PTB 76-90

There are new orders for the client's intravenous solution: "Decrease IV rate to 50 mL/hr and discontinue when infusion is complete." There is 250 mL remaining in the current 500 mL bag. The time is 10:30 am (1030 in military time). At what time will the infusion be complete? State the answer in military time.

1530 Solving with ratio proportion: 50 mL/1 hr = 250 mL/x hr x= 5 hr and 1030 + 5 = 1530. Or solving with logic: 250 mL remain/50 mL = 5 hours left 1030 (10:30 am) + 5 more hours = 1530 (using the 24-hour clock, or 3:30 pm)

An 18 month-old weighing 22 pounds is admitted to the pediatric unit with a diagnosis of dehydration. A replacement bolus of normal saline at 20 mL/kg is ordered to be administered intravenously over 40 minutes. In mL/hour, what will be the setting for the IV delivery system? mL/hr.

300 Using ratio proportion: First, convert 22 pounds to kilograms (22/2.2) = 10 kg 20 mL/kg = 20 x 10 kg = 200 mL 200 mL/40 minutes = x mL/60 minutes (in an hour) 200 x 60 = 12000/40 = 300 mL/hr Using dimensional analysis: 20 mL/kg x 1 kg/2.2 lb x 22 lb x 60 min/hr x 1/40 min = 300 mL/hr

There is an order for a continuous lidocaine infusion at a rate of 4 mg/minute to treat PVCs. The IV solution contains 2 grams of lidocaine in 500 mL of D5W. The infusion pump delivers 60 microdrops/mL. What rate in microdrops/minute would deliver 4 mg of lidocaine/minute? Report the response using a whole number. microdrops/minute.

60 Remember in dimensional analysis, you always want to start your equation with what's called for in the solution. In this case, you want to know microdrops/minute. microdrops/minute = 4 mg/min X 1 g/1000 mg X 500 mL/2 g X 60 microdrops/mL = 4 X 500 X 60/1000 X 2 = 120000/2000 = 60 microdrops/mL

A nurse is assessing several clients in a long-term health care facility. Which client is at highest risk for developing a pressure ulcer? An 80 year-old ambulatory client with a history of diabetes mellitus An obese client who uses a wheelchair An incontinent client who has had three diarrhea stools in the past hour A 79 year-old malnourished client on bed rest

A 79 year-old malnourished client on bed rest Weighing significantly less than ideal body weight increases the number and surface area of bony prominences, which are susceptible to pressure ulcers. In addition, malnutrition is a major risk factor for pressure ulcers, from poor hydration and inadequate protein intake. Note that this is a priority question so that all of the clients are at risk for pressure ulcers. However, the question asks for the client with the highest risk.

A home health nurse is caring for a client with a pressure sore, which is two inches in diameter, red with serous drainage and loss of subcutaneous tissue. What is the appropriate dressing for this wound? A wet to dry with hydrogen peroxide A moist saline dressing A wet dressing with debridement granules A transparent film dressing

A moist saline dressing' This wound is at a stage III pressure ulcer. The wound is red (granulation tissue) and does not require debridement. The wound must be protected to have granulation tissue proliferate. A moist dressing allows epithelial tissues to migrate more rapidly.

The client has just had an enteral feeding tube inserted. What would be the most accurate method to verify initial placement of the feeding tube? Abdominal x-ray Auscultation with air insertion Aspiration for gastric contents Flushing tube with saline

Abdominal x-ray

A woman diagnosed with bipolar disorder is to take lithium (Eskalith, Lithobid) as part of her treatment. What should the nurse discuss with the client as part of the teaching plan? Risk of concomitant use of oral contraceptives Weight reduction Alcohol abstinence Smoking cessation

Alcohol abstinence Alcohol potentiates the effects of lithium, resulting in central nervous system depression and impairment of judgment, thinking and psychomotor skills. The client should be cautioned to avoid drinking alcoholic beverages.

A 12 year-old pediatric cancer client is distraught about the alopecia that occurred after the last chemotherapy treatment. Which nursing interventions are appropriate for this side effect of chemotherapy? (Select all that apply.) Administer prescribed antiemetic medication before nausea is too severe Allow the child to choose a cap, scarf, wig or other head cover to use Encourage visits from friends before discharge from the hospital Practice and teach thorough hand washing

Allow the child to choose a cap, scarf, wig or other head cover to use This is a part of the correct response Encourage visits from friends before discharge from the hospital This is a part of the correct response Alopecia is the loss of hair, which is a frequent side effect of certain types of chemotherapy. Although it is not life-threatening, the body image change is difficult for many individuals, particularly children and adolescents. Encouraging visits from friends before discharge helps the young client and friends adjust. Wearing preferred forms of head cover-ups increases comfort and decreases embarrassment. The other options are proper interventions for chemotherapy, but do not help the client with hair loss.

A nurse is to administer meperidine (Demerol) 100 mg, atropine sulfate 0.4 mg, and promethazine (Phenergan) 50 mg IM to a preoperative client. Which action should the nurse take first? Instruct the client to remain in the bed Place the call bell within the client's reach Raise the side rails on the bed Assist the client to the bathroom

Assist the client to the bathroom Meperidine is a narcotic analgesic and promethazine is an antihistamine; together they can potentiate CNS effects such as drowsiness, dizziness, lightheadedness and confusion. Although all of the options involve client safety, the first thing to do is to assist the client to the bathroom to void. After administering the preoperative medications, the nurse will instruct the client to remain in bed, place the call light in the client's hand and raise the side rails.

A nurse is teaching parents of an infant about the introduction of solid food to their baby. What is the first food that the nurse should teach the parents to add? Fruit Vegetables Meats Cereal

Cereal Cereal is usually introduced first because it is well-tolerated, easy to digest and fortified with iron. Then the meats or vegetables are introduced. The fruit is sweeter and often is recommended to be introduced last because of this; infants often like fruit the best.

After surgery, a client with a nasogastric tube reports feeling nauseous. What action should the nurse take? Put the head of the bed in a higher position Check the patency of the nasogastric tube Call the health care provider to troubleshoot the problem Administer an antiemetic that is ordered PRN

Check the patency of the nasogastric tube An initial indication that the nasogastric tube is obstructed is a client's report of nausea. Nasogastric tubes may become obstructed by being kinked or with mucus or sediment.

A nurse is caring for a client with left ventricular heart failure with an ejection fraction (EF) of 40%. Which assessment finding is an early indication of inadequate tissue perfusion? Use of accessory muscles Crackles in the lungs Confusion and restlessness Distended jugular veins

Confusion and restlessness Neurological changes, including impaired mental status, are early signs of inadequate tissue perfusion and decreased oxygenation of the brain tissues. Other signs of low EF are shortness of breath, dependent edema, and arrhythmias. The low EF indicates that this client has severe damage to the left ventricle (normal EF is about 55-70%).

A nurse is caring for a client who is receiving procainamide intravenously. It is important for the nurse to monitor which of these parameters? Serum potassium levels Continuous ECG readings Neurological signs Hourly urinary output

Continuous ECG readings Procainamide is used to suppress cardiac arrhythmias. When administered intravenously, it must be accompanied by continuous cardiac monitoring.

A nurse is caring for a client who has developed cardiac tamponade. Which finding would the nurse anticipate? Widening pulse pressure Bradycardia Distended neck veins Pleural friction rub

Distended neck veins In cardiac tamponade, intrapericardial pressures prevent adequate filling of the heart from the vena cava, and reduce cardiac output. As a result, venous pressures rise and the neck veins become distended.

A 16 month-old child has just been admitted to the hospital. As the nurse assigned to this child enters the hospital room for the first time, the toddler runs to the mother, clings to her and begins to cry. What should be an initial action by the nurse? Discuss the appropriate use of "time-out" Explain that the child needs extra attention Explain that this behavior is expected Arrange to change client care assignments

Explain that this behavior is expected During normal development, fear of strangers becomes prominent and begins around age 6 to 8 months-old. Such behaviors include clinging to parent, crying and turning away from the stranger. These fears and behaviors extend into the toddler period. In the toddler period, separation anxiety is at its peak. As the child ages the behavior has a tendency to wane.

A nurse manager considers changing staff assignments from 8-hour shifts to 12-hour shifts. A staff-selected planning committee has approved the change, yet the staff are not receptive to the plan. The nurse manager should first take what action? Support the planning committee and post the new schedule Explore how the planning committee evaluated barriers to the plan Design a different approach to deliver care with fewer staff Retain the previous staffing pattern for another six months

Explore how the planning committee evaluated barriers to the plan A manager is ultimately responsible for delivery of care and yet has given a committee chosen by staff the right to approve or disapprove the change. Planned change involves exploring barriers and restraining forces before implementing change. To smooth acceptance of the change, restraining factors need to be evaluated. The manager wants to build the staff's skills at implementing change. Helping the committee evaluate its decision making is a useful step before rejecting or implementing the change. When possible, all affected by the change should be involved in the planning. The question is whether staff input has been thoroughly taken into consideration. This also illustrates the application of the nursing process to nonclient-care issues with assessment of the situation being the first step.

The nurse auscultates bibasilar inspiratory crackles in a newly admitted 68 year-old client with systolic heart failure and an ejection fraction of 30%. Which other finding is most common with this diagnosis? Nail clubbing Fatigue Chest pain Peripheral edema

Fatigue Systolic heart failure is the result of a pumping problem, which is why the ejection fraction is reduced (normal is 60%). Heart failure can be caused by a heart attack, but chest pain is not normally a finding in heart failure. Nail clubbing is usually associated with disorders of the lungs. Exertional dyspnea and fatigue are common in clients with left-sided (systolic) heart failure due to fluid backing up into the lungs and pulmonary congestion. Peripheral edema is more commonly seen with right-sided (diastolic) heart failure.

Upon completion of the admission documents, the nurse identifies that an elderly client does not have an advance directive. What action should the nurse take? Assume that the client wishes full resuscitation efforts Refer this issue to the nurse manager and the risk manager Document this information on the chart Give the client written information about advance directives

Give the client written information about advance directives For each admission, nurses should request a copy of a client's current advance directive. If there is none, the nurse must provide written information about what an advance directive implies. It is then the client's choice to sign the forms. Note that a standard is for non-direct care providers to witness these forms; a social worker or other health care professional would need to witness a client's signature.

