pulled from the bones). Hypercalcemia occurs with hyperparathyroidism. Elevated serum calcium levels produce osmotic diuresis and thus polyuria. This diuresis leads to dehydration (weight loss rather than weight gain). Loss of calcium from the bones causes bone pain. Options 2, 4, and 5 are not associated with hyperparathyroidism. Some gastrointestinal symptoms include anorexia, nausea, vomiting, and constipation.

A client's electrocardiogram strip shows atrial and ventricular rates of 110 beats/minute. The PR interval is 0.14 seconds, the QRS complex measures 0.08 seconds, and the PP and RR intervals are regular. How should the nurse correctly interpret this rhythm?

*1.Sinus tachycardia 2.Sinus bradycardia 3.Sinus dysrhythmia 4.Normal sinus rhythm Sinus tachycardia has the characteristics of normal sinus rhythm, including a regular PP interval and normal-width PR and QRS intervals; however, the rate is the differentiating factor. In sinus tachycardia, the atrial and ventricular rates are greater than 100 beats/minute.

Nitrofurantoin is prescribed for an adult client to treat acute urinary tract infection (UTI). Based on the normal adult dose, how should the nurse instruct the client to take this medication?

*50 mg every 6 hours 2.150 mg 3 times daily 3.300 mg administered at bedtime 4.1 g distributed evenly throughout the day For treatment of acute UTI, the adult dosage is 50 mg every 6 hours. For prophylaxis of recurrent UTI, low doses are used, such as 50 to 100 mg at bedtime for adults.

The nurse is administering a dose of a prescribed diuretic to an assigned client. The nurse should monitor the client for hypokalemia as a side effect of therapy if the client has been receiving which medication?

*Bumetanide 2.Triamterene 3.Amiloride HCl 4.Spironolactone Bumetanide is a loop diuretic that places the client at risk for hypokalemia. The nurse would monitor this client carefully for signs of hypokalemia, monitor serum potassium levels, and encourage intake of high-potassium foods. The other medications listed are potassium-retaining diuretics.

The nurse monitoring a client receiving peritoneal dialysis notes that the client's outflow is less than the inflow. Which actions should the nurse take? Select all that apply. Check the level of the drainage bag. 2.Reposition the client to his or her side. 3.Contact the health care provider (HCP). 4.Place the client in good body alignment. 5.Check the peritoneal dialysis system for kinks. 6.Increase the flow rate of the peritoneal dialysis solution.

*Check the level of the drainage bag. *2.Reposition the client to his or her side. *4.Place the client in good body alignment. * 5.Check the peritoneal dialysis system for kinks. If outflow drainage is inadequate, the nurse attempts to stimulate outflow by changing the client's position. Turning the client to the side or making sure that the client is in good body alignment may assist with outflow drainage. The drainage bag needs to be lower than the client's abdomen to enhance gravity drainage. The connecting tubing and peritoneal dialysis system are also checked for kinks or twisting and the clamps on the system are checked to ensure that they are open. There is no reason to contact the HCP. Increasing the flow rate should not be done and also is not associated with the amount of outflow solution.

The nurse is preparing to care for a client who will be weaned from a cuffed tracheostomy tube. The nurse is planning to use a tracheostomy plug and plans to insert it into the opening in the outer cannula. Which nursing action is required before plugging the tube?

*Deflate the cuff on the tube. 2.Place the inner cannula into the tube. 3.Ensure that the client is able to speak. 4.Ensure that the client is able to swallow. Plugging a tracheostomy tube is usually done by inserting the tracheostomy plug (decannulation stopper) into the opening of the outer cannula. This closes off the tracheostomy, and airflow and respiration occur normally through the nose and mouth. When plugging a cuffed tracheostomy tube, the cuff must be deflated. If it remains inflated, ventilation cannot occur, and respiratory arrest could result. A tracheostomy plug could not be placed in a tracheostomy if an inner cannula was in place. The ability to swallow or speak is unrelated to weaning and plugging the tube.

The nurse is preparing to perform an admission assessment on a client with a diagnosis of bulimia nervosa. Which assessment findings should the nurse expect to note? Select all that apply.

*Dental decay 2.Moist, oily skin *3.Loss of tooth enamel *4.Electrolyte imbalances 5.Body weight well below ideal range Clients with bulimia nervosa initially may not appear to be physically or emotionally ill. They are often at or slightly below ideal body weight. On further inspection, a client exhibits dental decay and loss of tooth enamel if the client has been inducing vomiting. Electrolyte imbalances are present. Dry, scaly skin (rather than moist, oily skin) is present.