A health care provider has written, "Morphine sulfate 2 mg IV every three to four hours as needed for pain" on the chart of a child weighing 22 pounds (10 kg). What should be the nurse's action? Hold the medication and contact the health care provider Check with the pharmacist Administer the prescribed dose as ordered Give the dose every six to eight hours

Hold the medication and contact the health care provider The usual pediatric dose of morphine is 0.1 mg/kg every three to four hours. At 10 kg, this child typically should receive 1 mg every three to four hours.

A nurse is caring for a client on mechanical ventilation. When performing endotracheal suctioning, the nurse will avoid hypoxia by which action? Hyperoxygenation with 100% O2 for one to two minutes before and after each suction pass Complete a suction pass in 30 seconds with a pressure of 150 mm Hg Minimize a suction pass to 60 seconds while slowly rotating the lubricated catheter Insertion of a fenestrated catheter with a whistle tip without suction

Hyperoxygenation with 100% O2 for one to two minutes before and after each suction pass The nurse would administer supplemental 100% oxygen through the mechanical ventilator or using a manual resuscitation bag for one to two minutes before, after and between suctioning passes to prevent hypoxemia.

The nurse is assessing a 1 month-old infant. Which finding should the nurse report immediately? Increased heart rate with crying Abdominal respirations Irregular breathing rate Inspiratory grunt

Inspiratory grunt Inspiratory grunt is an abnormal finding and indicates respiratory distress in infants. Other signs of respiratory distress in this age group are nasal flaring, often the initial finding, as well as sternal and intracostal retractions. Abdominal breathing is a normal expected breathing process for infants. The other findings are also normal in infants.

A nurse is teaching a newly diagnosed client with asthma how to use a peak flow meter. The nurse should explain that it is to be used to achieve which outcome? Determine the client's oxygen saturation Provide metered doses for inhaled bronchodilator Monitor atmosphere for presence of allergens Measure forced expiratory volumes

Measure forced expiratory volumes The peak flow meter is used to measure peak expiratory flow volumes. It provides useful information about the presence and/or severity of airway obstruction. If the result falls in the green, the client is good without any problems. If it falls into the yellow or red category, immediate action is required. The specific action should be determined with the health care provider ahead of time before this happens. Often the clients are advised to use a bronchodilator inhaler and then recheck for improvement. When teaching the colors for the peak flow meters, nurses often associated the colors and actions with those of a traffic light. Green = go; yellow = proceed with caution; and red = stop and get help.

A 10-month old infant is admitted with a diagnosis of bacterial meningitis. Several hours after admission, during a planning conference, which of the actions suggested to the registered nurse (RN) by the practical nurse (PN) would be appropriate to add to the plan of care? Provide an over-the-crib protective top Measure head circumference Provide passive range of motion Initiate droplet precautions

Measure head circumference In meningitis, assessment of neurological signs should be done frequently. Head circumference is measured because subdural effusions and obstructive hydrocephalus can develop as a complication of meningitis. The client would have already been placed on droplet precautions and had a crib top applied to the bed when he was admitted to the unit.

A 1 year-old child is receiving temporary total parental nutrition (TPN) through a central venous line. This is the first day of TPN therapy. Although all of the following nursing actions must be included in the plan of care of this child, which one would be a priority at this time? Maintain central line catheter integrity Check results of liver enzyme tests Use aseptic technique during dressing changes Monitor serum glucose levels

Monitor serum glucose levels Hyperglycemia may occur during the first day or two as the child adapts to the high-glucose load of the TPN solution. Thus, a priority nursing responsibility is blood glucose testing.

A nurse is educating parents on accidental poisoning in children. Which type of accidental poisoning is expected to occur in children under age six? Inhalation Eye splashes Oral ingestion Topical contact

Oral ingestion The greatest risk for young children is from oral ingestion. While children under age six may come in contact with other poisons or inhale toxic fumes, these are not as common.

The nurse is planning care for a 12 year-old child diagnosed with sickle cell disease who is in a vaso-occlusive crisis of the elbow. Which intervention should be included in the plan of care? Fluid restriction Passive range of motion exercise Pain management Cold compresses to elbow

Pain management Management of a sickle cell crisis is directed towards supportive and symptomatic treatment. The priority of care is pain relief. In a 12 year-old child, patient-controlled analgesia promotes maximum comfort. Fluid are usually increased and range of motion exercises are avoided in the acute phase of the crisis. Cold is avoided because it constricts the vessels and may result in increased pain.

A nurse is caring for a client who requires a mechanical ventilator for breathing. The high-pressure alarm goes off on the ventilator. What is an appropriate action for the nurse to take? Disconnect the client from the ventilator and use a manual resuscitation bag Perform a quick assessment of the client's overall condition along with respiratory effort Call the respiratory therapist for help to troubleshoot the alarm Press the alarm re-set button on the ventilator and observe the client

Perform a quick assessment of the client's overall condition along with respiratory effort A number of situations can cause the high-pressure alarm to sound. It can be as simple as the client coughing. A quick assessment of the client will alert the nurse to whether it is a more serious or complex situation that might then require using a manual resuscitation bag and calling the respiratory therapist.

A nurse is caring for a client with a distal tibia fracture. The client has had a closed reduction and application of a toe to groin plaster cast. Thirty-six hours after surgery, the client suddenly becomes confused, short of breath and spikes a temperature of 103 F (39.4 C). What is the initial assessment the nurse should perform? Pulse oximetry Blood pressures lying and dangling Orientation to time, place and person The distal circulation to casted extremity

Pulse oximetry Sudden restlessness, confusion, irritability and disorientation are often the first signs of fat embolism syndrome followed by a very high temperature. Fat embolism more often occurs after the initial 24 hours of a fractured lower extremity. The nurse needs to confirm hypoxia first. Then the other actions would be performed.

A nurse asks a client with a history of alcoholism about recent drinking behavior. The client states, "I didn't hurt anyone. I just like to have a good time, and drinking helps me to relax." The client is using which defense mechanism? Intellectualization Projection Rationalization Denial

Rationalization Rationalization is justifying illogical or unreasonable ideas, actions or feelings by the development of acceptable explanations for unacceptable actions. Both the teller and the listener find the rationalizations more satisfactory than the reality. Intellectualization is the use of reasoning in response to confrontation with unconscious conflicts and accompanying stressful emotions. Projection is the assignment of one's own feelings or thoughts to others.

The nurse has an order to insert a Foley catheter for a male client. What is the best reason for lubricating the tip of the catheter prior to insertion? Minimize risk for infection Diminish the leakage of urine around the catheter Reduce the friction within the urethra Prevent bladder distention

Reduce the friction within the urethra Due to the somewhat long length of the male urethra, lubrication reduces potential discomfort and localized tissue irritation as the catheter is passed.

A nurse is assessing a client two hours postoperatively after a femoral popliteal bypass to find that the upper leg dressing has become saturated with fresh blood. What should be the nurse's appropriate action? Apply pressure at the site of the bleeding Wrap the entire leg with elastic bandages Remove the old dressings with dressing reapplication Reinforce the saturated dressing with a pressure dressing

Reinforce the saturated dressing with a pressure dressing The fresh blood indicates active bleeding that need direct pressure with a pressure dressing. Because this type of surgery has long incisions the "site of the bleeding" may not be where the active bleeding is. Thus, this action is the best option of those given. The health care provider should be contacted next as the client undergoes continuous assessment for heart rate, blood pressure and respirations.

The RN is responsible for a client in isolation. Which task can be delegated to a practical nurse (PN)? Observation of the client's total environment for risks of harm Assessment of the client's attitude about infection control Reinforcement of isolation precautions with visitors Evaluation of staff compliance with infection control measures

Reinforcement of isolation precautions with visitors PNs and UAPs can reinforce information that was originally given by the RN. The other options are responsibilites of the RN and cannot be delegated.

A nurse is caring for a 7 year-old child who is being discharged following a tonsillectomy. Which instruction is appropriate for the nurse to include during discharge teaching with the parents? Report a persistent cough to the health care provider within 24 hours The child may gargle with saline as necessary for discomfort Administer chewable aspirin for pain around the clock every six hours The child can return to school after being home for four days

Report a persistent cough to the health care provider within 24 hours Persistent coughing should be reported to the health care provider as this may indicate bleeding by a trickling of blood into the back of the throat. The other items are incorrect information especially the aspirin, which is not to be given to children. The saline may irritate the wound where the tonsils were removed.

The nurse observes a coworker removing a narcotic from the electronic medication dispensing machine and self-medicating. Which action is required for the nurse who observes this behavior? Schedule an intervention to confront the coworker Encourage the coworker to talk to someone about getting help Ask other staff members if they have observed the coworker diverting drugs Report the coworker to the nursing supervisor

Report the coworker to the nursing supervisor Nurses who divert drugs pose a threat to client safety and are a legal liability for the facility, which is why the behavior must first be reported to the unit manage or other nursing supervisor. The nurse practice act in some states also mandate reporting unsafe nursing practice to the board of nursing. Drug diversion is often a symptom of substance use disorder but the coworker may not necessarily be an addict. An intervention may be scheduled after specific examples of destructive behaviors are collected (from other staff and medication audits) and the coworker is confronted with the evidence.

The client is admitted with the diagnosis of chronic obstructive pulmonary disease (COPD). Which findings would require the nurse's immediate attention? Low-grade fever and cough Restlessness and confusion Nausea and vomiting Frequent productive cough with brownish sputum

Restlessness and confusion Hypoxia and respiratory failure in COPD may be signaled by excessive somnolence, restless, aggressiveness, confusion, central cyanosis and shortness of breath. When these findings occur, the oxygen saturation and arterial blood gases (ABGs) should be assessed and oxygen should be rapidly titrated upward to correct the hypoxia. Signs of respiratory distress or failure may necessitate the use of ventilatory assistance BIPAP or emergent intubation and mechanical ventilation. Cough, discolored sputum, and fever may indicate a respiratory infection such as pneumonia, but this is a less urgent situation.

The nurse works in an inpatient psychiatric setting. What would be the best reason why the nurse should limit touch to a handshake with a client? Touching a client can set off a violent episode Shaking hands allows the use of touch in a professional manner Refusing to touch a client indicates a lack of concern Clients may misconstrue touch as an invitation to more intimate behavior

Shaking hands allows the use of touch in a professional manner The therapeutic use of touch is a basic part of the nurse-client relationship. However, in a psychiatric setting, the extent of physical contact should be limited to handshakes. Some facilities may even have a no-touch policy, especially when working with clients who have a history of sexual trauma. Even reassuring touching can be misinterpreted by the client

A nurse states, "I dislike caring for African-American clients because they are all so hostile." The nurse's statement is an example of which concept? Prejudice Discrimination Stereotyping Racism

Stereotyping Stereotyping refers to defining people and institutions, mentally or by attitudes, with narrow, fixed traits, rigid patterns, or with inflexible "boxlike" profile characteristics. Stereotyping is one of the common concerns of nurses when they begin to study different cultures and learn about transcultural nursing. Prejudice refers to preconceived ideas, beliefs, or opinions about an individual, group, or culture that limit a full and accurate understanding of the individual, culture, gender, race, event or situation. Discrimination is the unfair treatment of a person or group on the basis of prejudice. Racism is the belief that race is the primary determinant of human traits and capacities and that racial difference produces an inherent superiority of a particular race.

The nurse notes cloudy drainage two days post-insertion of an abdominal catheter for peritoneal dialysis. What other data does the nurse need to collect before reporting this finding to the provider? Temperature Bowel sounds Urine output Breath sounds

Temperature Cloudy drainage may indicate a peritoneal infection, so it is essential to evaluate the client's temperature before notifying the health care provider. In a client on dialysis for renal failure little to no urine output would be an expected finding.

The client is diagnosed with infective endocarditis and is receiving antibiotic therapy. Which finding suggests that the antibiotic therapy has not been effective and must be reported to the health care provider immediately? Temperature of 103 F (39.5 C) Nausea with vomiting Muscle tenderness Diffuse macular rash

Temperature of 103 F (39.5 C) Persistent, prolonged fever over 72 hours after the initiation of antibiotic therapy may be an indication that the antibiotics are not effective and may need to be changed to a different medication.

A nursing student asks the nurse manager to explain the forces that drive health care reform. The appropriate response by the nurse manager should include which approach? A steep rise in provider fees and in insurance premiums High costs of diagnostic and end-of-life treatment procedures Increased numbers of older adults and of the chronically ill of all ages The escalation of fees with a decreased reimbursement percentage

The escalation of fees with a decreased reimbursement percentage The percentage of the gross national product representing health care costs rose dramatically with reimbursement based on fee-for-service. Reimbursement for Medicare and Medicaid recipients based on fee-for-service also escalates health care costs.

A nurse is attending a workshop about caring for persons infected with hepatitis. Which characteristic is most appropriate when defining the incidence rate of hepatitis B? The number of persons in a population who develop hepatitis B during a specific period of time The percentage of deaths resulting from hepatitis B during a specific time The total number of persons in a population who have hepatitis B at a particular time The occurrence of hepatitis B in the population at a particular time

The number of persons in a population who develop hepatitis B during a specific period of time This is the correct definition of incidence of a disease.

The nurse manager identifies that time spent charting is excessive. The nurse manager states that "staff will form a task force to investigate and develop potential solutions to the problem and then report on this at the next staff meeting." What is the nurse manager's leadership style? Affiliative Transformational Autocratic Dynamic

Transformational A transformational style of management involves staff members in the decision-making processes. Staff members review current policies and provide feedback to their leader in the pursuit of the common good.

The nurse is taking the history of a pregnant woman. Which factor should the nurse recognize as the primary contraindication for breastfeeding? Family history of breast cancer Lactose intolerance Use of cocaine on weekends Age 40-years old

Use of cocaine on weekends Binge use of cocaine can be just as harmful to the breast-fed newborn as regular daily use of cocaine.

A nurse is discussing negativity with the parents of a 30 month-old child. How should the nurse tell the parents to best respond to this behavior? Reprimand the child and give a 15-minute "time out" Assert authority over the child through limit setting Maintain a permissive attitude for this behavior Use patience and a sense of humor to deal with this behavior

Use patience and a sense of humor to deal with this behavior The nurse should help the parents see that negativity is a normal part of growth of autonomy in the toddler. They can best handle the negative toddler by using patience and humor.

A nurse is discussing negativity with the parents of a 30 month-old child. How should the nurse tell the parents to best respond to this behavior? Reprimand the child and give a 15-minute "time out" Assert authority over the child through limit setting Maintain a permissive attitude for this behavior Use patience and a sense of humor to deal with this behavior

Use patience and a sense of humor to deal with this behavior The nurse should help the parents see that negativity is a normal part of growth of autonomy in the toddler. They can best handle the negative toddler by using patience and humor.

The client is one day post-op following a colon resection and there is an order to assist the client to walk in the hallway at least three times while awake. When the nurse delegates this task to the unlicensed assistive personnel (UAP), which instruction by the nurse is most appropriate? "Apply a gait belt around the client's waist if the client reports feeling dizzy." "Allow the client to sit on the side of the bed before assisting the client to stand and walk." "When assisting the client, be sure to ask about the intensity of the pain." "Have the client stand for at least two minutes before starting to walk."

"Allow the client to sit on the side of the bed before assisting the client to stand and walk." The only statement that's appropriate for a UAP is to allow the client to sit on the side of the bed first, before standing and walking. It's not necessary to stand up for two minutes before starting to walk. A gait belt should not be used since the client had abdominal surgery; besides, the UAP should not assist clients to stand and walk if they report feeling dizzy. UAP cannot assess (ie., ask about the intensity of the pain).

A client is admitted to the hospital with a history of confusion. The client has difficulty remembering recent events and becomes disoriented when away from the home. Which statement would provide the best reality orientation for this client? "Good morning. You're in the hospital. I am your nurse Elaine Jones." "Hello. My name is Elaine Jones and I am your nurse for today." "How are you today? Remember, you're in the hospital." "Good morning. Do you remember where you are?"

"Good morning. You're in the hospital. I am your nurse Elaine Jones." As cognitive ability declines, the nurse should provide a calm, predictable environment for the client. This response establishes time, location and the caregiver's name.

The nurse is discussing dietary intake with an adolescent who has acne. What is the most appropriate statement by the nurse? "Do not use caffeine in any form, including chocolate." "Good nutritional habits promote healthy skin." "Decrease fatty foods from your diet." "Increase your intake of protein and vitamin A."

"Good nutritional habits promote healthy skin." The exact cause of acne is not known, but genetics and hormones (androgens) play a role. Stress, picking or squeezing blemishes and harsh scrubbing can make acne worse. While poor nutrition may make acne-prone teens more susceptible to breakouts, chocolate or greasy foods don't cause acne. Vitamin A helps regulate the skin cycle, but too much can lead to toxic side effects. Teens should simply eat an age-appropriate, well-balanced diet.

client diagnosed with angina has been instructed about the use of sublingual nitroglycerin. Which statement made by the client is incorrect and indicates a need for further teaching? "I will rest briefly right after taking one tablet." "I can swallow two or three tablets at once if I have severe pain." "I'll call the health care provider if pain continues after three tablets five minutes apart." "I understand that the medication should be kept in the dark bottle."

"I can swallow two or three tablets at once if I have severe pain." Clients must understand that just one sublingual tablet should be taken at a time and placed under the tongue. After rest and a five-minute interval, a second and then eventually a third tablet may be necessary.

A client who had surgery is discharged on warfarin (Coumadin). Which statement by the client is incorrect and indicates a need for further teaching? "I will keep all laboratory appointments." "I will report any bruises or unusual bleeding." "I plan on using an electric razor for shaving." "I know I must avoid crowds."

"I know I must avoid crowds." There are no specific reasons for the client on warfarin to avoid crowds. Clients should not use a straight edge razor, should report any unusual bleeding and must keep all laboratory appointments when taking the blood thinner warfarin.

The nurse is teaching a group of clients about skin cancer. Which client statement indicates the need for further education about reducing the risk of skin cancer? "I wear sunglasses with ultraviolet protective lenses." "I only tan in the controlled setting of a tanning booth." "I found a sunscreen with a sun protective factor of 30." "I make sure to come inside between noon and 2 pm."

"I only tan in the controlled setting of a tanning booth." Tanning booths and sun lamps are no safer than the natural sun in terms of cellular damage and potential for developing skin cancer. The other self-help measures have positive effects on reducing the chance of damage from ultraviolet rays.

The nurse is teaching a Lamaze class about postpartum depression. Which statement, made by a class member, indicates that more teaching is needed? "I may experience postpartum depression up to a year after delivery." "It's common for women with postpartum depression to have delusions about the infant." "Women with postpartum depression have feelings of guilt and worthlessness." "I will make an effort to talk with someone about my feelings if I start to feel overwhelmed."

"It's common for women with postpartum depression to have delusions about the infant." Postpartum depression symptoms include sleep and appetite disturbances, uncontrolled crying, with feelings of guilt and/or worthlessness. Although postpartum depression typically occurs within the first three months after delivery, it can occur up to a year later. A new mother who has symptoms of postpartum depression should take steps to get help right away. Delusions are associated with postpartum psychosis, not depression.

A child is admitted to the hospital with findings consistent with rheumatic fever. During the admission process, which statement made by a parent would the nurse associate with this disease? "Our child is being tested for allergies and has reacted to some allergens." "Last week both feet had a fungal skin infection." "Our child had a sore throat a month ago, which I treated with an herbal remedy." "Both ears were infected when our child was 3 months-old."