The nurse is caring for a client with a chest tube who accidentally disconnects the tube from the drainage system when trying to get out of bed. The nurse immerses the end of the tube in sterile water. What immediate action should the nurse take?

*Obtain a new drainage system. 2.Ask the client to hold his or her breath. 3.Place the client in a prone position. 4.Place a sterile dressing over the chest tube insertion site. If the drainage system is broken or interrupted or the tube disconnects, the end of the tube should be placed in a bottle of sterile water held below the level of the chest. A new drainage system is then immediately obtained and set up. Placing the client in the prone position and asking the client to hold his or her breath are not helpful. Placing a sterile dressing over the disconnection site will not prevent complications resulting from the tube disconnection. The nurse should also perform an assessment on the client and contact the health care provider.

A client who has been advanced to a solid diet after undergoing a subtotal gastrectomy. What is the appropriate nursing intervention in preventing dumping syndrome?

*Remove fluids from the meal tray. 2.Give the client 2 large meals per day. 3.Ask the client to sit up for 1 hour after eating. 4.Provide concentrated, high-carbohydrate foods. Factors to minimize dumping syndrome after gastric surgery include having the client lie down for at least 30 minutes after eating; giving small, frequent meals; having the client maintain a low Fowler's position while eating, if possible; avoiding liquids with meals; and avoiding high-carbohydrate food sources. Antispasmodic medications also are prescribed as needed to delay gastric emptying.

The prenatal client asks the nurse about substances that can cross the placental barrier and potentially affect the fetus. The nurse most appropriately explains that which substances can cross this barrier? Select all that apply.

*Viruses 2.Bacteria *3.Nutrients *4.Antibodies *5.Medications Large particles such as bacteria cannot pass through the placenta, but viruses, nutrients, medications, antibodies, and recreational drugs can pass through the placenta and potentially affect the fetus. Metabolic waste products of the fetus cross the placental membrane from the fetal blood into the maternal blood. The maternal kidneys then excrete them.

A client has just been given a prescription for diphenoxylate with atropine. The nurse determines that the client understands important information about this medication if the client makes what statement?

1."It's best to take this medication with a laxative." *2."This medication contains a habit-forming ingredient." 3."I might drool frequently from taking this medication." 4."I will probably become irritable from taking this medication." The client should understand that an adverse effect of this medication is that it may be habit forming, so careful adherence to proper dose is important. The medication is an antidiarrheal and therefore should not be taken with a laxative. Side effects of the medication include dry mouth and drowsiness. Drooling and irritability are not associated with the use of this medication.

A client has undergone a 2-hour oral glucose tolerance test (OGTT). Which of the listed glucose levels is compatible with diabetes mellitus at the conclusion of the test?

1.80 mg/dL (4.57 mmol/L) 2.110 mg/dL (6.0 mmol/L) 3.130 mg/dL (7.42 mmol/L) *4.160 mg/dL (9.14 mmol/L) The normal reference values for OGTTs are lower than 140 mg/dL (8 mmol/L) at 120 minutes; lower than 200 mg/dL (11.4 mmol/L) at 30, 60, and 90 minutes; and lower than 115 mg/dL (6.57 mmol/L) in the fasting state. A glucose level of 160 mg/dL (9.14 mmol/L) is higher than the normal reference range, so therefore is the correct answer.

The nurse is caring for a chemotherapy client with a low platelet aggregation level. Which likely caused this decreased platelet production?

1.Anemia 2.Thrombocytopenia *3.Bone marrow suppression 4.Low hemoglobin and hematocrit (H&H) counts Suppression of bone marrow function is a result of many chemotherapy medications leading to inhibition of platelet production. Because of bone marrow suppression, chemotherapy clients are at risk of bruising and bleeding, and these risks are increased by medications that inhibit platelet function, such as most conventional nonsteroidal antiinflammatory drugs (NSAIDs). Aspirin is especially dangerous because it causes irreversible inhibition of platelet aggregation. The other options are incorrect.

The nurse is preparing to provide care for a client who will need an ear irrigation to remove impacted cerumen. Which interventions should the nurse take when performing the irrigation? Select all that apply.

1.Apply some force when instilling the irrigation solution. *2.Position the client with the affected side down after the irrigation. *3.Warm the irrigating solution to a temperature that is close to body temperature. *4.Position the client to turn the head so that the ear to be irrigated is facing upward. *5.Direct a slow, steady stream of irrigation solution toward the upper wall of the ear canal. During the irrigation, the client is positioned so that the ear to be irrigated is facing downward because this allows gravity to assist in the removal of the earwax and solution. Delivery of irrigation solutions at temperatures that are not close to body temperature can cause discomfort for the client and may result in tissue injury, nausea, and vertigo. A slow, steady stream of solution should be directed toward the upper wall of the ear canal, not toward the tympanic membrane. After the irrigation, the client should lie on the affected side for a period of time that is necessary to allow the irrigating solution to finish draining (usually 10 to 15 minutes). Too much force could cause the tympanic membrane to rupture.