"Our child had a sore throat a month ago, which I treated with an herbal remedy." vidence supports a strong relationship between group A streptococcal infections and subsequent rheumatic fever (usually within two to six weeks). Therefore, the history of sore throat may have been an undiagnosed strep A infection. Appropriate antibiotic treatment of strep throat is the most effective way to reduce the risk of developing rheumatic fever.

A nurse is giving instructions to the parents of a newborn infant with oral candidiasis. Which statement made by a parent is incorrect and indicates a need for more teaching? "The therapy can be discontinued when the spots disappear." "I will boil the nipples and pacifiers for 20 minutes." "I will use a dropper to place the medicine on each side of my baby's mouth." "Nystatin should be given four times a day after my baby eats."

"The therapy can be discontinued when the spots disappear." The therapy should be continued for a week, even if lesions have disappeared within a few days. If the mother is breast-feeding, mother and baby should be treated at the same time to prevent re-infection.

An anxious parent of a 4 year-old consults the nurse for guidance on how to answer the child's question: "Where do babies come from?" What is the nurse's best response to the parent? "Full and detailed answers should be given to any questions." "Children ask many questions, but are not looking for answers." "This question indicates interest in sex beyond this age." "When a child asks a question, give a simple answer."

"When a child asks a question, give a simple answer."'' During discussions related to sexuality, honesty is very important. However, honesty does not mean imparting every fact of life associated with the question. When children ask one question, they are looking for one answer. When they are ready, they will ask for more detailed information.

The client has just had an enteral feeding tube inserted. What would be the most accurate method to verify initial placement of the feeding tube? Abdominal x-ray Auscultation with air insertion Aspiration for gastric contents Flushing tube with saline

Abdominal x-ray The most objective and recommended approach to confirm correct tube placement after initial placement is radiography. This will determine if the tube is in the duodenum or jejunum and not in the airways of the lungs. After initial placement has been confirmed, the nurse can then verify placement by checking the pH of the aspirated gastric contents. Aspirates of pH 5.5 or below will indicate correct placement in most clients. The "whoosh" test is no longer recommended and should not be used.

A nurse is to administer meperidine (Demerol) 100 mg, atropine sulfate 0.4 mg, and promethazine (Phenergan) 50 mg IM to a preoperative client. Which action should the nurse take first? Instruct the client to remain in the bed Place the call bell within the client's reach Raise the side rails on the bed Assist the client to the bathroom

Assist the client to the bathroom Meperidine is a narcotic analgesic and promethazine is an antihistamine; together they can potentiate CNS effects such as drowsiness, dizziness, lightheadedness and confusion. Although all of the options involve client safety, the first thing to do is to assist the client to the bathroom to void. After administering the preoperative medications, the nurse will instruct the client to remain in bed, place the call light in the client's hand and raise the side rails.

The nurse is working with clients who are diagnosed with eating disorders. Which eating disorder would the nurse expect to cause the greatest fluctuation in serum potassium levels? Bulimia nervosa Dysthymic disorder Anorexia nervosa Binge eating disorder

Bulimia nervosa Hypokalemia can be caused by overuse of laxatives and by prolonged fasting and starvation. But the greatest fluctuation in potassium levels is associated with bulimia, due to the purging process that causes dehydration and potassium loss. Low potassium levels can cause weakness, abdominal cramping and irregular heart rhythms. Dysthymic disorder is associated with poor appetite or overeating.

The client returned from the cardiac catheterization lab four hours ago. The groin was used as the insertion site. Which of the assessment findings would the nurse immediately report to the health care provider? (Select all that apply.) Capillary refill 6 seconds on the affected toes Trace amount of serosanguineous drainage on the groin dressing Pale color of the affected limb Bruising or lump at the insertion site Nonpalpable pedal pulse on the affected limb

Capillary refill 6 seconds on the affected toes Correct response Pale color of the affected limb This is a part of the correct response Nonpalpable pedal pulse on the affected limb This is a part of the correct response A trace of serosanguineous drainage on the dressing is common. Some bruising or a small lump is expected at the insertion site. Reportable conditions include significant reports of pain; abnormal lab values; abnormal ECG strip; post-procedure bleeding or swelling; color, temperature or pulse changes, especially to the affected limb. Capillary refill should be about 3 seconds.

A nurse is caring for a 4 year-old two hours after a tonsillectomy and adenoidectomy. Which of these assessments must be reported immediately? Apical heart rate of 110 Vomiting of dark emesis Complaints of throat pain Increased restlessness

Increased restlessness Increased restlessness with increased respiratory and heart rates are often early signs of active bleeding. The other options are expected findings at this time in the postop period for this surgery. The dark emesis indicates old blood that most likely was swallowed during surgery.

A nurse enters the room as a 3 year-old child is having a generalized seizure. Which intervention should the nurse perform first? Place the child on his or her side Give the prescribed anticonvulsant Restrain the child Place a padded tongue blade in the mouth

Place the child on his or her side Protecting the airway is the top priority in a seizure, and the first action should be to roll the client on their side to open the airway and prevent aspiration in case of vomiting. If a child is actively convulsing, a patent airway and oxygenation must be assured. Nothing should be placed in the mouth when the client is having a seizure. Administration of the prescribed anticonvulsant would be another appropriate intervention for a prolonged seizure and to prevent further seizure activity during the post-ictal phase.

A school nurse is called to the playground for an episode of mouth trauma. The nurse finds that the front tooth of a 9 year-old child has been avulsed ("knocked out"). After recovering the tooth, the initial response by the nurse should be to do what with the tooth? Place the tooth in a clean plastic bag for transport to the dentist Rinse the tooth in water before placing it into its socket Ask the child to replace the tooth even if the bleeding continues Hold the tooth by the roots until reaching the emergency room

Rinse the tooth in water before placing it into its socket Following avulsion of a permanent tooth, it is important to rinse the dirty tooth in water, saline solution or milk before re-implantation. If possible, replace the tooth into its socket within 30 minutes while avoiding contact with the root. The child should be taken to the dentist as soon as possible.

The nurse has been teaching a client diagnosed with heart failure about proper nutrition. Which of these lunch selections indicates that the client has learned about sodium restriction? Sliced turkey sandwich with a side of canned pineapple Cheeseburger and baked potato with butter Cheese sandwich with a glass of 2% milk Mushroom pizza and ice cream made from whole milk

Sliced turkey sandwich with a side of canned pineapple Sliced turkey sandwich is appropriate because it is not a highly processed food and canned fruits are low in sodium. All of the other choices contain one or more high-sodium foods.

A nurse practicing in a maternity setting has a client whose fetus is post-mature. The nurse recognizes that the fetus is at risk due to what factor? Excessive fetal weight Depletion of subcutaneous fat Low blood sugar levels Progressive placental insufficiency

Progressive placental insufficiency The placenta functions less efficiently as pregnancy continues beyond 42 weeks. Immediate and long-term effects may be related to hypoxia. These newborns are typically meconium stained.

A newborn born prematurely is to be fed breast milk through a nasogastric tube. Why is breast milk preferred over formula for premature infants? Has less fatty acids Provides antibodies Contains less lactose Is higher in calories/ounce

Provides antibodies Breast milk is ideal for the preterm baby who needs additional protection against infection through maternal antibodies. It is also much easier to digest. Therefore, less residual is left in the infant's stomach.

In response to a call for assistance by a client in labor, the nurse notes that a loop of the umbilical cord is protruding from the vagina. What is the priority action? Call the health care provider Apply oxygen by mask Put the client into a knee-chest position Check for a fetal heart beat

Put the client into a knee-chest position Immediate action is needed to relieve pressure on the cord to prevent the risk of fetal hypoxia. A Trendelenburg or knee-chest position accomplishes this. The exposed cord should be covered with saline soaked gauze and not reinserted. The fetal heart rate should be checked rapidly, the health care provider should be called immediately and the client should be prepared for immediate vaginal or C-section birth. A prolapsed umbilical cord is a medical emergency, which can result in brain damage or death to the fetus if not treated promptly and properly.

The nurse is providing preprocedural education to the client preparing for a barium enema. What statement made by the client indicates a need for further education? "I will use the prescribed laxative before the procedure." "A barium enema is used to examine the upper and lower GI tracts." "I will need to drink plenty of fluids and eat foods high in fiber after the procedure." "I will not eat or drink anything after midnight before the procedure."

"A barium enema is used to examine the upper and lower GI tracts." A barium enema involves filling the large intestine (lower GI tract) with diluted barium liquid while x-ray images are taken. After the procedure, a small amount of barium will be immediately expelled and the remainder will be excreted in the stool. Because barium liquid may cause constipation, clients should eat foods high in fiber and drink plenty of fluids to help expel the barium from the body.

The nurse checks lab results for an adult client with suspected cancer prior to a liver biopsy. Which finding requires immediate notification of the health care provider? Elevated blood urea nitrogen (BUN) and creatinine Activated partial thromboplastin time (aPTT) of 50 seconds Increased serum ammonia Hemoglobin of 11 grams/dL

Activated partial thromboplastin time (aPTT) of 50 seconds Because the liver is a vascular organ and a biopsy is an invasive procedure, bleeding is one of the risks. An elevated aPTT increases the risk of bleeding. Abnormal findings in the other labs would not increase the client's risk of complications following a liver biopsy.

A client admitted with heart failure is experiencing severe shortness of breath and states, "I feel like something is terribly wrong!" The client is restless and begins to cough up large amounts of pink frothy sputum. The client's skin is a dusky grayish color and the oxygen saturation levels have decreased from 92% to 76% in the last hour. What is the first action the nurse should take? Administer the PRN ordered oxygen Call the health care provider Check vital signs Place the bed in high Fowler's position

Administer the PRN ordered oxygen When dealing with a medical emergency, the rule is to assess airway first, then breathing, and then circulation. Starting oxygen is the priority. The other actions should also be implemented as quickly as possible, including activation of the rapid response team. The client is experiencing an acute episode of fulminant pulmonary edema, likely as a result of a new and severe cardiac event and possible cardiogenic shock. Emergency assessment and intervention is indicated to prevent cardiac arrest and possible death.

The client is diagnosed with tuberculosis (TB). The nurse understands that the treatment plan for this client will involve what type of drug therapy? Administering two antituberculosis drugs Aminoglycoside antibiotics High doses of B complex vitamins An anti-inflammatory agent

Administering two antituberculosis drugs In order to prevent drug-resistant strains of TB, clients are always prescribed at least two different antitubercule medications. Rifampin and isoniazid are the most effective drugs used to treat TB and are always used together, for at least six months. Additional medications, such as pyrazinamide and either streptomycin or ethambutol, may also be prescribed. Vitamin B6 is usually prescribed to help prevent expected side effect of isoniazid.

A client is receiving total parenteral nutrition (TPN) via a tunneled catheter. The catheter accidentally becomes dislodged from the site. Which action by the nurse should take priority? Check that the catheter tip is intact Assess for mental status changes Monitor respiratory status Apply a pressure dressing to the site

Apply a pressure dressing to the site The client is at risk of bleeding or developing an air embolus if the catheter exit site is not covered with a pressure and occlusive dressing. An occlusive dressing is one that is totally covered by adhesive tape around the edges, as well as over the entire dressing.

The nurse has received a report on a group of clients and plans to delegate care of several clients to a practical nurse (PN). The first action the RN should take before the delegation of care is which of these approaches? Assure the PN that the RN will be available for assistance Provide a time frame for the completion of the client care Review the specific procedures unique to the assignment Ask the PN about any prior experience with similar clients

Ask the PN about any prior experience with similar clients The first step in delegation is to determine the qualifications of the person to whom one is delegating. By asking about the PN's prior experience with similar clients/tasks, the RN can determine whether the PN has the requisite experience to care for any of the assigned clients.

A 4 month-old infant is being given digoxin (Lanoxin). The client's blood pressure is 92/78 mm Hg; resting pulse is 78 BPM; respirations are 28 BPM; and the serum potassium level is 4.8 mEq/L. The client is irritable and has vomited twice since the morning dose of digoxin. Which finding is most indicative of digoxin toxicity? Dyspnea Vomiting Irritability Bradycardia

Bradycardia The most common sign of digoxin toxicity in children is bradycardia which is a heart rate below 100 BPM in an infant. Normal resting heart rate for infants 1-11 months-old is 100-160 BPM.

The mother of a 2 month-old baby calls a pediatrician's nurse two days after the first DTaP, inactivated polio vaccine (IPV), Hepatitis B and Haemophilus influenzae type B (HIB) immunizations. She reports that the baby feels very warm, cries inconsolably for as long as three hours, and has had several shaking spells. Which immunization would the nurse expect to be primarily responsible with these findings? DTaP IPV HIB Hepatitis B

DTaP DTaP immunization is a vaccine that protects against diptheria, tetanus and pertussis (whooping cough). The majority of reactions described in this question occur with the administration of the DTaP vaccination. Contraindications to giving repeat DTaP immunizations include the occurrence of severe side effects after a previous dose, as well as signs of encephalopathy within seven days of the immunization.

The nurse suspects that the client is in cardiogenic shock. Which of the following findings supports this information? Bradycardia Decreased or muffled heart sounds Bounding pulses Increased cardiac output

Decreased or muffled heart sounds Cardiogenic shock involves decreased cardiac output and evidence of tissue hypoxia in the presence of adequate intravascular volume; it is the leading cause of death in acute MI. Findings of cardiogenic shock include hypotension, rapid and faint peripheral pulses, distant-sounding heart sounds, cool and mottled skin, oliguria and altered mental status.

The home care nurse is admitting a new client with a diagnosis of COPD, atrial fibrillation and gout. After reviewing the client's medication list, the nurse would arrange for periodic monitoring of blood drug levels for which of the following medications? (Select all that apply.) Glipizide (Glucotrol) Beclomethasone inhaled (Qvar) Digoxin (Lanoxin) Allopurinol (Aloprim, Zyloprim) Theophylline (Elixophyllin, Theo-24, Uniphyl)

Digoxin (Lanoxin) Theophylline (Elixophyllin, Theo-24, Uniphyl) It is necessary to monitor blood levels for the client taking theophylline and digoxin to prevent the client from developing toxicity.

A nurse, who is assigned for five days to a client who has exhibited manipulative behaviors, becomes aware of feeling reluctance to interact with the client. The nurse should take what action next? Limit contacts with the client to avoid reinforcement of the manipulative behavior during the work times Develop a behavior modification plan for the client that will promote more functional behavior within the next week Discuss the feelings of reluctance with an objective peer or supervisor within the next 24 hours Talk with the client about the negative effects of manipulative behaviors on other clients and staff within the next few days

Discuss the feelings of reluctance with an objective peer or supervisor within the next 24 hours The nurse who experiences stress in a therapeutic relationship can gain objectivity through discussion with other professionals. The nurse may wish to have a peer observe the nurse-client interactions with this client for a shift and then have a debriefing of positive and negative actions. The nurse must attempt to discover attitudes and feelings in the self that influence the nurse-client relationship in positive and negative ways.

The client who has returned from surgery reports feeling nauseated and later has an emesis. The nurse administers promethazine (Phenergan) per standing orders. In addition to relief from nausea, what other effects of this medication does the nurse expect? (Select all that apply.) Heart palpitations Dry mouth Pinpoint pupils Runny nose Sedation

Heart palpitations Correct response Dry mouth This is a part of the correct response Sedation This is a part of the correct response Promethazine is used as an antihistamine, sedative and antiemetic. It produces anticholinergic effects, such as dry mouth and nasal congestion, dilated pupils and urinary retention. Although promethazine is a sedative, the nurse should understand that it can cause some people to have heart palpitations and to feel restless and unable to sleep.

A nurse is caring for a client with a confirmed diagnosis of myocardial infarction. Which finding requires the nurse's immediate action? Periorbital edema Lightheadedness Lethargy Shortness of breath

Lightheadedness' Heart rhythms that are too fast or too slow may cause a transient drop in cardiac output during the arrhythmia. Inadequate cardiac output compromises blood flow to the brain causing lightheadedness, near syncope or unresponsiveness, which are the most concerning findings in the client with an arrhythmia. These findings should be reported immediately after a verification of the cardiac status through assessment cardiac rhythm and for other signs of poor cardiac output such as chest discomfort, shortness of breath or hypotension.

The nurse is caring for a client who is exhibiting a panic attack. What should the nurse do for this client? Teach the client to control behaviors Maintain safety for the client Assist the client to describe the experience in detail Develop a trusting relationship

Maintain safety for the client Clients who display signs of severe anxiety in the form of a panic attack need to be supervised closely until the anxiety is lessened. They may harm themselves or others because during panic attacks perception is narrowed and thinking is flawed.

The nurse who is caring for clients over the age of 70, implements a teaching plan about diet. Using knowledge based on age-related changes, the nurse will emphasize which of the following factors? Look for foods fortified with iron and other minerals Make at least half your grains whole grain Add high protein supplements to your diet Follow the DASH eating plan

Make at least half your grains whole grain Anyone, regardless of age, should eat a balanced diet of nutrient-packed foods. However, the diet of the older adult without other chronic health issues should include an increase of fiber and whole grains. The DASH diet is recommended to reduce blood pressure, but there is nothing to indicate this client is hypertensive. Older adults should eat lean proteins but don't necessarily need protein supplements. They should also look for foods fortified with vitamins B12 and D, as well as calcium.

The nurse is assessing a child with suspected lead poisoning. Which assessment should a nurse expect to find? Excessive perspiration A history of difficulty sleeping Auditory wheezes with expiration Numbness and tingling in feet

Numbness and tingling in feet A child who has unusual neurologic complaints, such as neuropathy or footdrop that cannot be attributed to other causes, may be affected by lead poisoning. This may occur when a child ingests or inhales paint chips from lead-based paint or dust during remodeling in older buildings. Other findings of lead poisoning are appearance of bluish gum line, hyperactivity and developmental delays.

A client has been admitted with a fractured femur and has been placed in a skeletal traction. Which of these nursing interventions should be the priority? Inspect the pin sites for evidence of drainage or inflammation Apply an over-bed trapeze to assist the client with movement in bed Maintain proper body alignment Perform frequent neurovascular assessments of the affected leg

Perform frequent neurovascular assessments of the affected leg The priority activity for a nurse is to assess neurovascular status after an extremity fracture. Compartment syndrome, a serious complication of fractures, requires prompt recognition and early intervention to prevent permanent limb damage. Findings of compartment syndrome are due to compression of the arteries and the nerves in the injured extremity. The other options are also correct and would be done afterwards.

A client has a history of chronic obstructive pulmonary disease (COPD). The nurse enters the client's room to find that the nasal cannula is in proper position with the oxygen set at 6 liters per minute, the client's color is flushed and the respirations are 8 per minute. What should the nurse do first? Remove the nasal cannula for at least five minutes Lower the oxygen's flow rate Check the client's pulse for strength and rate Place client in a higher sitting position

Remove the nasal cannula for at least five minute The client has findings of oxygen toxicity so the nurse should first remove the cannula for a least five minutes. Then the nurse should perform these next sequence of actions: pulse assessment, change of position and then lower the oxygen flow rate and reapply if respirations are within normal parameters. A higher concentration of supplemental oxygen removes the hypoxic drive to breathe and leads to increased hypoventilation, respiratory decompensation, and the development or worsening of respiratory acidosis.

The nurse is caring for a client admitted with a diagnosis of Meniere's disease. When teaching the client about the disease, the nurse should explain that the client should avoid foods high in which substance? Carbohydrates Sodium Fiber Calcium

Sodium The client with Meniere's disease has an alteration in the balance of the fluid in the inner ear (endolymph). A low-sodium diet will aid in reduction of the fluid. Sodium restriction is commonly ordered as adjunct to diuretic therapy in the acute and chronic treatment.