A client comes to the emergency department after an assault and is extremely agitated, trembling, and hyperventilating. What is the priority nursing action for this client?

1.Begin to teach relaxation techniques. 2.Encourage the client to discuss the assault. *3.Remain with the client until the anxiety decreases. 4.Place the client in a quiet room alone to decrease stimulation. This client is in a severe state of anxiety. When a client is in a severe or panic state of anxiety, it is crucial for the nurse to remain with the client. The client in a severe state of anxiety would be unable to learn relaxation techniques. Discussing the assault at this point would increase the client's level of anxiety further. Placing the client in a quiet room alone may also increase the anxiety level.

A 6-year-old child with diabetes mellitus and the child's mother come to the health care clinic for a routine examination. The nurse evaluates the data collected during this visit to determine if the child has been euglycemic since the last visit. Which information is the most significant indicator of euglycemia?

1.Daily glucose monitor log 2.Dietary history for the previous week *3.Glycosylated hemoglobin (hemoglobin A1c) 4.Fasting blood glucose performed on the day of the clinic visit The glycosylated hemoglobin assay measures the glucose molecules that attach to the hemoglobin A molecules and remain there for the life of the red blood cell, approximately 120 days. This is not reversible and cannot be altered by human intervention. Daily glucose logs are useful if they are kept regularly and accurately. However, they reflect only the blood glucose at the time the test was done. A fasting blood glucose test performed on the day of the clinic visit is time limited in its scope, as is the dietary history.

A client arrives at the emergency department with a foreign body in the left ear and tells the nurse that an insect flew into the ear. Which intervention should the nurse implement initially?

1.Irrigation of the ear *2.Instillation of mineral oil 3.Instillation of antibiotic eardrops 4.Instillation of corticosteroid ointment Insects are killed before removal unless they can be coaxed out by a flashlight or by a humming noise. Mineral oil or diluted alcohol may be instilled into the ear to suffocate the insect, which is then removed by using ear forceps. When the foreign object is vegetable matter, irrigation is not used because such material may expand with hydration, thereby worsening the impaction. Antibiotic eye drops and corticosteroid ointment are not initial nursing actions.

The nurse is preparing a plan of care for a client with diabetes mellitus who has hyperglycemia. The nurse places priority on which client problem?

1.Lack of knowledge *2.Inadequate fluid volume 3.Compromised family coping 4.Inadequate consumption of nutrients Rationale: An increased blood glucose level will cause the kidneys to excrete the glucose in the urine. This glucose is accompanied by fluids and electrolytes, causing an osmotic diuresis leading to dehydration. This fluid loss must be replaced when it becomes severe. Options 1, 3, and 4 are not related specifically to the information in the question.

The community health nurse is working with disaster relief after a tornado. The nurse assists in finding safe housing for survivors, providing support to families, organizing counseling, and securing physical care when needed. Which level of prevention does the nurse exercise?

1.Primary level of prevention 2.Secondary level of prevention *3.Tertiary level of prevention 4.Quaternary level of prevention Tertiary prevention involves reduction of the amount and degree of disability, injury, and damage after a crisis. Primary prevention means keeping the crisis from occurring, and secondary prevention focuses on reducing the intensity and duration of a crisis. There is no known quaternary prevention level.

The client complains of pain as the nurse is inflating the balloon during insertion of a Foley catheter. The nurse should take which immediate action?

1.Withdraw the catheter slightly and reinflate the balloon. 2.Remove the catheter, and reinsert a new one that is 1 size smaller. 3.Finish inflating the balloon; the discomfort is normal and temporary. *4.Aspirate the fluid, advance the catheter farther, and reinflate the balloon. If the balloon is malpositioned in the urethra, balloon inflation could cause trauma and pain. If this occurs, the fluid should be aspirated and the catheter inserted a little farther to move the balloon past the neck of the urethra into the bladder. The catheter should not be withdrawn slightly because this will worsen the problem. There is no need to remove the catheter and reinsert a smaller one. The balloon should not continue to be inflated because the pain is not normal and will not go away.

The nurse is preparing to assist in administering neonatal resuscitation with a ventilation bag and mask because the newborn is apneic, gasping, and has a heart rate below 100 beats/min. The nurse should perform how many ventilations per minute at which pressure?