The nurse assesses delayed gross motor development in a 3 year-old child. The inability of the child to do which action confirms this finding? Ride a bicycle Skip on alternate feet Stand on one foot Catch a ball

Stand on one foot At this age, gross motor development allows a child to balance on one foot

A client is scheduled to have a blood test for cholesterol and triglycerides the next day. What statement should the nurse include in the directions for the client? "Stay at the laboratory so two blood samples can be drawn an hour apart." "Be sure and eat a fat-free diet until the test." "Have the blood drawn within two hours of eating breakfast." "Do not eat or drink anything but water for 12 hours before the test."

"Do not eat or drink anything but water for 12 hours before the test." Serum lipid levels should be obtained from clients who have been fasting for at least 12 hours.

A nurse is providing information to a client who is newly diagnosed with tuberculosis (TB). The nurse should be sure to include which statement when teaching the client about managing this disease? "Continue to get yearly tuberculin skin tests." "Continue to take your medications even when you are feeling fine." "Follow up with your primary care provider in three months." "Isolate yourself from others until you are finished taking your medication."

"Continue to take your medications even when you are feeling fine." The client with TB needs is to understand the importance of medication compliance, even when the client is no longer having any symptoms. TB treatment usually requires a combination of medications with treatment for at least six months. Stopping treatment or skipping doses can lead to a drug-resistant form of TB. Clients are most infectious early in the course of therapy but the numbers of acid-fast bacilli are greatly reduced as soon as two weeks after therapy begins. Once clients no longer have a productive cough, they are not considered contagious.

A nurse is reviewing the nutritional needs for a child diagnosed with cystic fibrosis. The nurse should anticipate that this client would be deficient in which vitamins? B12, D and K A, B1 and C A, C and D A, D and K

A, D and K The uptake of fat-soluble vitamins, A, D and K, is decreased in children with cystic fibrosis. Vitamin B12 is deficient in clients who have had bariatric surgery or various degrees of a gastrectomy. Vitamin B1 is often deficit in clients who have an alcohol addiction. These clients are given a thiamine (B1) injections daily times three to prevent Korsakoff syndrome. Vitamin D may be deficient in people who do not get at least 10 to 15 minutes of sunlight on the arms each day. Vitamin C deficit is associated with less than the needed intake of foods with vitamin C.

A nurse working at a clinic is reviewing a client's blood sugar log and recognizes that the client is not consistently monitoring blood sugar. Which of the following diagnostic tests would assist the nurse in evaluating the client's overall management of diabetes? Hemoglobin Fasting blood sugar White blood cell count Hemoglobin A1C

Hemoglobin A1C The hemoglobin A1C is the best indicator of glycemic control because it reflects an average of the blood sugar over the life of a red blood cell (approximately 90 to 120 days). The fasting blood sugar will only evaluate the client's blood sugar at that specific testing time. Hemoglobin and a white blood cell count are not used to determine blood sugar levels.

The clinic nurse is examining a 15 month-old child with suspected otitis media. Which group of findings should the nurse anticipate? Vomiting, pulling at ears and pearly white tympanic membrane Irritability, rhinorrhea, and bulging tympanic membrane Periorbital edema, absent light reflex and translucent tympanic membrane Diarrhea, retracted tympanic membrane and enlarged parotid gland

Irritability, rhinorrhea, and bulging tympanic membrane Clinical manifestations of otitis media include irritability, rhinorrhea, bulging tympanic membrane, and pulling at the ears.

The nurse is admitting a 72 year-old with a diagnosis of right-sided heart failure. What finding should the nurse anticipate when assessing the client? Bibasilar crackles Decreased urine output Jugular vein distention Pleural effusion

Jugular vein distention Signs of right-sided heart failure include jugular vein distention at 35 to 45 degrees or higher elevation of the head of the bed, fatigue, nausea, vomiting, sacral edema and bilateral feet and/or ankle edema.

If a client is stated to have a dual diagnosis. The nurse should understand that this indicates a substance abuse problem as well as what other type of problem? Medical problem Cross addiction Mental disorder Disorder of any type

Mental disorder A dual diagnosis is the concurrent presence of a major psychiatric disorder and chemical dependence.

While assessing the vital signs in children, the nurse should know that the apical heart rate is preferred until the radial pulse can be accurately assessed at about what age? Four years One year Three years Two years

Two years A child should be at least 2 years old to use the radial pulse to assess heart rate.

A client has just joined a health care maintenance organization (HMO) and asks for information about the payment obligations with this plan. Which statement below is the most accurate about health care costs the client will be charged? Only for services provided by specialists One flat rate for each service rendered A predetermined fee for all services The usual and customary fee for services

A predetermined fee for all services An HMO plan is a plan that provides for all services based on a predetermined fee. During the specified period of enrollment, all health care services are provided with no additional fees.

A 57 year-old male client has a hemoglobin of 10 mg/dL and a hematocrit of 32%. What would be the most appropriate follow-up by a home care nurse? Ask the client if the client has noticed any bleeding or dark stools Refer the client to schedule an appointment with a hematologist Schedule a repeat hemoglobin and hematocrit in one month Call 911 and send the client to the emergency department

Ask the client if the client has noticed any bleeding or dark stools Normal hemoglobin for males is 14 - 18 g/100 mL. Normal hematocrit for males is 42 - 52%. These values are below normal and indicate a mild anemia. The first action a nurse should take is to ask the client if the client noticed any bleeding or change in stools that could indicate bleeding from the GI tract.

A child is injured on the school playground and appears to have a fractured leg. Which of the following is the first action a school nurse should take? Assess the child and the extent of the injury Call for emergency transport to the hospital Apply cold compresses to the injured area Immobilize the limb and joints above and below the injury

Assess the child and the extent of the injury

The school nurse is screening the children for scoliosis. At what time of development should the nurse expect to see early findings of scoliosis? During the years when children begin to run and jump When a child begins to play competitive sports In early infancy before 8 months of age During a preadolescent growth spurt

During a preadolescent growth spurt Idiopathic scoliosis is seldom apparent before 10 years of age and is most noticeable at the beginning of the preadolescent growth spurt. It is more common in females than in males.

A woman in early labor puts her call light on and tells the nurse "I think my water bag just broke and I feel like something came out with the water." A visual exam by the nurse reveals a prolapsed umbilical cord. List in order of priority the actions the nurse should perform in this obstetrical emergency. Call for assistance, asking that the health care provider is notified Administer oxygen to the mother via mask at 10 L/min Glove and place two fingers into the cervical opening, beside the umbilical cord, to relieve pressure Place the client in a knee-chest position on the bed

Glove and place two fingers into the cervical opening, beside the umbilical cord, to relieve pressure Call for assistance, asking that the health care provider is notified Place the client in a knee-chest position on the bed Administer oxygen to the mother via mask at 10 L/min A prolapsed cord is a medical emergency; the blood flow from the placenta to the fetus will be occluded with each contraction if the umbilical cord is compressed against the presenting part of the fetus and the dilated cervix which is why the priority intervention is to apply gloves and place two fingers to one side of the cord (or entire hand) to relieve pressure. The nurse is also calling for assistance so that someone can notify the health care provider and staff can prepare for emergent cesarean. Placing the client in a modified Sims or knee-chest position will allow gravity to help decrease pressure on the cord from the presenting part, but the primary relief from pressure on the umbilical cord is the gloved fingers. Oxygen administration will help once the circulation of blood to the fetus is re-established.

The home health nurse observes the client change an ileostomy pouch. Which action is best to help prevent skin breakdown? Change the stoma pouch daily Use deodorant soaps the contain lotion to clean the stoma Make sure the skin around the stoma is wrinkle-free Apply antiseptic cream to reddened stoma

Make sure the skin around the stoma is wrinkle-free The ileostomy pouch should be changed approximately every 5 to 7 days; the bag should be emptied about every 4 to 6 hours. Before applying a pouch, the stoma and skin around the stoma should be gently cleaned using mild soap and water and allowed to dry. A skin barrier powder or other skin prep can be applied to intact skin around the stoma - but not to the stoma. The skin around the stoma should be dry and wrinkle-free before applying a new pouch or wafer to ensure a tight, leak-free seal.

A client being treated for hypertension returns to the community clinic for a follow-up. The client says, "I know these pills are important, but I just can't take these water pills anymore. I drive a truck for a living, and I can't be stopping every 20 minutes to go to the bathroom." Which nursing diagnosis should the nurse select for this client? Knowledge deficit related to misunderstanding of disease state Altered health maintenance related to occupation Noncompliance related to medication side effects Defensive coping related to chronic illness

Noncompliance related to medication side effects The client kept the appointment and stated knowledge that the pills were important. The client is unable to comply with the regimen due to side effects, not because of a lack of knowledge about the disease process.

A client asks the nurse about including her 2 year-old and 12 year-old sons in the care of their newborn sister. Which response is an appropriate initial statement by the nurse? "Focus on your sons' needs during the first days at home." "Tell each child what he can do to help with the baby." "Ask the children what they would like to do for the newborn." "Suggest that your partner spend more time with the boys."

"Focus on your sons' needs during the first days at home." In an expanded family, it is important for parents to reassure older children that they are loved and as important as the newborn.

A client has end-stage renal disease. Which of these statements made by the client indicates a correct understanding of the issues related to this disease? "I know I have a high risk of clot formation since my blood is thick from too many red cells." "I have to go for epoetin (Procrit) injections at the health department." "I can expect to have periods of little urine and then sometimes a lot of urine." "My bones will be stronger with this disease since I will have higher calcium than normal."

"I have to go for epoetin (Procrit) injections at the health department." Anemia in end-stage renal failure is caused by reduced endogenous erythropoietin production in the kidney. Anemia in primary end-stage renal disease is treated with subcutaneous injections of Procrit or Epogen to stimulate the bone marrow to produce red blood cells. With kidney failure, too much phosphorus can build up in the blood and calcium is pulled from the bones, resulting in weakened bones. The statement about producing variable amounts of urine is incorrect, as the client will produce little to no urine at this stage of the disease.

The nurse is teaching diet restrictions to a client diagnosed with Addison's disease. The client indicates an understanding of the dietary restrictions when making which of these statements? "I will increase fluids and restrict sodium and potassium." "I will increase sodium and fluids and restrict potassium." "I will increase sodium, potassium and fluids." "I will increase potassium and sodium and restrict fluids."

"I will increase sodium and fluids and restrict potassium." The manifestations of Addison's disease (also called adrenal insufficiency or hypocortisolism) are due to mineralocorticoid deficiency that results in renal sodium wasting and potassium retention. Other findings are dehydration, hypotension, hyponatremia, hyperkalemia and metabolic acidosis.

A client has been given a prescription for alendronate (Fosamax). Which of the following statements indicate the client understands how to safely take this medication? (Select all that apply.) "I will notify the health care provider if I have any difficulty swallowing." "I will stand or sit quietly for 30 minutes after taking it." "I will take the pill immediately preceding weight-bearing exercise." "I will swallow it with 8 ounces of water." "I will always eat breakfast before taking it."

"I will notify the health care provider if I have any difficulty swallowing." Correct response "I will stand or sit quietly for 30 minutes after taking it." Correct response "I will swallow it with 8 ounces of water." This is a part of the correct response This medication can cause esophagitis or esophageal ulcers unless precautions are followed. The client must be able to sit upright or stand for at least 30 minutes after taking the tablet. The client should take the tablet first thing in the morning, with a full glass of water, at least 30 minutes before eating or drinking anything or taking any other medication.

The nurse is assessing a client in the emergency department. Which statement suggests that the client is experiencing acute cardiac ischemia? "As I take a deep breath the pain gets worse." "The pain is right here in my stomach area." "When I sit up the pain gets worse." "I've got a pressure deep in my chest behind my breast bone."

"I've got a pressure deep in my chest behind my breast bone." Pain that gets worse with deep breaths may be related to a disorder of the lungs. Pain that gets worse with movement is probably from the muscles or bones in the chest, but is not cardiac ischemia. Pain that worsens in the supine position and is relieved with sitting up is characteristic of pericarditis. Although pain in the stomach, especially after a meal, may actually be angina, a person most typically will feel pain, aching or pressure in the middle of the chest, just beneath the sternum. Many people describe the sensation as discomfort or heaviness instead of pain, so the term discomfort should be used when asking clients about their findings.

A client tells a nurse: "I have decided to stop taking sertraline (Zoloft) because I don't like the nightmares, sex dreams and obsessions I have had since starting on the medication." What is an appropriate response by the nurse? "This medication should be continued despite unpleasant symptoms." "Many medications have potential side effects." "Side effects and benefits should be discussed with your health care provider." "It is unsafe to abruptly stop taking any prescribed medication."

"It is unsafe to abruptly stop taking any prescribed medication."

After placement of a ventriculoperitoneal (VP) shunt as a treatment for hydrocephalus of their infant, the parents ask a nurse: "Why is there a small incision in the abdomen?" Which response would be the best for explaining the purpose of the incision? "It's used to visualize the abdominal organs for correct catheter placement." "It's used to pass the catheter into the abdominal cavity." "That's what is used for insertion of the catheter into the stomach." "It's there so the tubing can be inserted into the urinary bladder."

"It's used to pass the catheter into the abdominal cavity." The preferred procedure in the surgical treatment of hydrocephalus is the placement of a ventriculoperitoneal shunt. This shunt procedure provides primary drainage of the cerebrospinal fluid from the ventricles to an extracranial compartment, which is commonly the peritoneum. A small incision is made in the upper quadrant of the abdomen so the shunt tip can be guided into the peritoneal cavity.

A 52 year-old postmenopausal woman asks the nurse how frequently she should have a mammogram. How should the nurse respond? "Yearly mammograms are advised for any women over 35." "Once a woman reaches 50, she should have a mammogram yearly." "Your health care provider will advise you about your risks and the frequency." "Unless you had previous problems, every two years is best."

"Once a woman reaches 50, she should have a mammogram yearly."' The American Cancer Society recommends a screening mammogram by age 40, every one to two years for women 40 to 49, and every year from age 50 onward. If there are family or personal health risks, other more frequent and additional assessments may be recommended.

The nurse and a student nurse are discussing the health issues related to a laboring HBsAg-positive client. Which of these comments by the student is incorrect and indicates a need for further instruction? "The infant will receive the hepatitis B immune globulin within 12 hours after birth." "The infant will receive the hepatitis B vaccine within 12 hours after birth." "The HBsAg-positive mother should not breastfeed her baby." "The HBsAg-positive mother should be reported to the state or local health department."

"The HBsAg-positive mother should not breastfeed her baby." All persons with HBsAg-positive laboratory results should be reported to the state or local health department. The newborn should receive the hepatitis B immune globulin and hepatitis B vaccine within 12 hours after birth, using different sites (the second vaccine is given between 1 and 2 months; the last vaccine is given between 6 and 18 months). HBV is not spread by breastfeeding, kissing, hugging, coughing, or casual contact.

The client is taking bupropion (Budeprion, Buproban, Wellbutrin, Zyban) to treat depression and is worried about taking the medication. The client tells the nurse a friend said the medication was removed from the market because it caused seizures. What is an appropriate response by the nurse? "Omit the next doses until you talk with the health care provider." "Your health care provider knows the best drug for your condition." "Ask your friend about the source of this information." "There were problems, but the recommended dose is changed."

"There were problems, but the recommended dose is changed." Bupropion was introduced in the United States in 1985 and then withdrawn because of the occurrence of seizures in some clients who took the drug. The drug was reintroduced in 1989 with specific recommendations about dose ranges to limit the occurrence of seizures. The risk of seizure appears to be strongly associated with higher dosages.

A 2 year-old child has just been diagnosed with cystic fibrosis. The child's father asks a nurse, "What is our major concern now, and what will we have to deal with in the future?" Which statement is the best response by the nurse? "Thick, sticky secretions from the lungs are a constant challenge in cystic fibrosis." "Cystic fibrosis results in nutritional concerns that can be dealt with." "There is a probability of life-long complications." "You will work with a team of experts and have access to a support group."

"Thick, sticky secretions from the lungs are a constant challenge in cystic fibrosis." All of the options will be concerned with cystic fibrosis. However, the respiratory threats are the primary concerns. Other information of interest is that cystic fibrosis is an autosomal recessive disease. For these parents there is a 25% chance that each pregnancy will result in a child with cystic fibrosis.

A nursing assistant is taking care of a 2 year-old child with Wilm's tumor. The assistant asks the nurse why there is a sign above the bed that says DO NOT PALPATE THE ABDOMEN. Which statement by the nurse would be the best response? "Touching the abdomen could cause cancer cells to spread." "Placing any pressure on the abdomen may cause the tumor to rupture." "Examining the area would be painful." "Pushing on the stomach might contribute to a bowel obstruction."

"Touching the abdomen could cause cancer cells to spread." Manipulation of the abdomen can lead to dissemination of cancer cells to nearby and distant areas. Bathing and turning the child should be done carefully.

A 3 year-old child has findings that may suggest a neuroblastoma. While listening to the concerns of the parents, which finding is consistent with this diagnosis and requires follow-up by the health care provider? "Our child has been quieter than normal lately and has lost weight." "He doesn't seem to be going to the bathroom as much and his urine is dark yellow in color." "We keep having to buy him larger size pants because he's growing so big around the waist." "He seems to be getting weaker and weaker and is sometimes unsteady on his feet."

"We keep having to buy him larger size pants because he's growing so big around the waist." One of the most common signs of neuroblastoma is increased abdominal girth due to the mass or tumor in the abdomen. The mass can cause pain and/or a feeling of fullness and the pressure may affect the child's bladder or bowel. Although the child with a neuroblastoma may not want to eat (which can lead to weight loss), this finding could have many causes. A more significant finding would be if the parents reported that child keeps outgrowing clothing or that clothing is tight around the abdomen.

The nurse is caring for a client who is experiencing frightening hallucinations that are markedly increased at night. The client's partner asks to stay a few hours beyond the visiting time, in the client's private room. What would be the best response by the nurse? "Yes, staying with the client and orienting the client to the surroundings may decrease any anxiety." "No, it would be best if you brought the client some reading material that the client could read at night." "Yes, would you like to spend the night when the client's behavior indicates that the client is or will be frightened?" "No, your presence may cause the client to become more anxious."

"Yes, staying with the client and orienting the client to the surroundings may decrease any anxiety." Encouragement of a family member or a close friend to stay with the client in a quiet surrounding cannot only help increase orientation, but can also minimize confusion and anxiety. The visitor could also report to the nurse any unusual findings of the client. This would be the most supportive approach for this client.

The client returns from the post anesthesia care unit (PACU) in stable condition following abdominal surgery. While planning immediate postoperative care, the nurse identifies the nursing diagnoses listed below. Prioritize these diagnoses by placing them in order of importance (with 1 being the most important). Risk for ineffective airway clearance related to anesthesia Impaired mobility related to invasive equipment Acute pain related to surgical procedure Risk for imbalanced nutrition: less than body requirements related to NPO status

1 3 2 4 Airway is the highest priority, especially in the immediate postoperative period. Pain control is the next priority because this client will most likely experience significant pain. Although impaired mobility is expected, it does increase the client's risk for postoperative complications. The client's risk for nutrition imbalance is the lowest priority and is to be expected for a client who has had abdominal surgery; hydration is provided intravenously.

The oncology client reports pain, and the provider orders hydromorphone (Dilaudid, Exalgo) IM 0.015 mg/kg right away. How many milligrams does the nurse administer? The nurse checks the chart and determines the client weighs 150 pounds. How many milligrams of hydromorphone (Dilaudid, Exalgo) will the nurse administer? (Round to the nearest hundredth and write only the number.) mg.