20 to 40 breaths/min, 15 to 20 cm H2O pressure 2.20 to 40 breaths/min, 30 to 40 cm H2O pressure *3.40 to 60 breaths/min, 15 to 20 cm H2O pressure 4.40 to 60 breaths/min, 30 to 40 cm H2O pressure If the newborn is apneic or has gasping respirations after stimulation or if the heart rate is below 100 beats/min, positive pressure ventilation by bag and mask can be given. The anesthesia bag used for neonatal resuscitation should have a pressure gauge. Ventilations should be given at a rate of 40 to 60 breaths/min at pressures of 15 to 20 cm H2O.

A health care provider prescribes 100 mL of normal saline to infuse over 1 hour. The drop factor is 15 drops (gtt)/mL. The nurse prepares to set the flow rate at how many drops per minute? Fill in the blank.

25gtt/min 100mL x 15 gtt/mL / 60 min

A client has just had surgery to deliver a nonviable fetus resulting from abruptio placentae. As a result of the abruptio placentae, the client develops disseminated intravascular coagulation (DIC) and is told about the complication. The client begins to cry and screams, "God, just let me die now!" Which client problem should be the priority for the client at this time Lack of power about the situation 2.Grieving because of the loss of the baby 3.Lack of knowledge regarding what occurred 4.Concern about the loss of the baby and personal health

4.Concern about the loss of the baby and personal health The client expresses that there is no way out of the situation except for death; therefore, the client exhibits concern about the loss of the baby and personal health. The data given do not support lack of power. Grieving is a possible client problem at a later time; however, at this time the concern over the loss should take priority. Lack of knowledge is a possible problem later, but not enough data support it at this point, and it is not the priority.

Which is the priority nursing action for the client with an ectopic pregnancy? 1.Assessing urine for proteinuria 2.Checking the electrolyte values 3.Monitoring for signs of infection 4.Monitoring the pulse and blood pressure

4.Monitoring the pulse and blood pressure Rationale: Nursing care for a client with a possible ectopic pregnancy is focused on preventing or identifying hypovolemic shock and controlling pain. An elevated pulse rate and a drop in blood pressure are indicators of shock. Proteinuria may be associated with preeclampsia, and an elevation in temperature is an indicator of infection. Electrolyte values are unrelated to ectopic pregnancy.

A client with atrial fibrillation who is receiving maintenance therapy of warfarin sodium has a prothrombin time (PT) of 35 seconds and an international normalized ratio (INR) of 3.5. On the basis of these laboratory values, the nurse anticipates which prescription?

Adding a dose of heparin sodium * 2.Holding the next dose of warfarin 3.Increasing the next dose of warfarin 4.Administering the next dose of warfarin The normal PT is 11 to 12.5 seconds (conventional therapy and SI units). The normal INR is 2 to 3 for standard warfarin therapy, which is used for the treatment of atrial fibrillation, and 3 to 4.5 for high-dose warfarin therapy, which is used for clients with mechanical heart valves. A therapeutic PT level is 1.5 to 2 times higher than the normal level. Because the values of 35 seconds and 3.5 are high, the nurse should anticipate that the client would not receive further doses at this time. Therefore, the prescriptions noted in the remaining options are incorrect.

The nurse in the pediatric unit is preparing for the admission of a child with a dislocated hip. The child will be placed in Buck's extension traction preoperatively for short-term immobilization. The nurse prepares to place the child in which type of traction setup? Click on the image to indicate your answer.

Buck's extension traction is a type of skin traction in which the legs are in an extended position. It is used primarily for short-term immobilization, such as in preoperative management of a child with a dislocated hip. A 90- to 90-degree femoral traction (option 2) is used for femur fractures. In this type of traction, the lower leg is put in a boot cast or supported in a sling, and a skeletal Steinmann pin or Kirschner wire is placed in the distal fragment of the fracture. Russell's traction (option 3) is used for fractures of the femur or for hip and knee contractures. It uses skin traction on the lower leg with a padded sling under the knee. Balanced suspension (option 4) may be used with or without skin or skeletal traction. It is used for femur, hip, or tibial fractures. The balanced suspension suspends the leg in a desired flexed position to relax the hip and hamstring muscles and does not exert any traction directly on a body part. In balanced suspension, a Thomas splint extends from the groin to midair above the foot, and a Pearson attachment supports the lower leg.

The nurse assigned to the pediatric unit finds an infant unresponsive and without respirations or a pulse. What is the nurse's next action after calling for help?

Check for carotid pulse. 2. Call anesthesia for intubation. 3. Begin rescue breathing with head tilt-chin lift. *4. Perform compressions at 100 to 120 times per minute. After pressing the emergency response button in the room, the nurse should begin cardiopulmonary resuscitation (CPR) on the infant, starting with chest compressions. The rate of chest compressions is 100 to 120 times per minute. The brachial pulse is assessed on infants; the carotid pulse is difficult to palpate due to their short, thick necks. When a cardiopulmonary arrest alert is called, an experienced staff member with intubation skills is usually included on the response team. Compressions are started before rescue breathing.

The nurse is performing an admission assessment on a newborn infant with the diagnosis of subdural hematoma after a difficult vaginal delivery. Which assessment technique assists to support the newborn's diagnosis?

Monitoring the urine for blood 2.Monitoring the urinary output pattern 3.Testing for contractures of the extremities *4.Stimulating for reflex responses in the extremities A subdural hematoma can cause pressure on a specific area of the cerebral tissue. If the infant is actively bleeding, such pressure can cause changes in the stimuli responses in the extremities on the opposite side of the body. Monitoring for hematuria and urinary elimination patterns are incorrect. Blood in the urine would indicate abdominal trauma and would not be a result of the subdural hematoma. An infant after delivery normally would be incontinent of urine. Contractures would not occur this soon after delivery.

The nurse prepares to take the blood pressure of a school-age child. To obtain an accurate measurement, how should the nurse position the blood pressure cuff?

One half of the distance between the antecubital fossa and the shoulder 2.One third of the distance between the antecubital fossa and the shoulder *3.Two thirds of the distance between the antecubital fossa and the shoulder 4.One quarter of the distance between the antecubital fossa and the shoulder The size of the blood pressure cuff is important. Cuffs that are too small will cause falsely elevated values, and those that are too large will cause inaccurate low values. The cuff should be positioned to cover two thirds of the distance between the antecubital fossa and the shoulder. It is also important for the nurse to remember that placing the stethoscope too firmly on the antecubital fossa causes error in ausculation and that sounds are difficult to hear in children because of low frequency and amplitude. Therefore, a pediatric stethoscope bell is often helpful.

The nurse has completed care for a client whose tracheostomy tube has a nondisposable inner cannula. Which action should the nurse perform prior to reinserting the inner cannula?

Suction the client's airway. 2.Wipe the inner cannula off with a clean washcloth. 3.Dry the inner cannula thoroughly with sterile gauze. *4.Allow the inner cannula to dry after washing it with sterile water. After washing and rinsing the inner cannula with sterile water (per agency policy), the nurse taps it against a sterile surface to remove excess liquid and allows it to dry. The nurse then inserts the cannula into the tracheostomy tube and turns it clockwise to lock it in place. The nurse would not suction a client without an inner cannula in place. This is a sterile procedure and therefore it is inaccurate to use a clean washcloth. Gauze is not used to dry the cannula because gauze particles can remain on the cannula.

The nurse is developing a plan of care for a preoperative client who has a latex allergy. Which intervention should be included in the plan? 1.Avoid using medications from glass ampules. 2.Use medications that are from ampules with rubber stoppers. 3.Avoid using intravenous tubing that is made of polyvinyl chloride. 4.Apply a cloth barrier to the client's arm under a blood pressure cuff when taking the blood pressure.

apply a cloth barrier If a client has a latex allergy, a cloth barrier should be applied to his or her arm under a blood pressure cuff to prevent skin contact with the cuff. Medications from glass ampules are safe to use, and medications from ampules with rubber stoppers are unsafe to use. Latex-safe intravenous tubing made of polyvinyl chloride should be used for a client with a latex allergy. Additionally, agency procedures should be followed for a client with a latex allergy; usually, a latex allergy cart containing latex-free supplies is kept in the client's room.

The nurse provides information to a client scheduled for a dual x-ray absorptiometry (DEXA) test. Which information should the nurse provide to the client? Select all that apply. 1.It is a painless test. 2.It emits slightly more radiation than a chest x-ray does. 3.Upper body clothing will need to be removed for testing. 4.Increased fluid intake is necessary following the procedure. 5.Metallic objects such as jewelry or belt buckles may interfere with the test and need to be removed.

painless test take off metallic objects The most commonly used screening and diagnostic tool for measuring bone mineral density is the dual x-ray absorptiometry (DEXA) test. It is a painless test that emits less radiation than a chest x-ray. A height is taken before the start of the test. The client stays dressed but is asked to remove any metallic objects such as belt buckles, coins, keys, or jewelry because they may interfere with testing. No special follow-up care for the test is necessary.