1.02 Using dimensional analysis, the final units will be milligrams, so begin the equation with milligrams on top, then multiply to cancel unwanted units until only the milligrams remain. (0.015 mg/kg) X (1 kg/2.2 lbs) X (150 lb/1) = 2.25/2.2 = 1.0227 = 1.02

The ICU nurse works in a rural hospital that has a remote electronic ICU monitoring system (eICU.) What is one of the best reasons for having access to an eICU? An ICU nurse and intensivist remotely monitor ICU clients around the clock An ICU nurse is on-call to answer questions when needed Less staff is needed on site when a remote eICU is available Clients can ask the intensivist for a second opinion

An ICU nurse and intensivist remotely monitor ICU clients around the clock Using cameras, microphones, and high-speed computer data lines, the eICU involves having an experienced ICU nurse and practicing intensivist monitoring ICU clients in remote locations around the clock. The eICU does not change the ratio of nurses to clients at the bedside, but it does make the nurse's bedside time more productive and assistance from their remote colleagues is only a push button away.

A 80 year-old client diagnosed with pneumonia is exhibiting new onset confusion. The client is pulling at tubes and items near the bed and trying to get out of bed. Which intervention would be most appropriate? Arrange for a sitter to stay with the client Frequently remind the client to stay in bed Request an order for wrist restraints Request an order for antianxiety medication

Arrange for a sitter to stay with the client The plan to use safety protective devices such as wrist restraints should be rethought with a review of other safe actions. Restraints are used to protect the client from harm caused by removing tubes or getting out of bed. In the event that this restricted movement could cause more harm, such as aspiration, then a sitter should be requested. These should be provided by the facility in the event the family cannot do so. This client who has a lung infection and productive cough needs to cough and be watched rather than restricted. Suctioning will not prevent aspiration in this situation. Cough suppressants should be avoided for this client.

The nurse is caring for a 17 month-old child diagnosed with acetaminophen poisoning. Which of these lab reports should the nurse review first? Prothrombin Time (PT) and partial thromboplastin time (PTT) Aspartate aminotransferase (AST) and Alanine transaminase (ALT) Red blood cell and white blood cell counts Blood urea nitrogen (BUN) and creatinine clearance

Aspartate aminotransferase (AST) and Alanine transaminase (ALT) Acetaminophen is toxic to the liver and causes hepatic cellular necrosis. This causes the liver enzymes AST and ALT to be released into the blood stream, which elevates serum levels. The next lab values to review are those associated with coagulation, then the blood counts and lastly the renal-associated labs, including BUN and creatinine.

A client continuously calls out to the nursing staff when anyone passes the client's door and asks them to do something in the room. The charge nurse should take which approach for this client? Keep the client's room door cracked to minimize the distractions of people passing by the room Arrange for each staff member to go into the client's room to check on needs every hour on the hour Assign a nursing staff member to visit the client at regular intervals Reassure the client that a staff person will check frequently to see if the client needs anything

Assign a nursing staff member to visit the client at regular intervals Regular, frequent, planned contact by a designated staff member is the best approach to provide a continuity of care and communicate to the client that care will be available as needed.

The nurse is caring for a school-aged child with a diagnosis of secondary hyperparathyroidism after treatment for chronic renal disease. Which serum lab data should receive priority attention by the nurse? Blood urea nitrogen and magnesium Calcium and phosphorus Osmolality and sodium Glucose and potassium

Calcium and phosphorus The parathyroid regulates the calcium and phosphorus serum levels. Calcium and phosphorous levels will be elevated in hyperfunction of this gland until the client is stabilized. To recall this information think of a see-saw. Associate that calcium is first in the alphabet and thus calcium follows the direction of the abnormality - hyper or hypo function - of the parathyroid. Put the calcium on one side and the phosphorus on the other side of the see-saw.

The nurse is caring for a client who just had a central venous catheter line inserted at the bedside. Which of these assessments requires immediate attention by the nurse? Increased temperature by one degree Dyspnea at rest Involuntary coughing spells Pallor in the extremities

Dyspnea at rest Complications of central catheter insertion include pneumothorax and hemothorax. Air embolism is another potential complication. Dyspnea, shallow respirations, sudden sharp chest pain that worsens with coughing or deep breathing are indications of pneumothorax. Other potential complications of central catheters may include thrombosis, local or systemic infection, or even cardiac tamponade (if the central line perforates the heart). When considering the options listed, the client who is dyspneic after central line insertion would be the greatest concern for the nurse.

The nurse is reviewing client assignments at the beginning of the shift. Which task could be safely delegated to an unlicensed assistive personnel (UAP)? Stay with a client during the self-administration of insulin Monitor a client's response to passive range of motion exercises Empty a client's colostomy bag Cleanse and dress a small pressure ulcer on the leg

Empty a client's colostomy bag The UAP may empty a client's colostomy bag. This is an uncomplicated, routine task with an expected outcome. The other tasks involve one or more parts of the nursing process and cannot be delegated to the UAP.

A client with considerable pain asks a nurse, "What is your opinion regarding acupuncture as a drug-free method for alleviating pain?" The nurse responds, "I'd forget about it as those weird non-Western treatments can be scary." The nurse's response is an example of what perspective? Ethnocentrism Prejudice Discrimination Cultural insensitivity

Ethnocentrism Ethnocentrism is the universal unconscious tendency of human beings to think that their ways of thinking, acting, and believing are the only right, proper and natural ways. It can be a major barrier to the provision of culturally conscious care. Ethnocentrism perpetuates an attitude that beliefs that differ greatly from one's own are strange, bizarre or unenlightened, and therefore wrong. At a more complex level, ethnocentric people regard others as inferior or immoral and believe their own ideas are intrinsically good, right, necessary, and desirable, while remaining unaware of their own value judgments.

The nurse is assessing a 4 year-old child who is in skeletal traction 24 hours after surgical repair of a fractured femur. The child is crying and reports having severe pain. The right foot is pale and there is no palpable pulse. What action should the nurse take first? Readjust the traction for comfort Administer the ordered PRN medication Notify the health care provider Reassess the extremity in 15 minutes

Notify the health care provider Pain and absence of a pulse within 48-72 hours after a severe injury to an extremity suggests acute compartment syndrome. This condition occurs when there's a build up of pressure within the muscles; this pressure decreases blood flow and can cause muscle and nerve damage. Acute compartment syndrome is a medical emergency. Surgery is needed immediately; delaying surgery can lead to permanent damage to the extremity.

A client who is 12 hours postop becomes confused and says: "Giant sharks are swimming across the ceiling." Which assessment is necessary by the nurse to adequately identify the source of this client's behavior? Cardiac rhythm strip Peripheral glucose stick Pupillary response Pulse oximetry

Pulse oximetry A sudden change in mental status in any postop client should trigger a nursing intervention directed toward evaluation of the client's respiratory status. Pulse oximetry would be the initial assessment. If available, arterial blood gases would be better. Acute respiratory failure is the sudden inability of the respiratory system to maintain adequate gas exchange, which may result in hypercapnia and/or hypoxemia. Clinical findings of hypoxemia include these finding, which are listed in order of initial to later findings: restlessness, irritability, agitation, dyspnea, disorientation, confusion, delirium, hallucinations, and loss of consciousness. While there may be other factors influencing the client's behavior, the first nursing action should be directed toward maintaining oxygenation. Once respiratory or oxygenation issues are ruled out, then significant changes in glucose would be evaluated.

A client has been scheduled for a transesophageal echocardiogram (TEE). Prior to the procedure, which activity could be delegated to the unlicensed assistive person (UAP)? Remove the pitcher of water from the bedside table Obtain a signed consent Assess the client's psychological state Provide basic instructions about the procedure

Remove the pitcher of water from the bedside table Removing the water pitcher would be an appropriate task because the client would be NPO. The health care provider is responsible for instructions about the procedure and needs to address client questions or concerns. The nurse is typically responsible to obtain a signed consent form and to assess the client both physically and psychologically before the procedure.

A hospitalized child has a seizure while the family is visiting. The nurse notes the child's whole body is rigid, followed generalized jerking movements of the extremities. The child vomits immediately after the seizure. What is a priority nursing diagnosis for the child at this time? Fluid volume deficit related to vomiting Risk for infection related to vomiting Risk for airway obstruction related to aspiration Altered family processes related to chronic illness and hospitalization

Risk for airway obstruction related to aspiration The tonic-clonic seizure appears suddenly and often leads to brief loss of consciousness. The greatest risk for this child is from airway obstruction due to aspiration of the vomit.

The nurse is caring for a 50 year-old client diagnosed with advanced cirrhosis of the liver. Which nursing diagnosis should take priority? Altered nutrition: less than body requirements Fluid volume excess: ascites Risk for injury: hemorrhage Risk for injury related to peripheral neuropathy

Risk for injury: hemorrhage Liver disease interferes with the production of prothrombin and other factors essential for blood clotting. In addition, hemorrhage, especially from esophageal varices, can be life-threatening. This takes priority over the other nursing diagnosis.

The client undergoes a laparoscopic removal of the appendix. Which postoperative instructions will the nurse reinforce? (Select all that apply.) Maintain bedrest for 24 hours before gradually resuming regular activities Some shoulder discomfort can be expected Use 2 tablespoons of Milk of Magnesia if no bowel movement 3 days after surgery Restrict diet to bland, easily digestible food for a few days No showering for 48 hours after surgery Gently scrub off the "skin glue" when you feel able

Some shoulder discomfort can be expected This is a part of the correct response Use 2 tablespoons of Milk of Magnesia if no bowel movement 3 days after surgery This is a part of the correct response Restrict diet to bland, easily digestible food for a few days This is a part of the correct response No showering for 48 hours after surgery This is a part of the correct response Laparoscopic surgery involves using carbon dioxide gas to open the inside of the abdomen, which pushes up the diaphragm; this may cause shoulder discomfort postoperatively. Clients should keep the dressings clean and dry for 48 hours before they can shower, but no tub baths for a few weeks. If "skin glue" is used over the incision(s), the client should not try to scrub it off because it will wear off on its own. Clients may resume normal activities as soon as they are able but no heavy lifting or aerobic exercise for about 2 weeks. If they do not have a BM after 2-3 days, clients can take 2 tablespoons of MOM several times a day until they have a BM. Diet can be advanced as tolerated but it's best to stick to non-greasy, non-spicy foods for a few days.

A nurse is caring for a client suspected to have a diagnosis of active tuberculosis (TB). Which diagnostic tests is essential for the nurse to obtain for the determination of the presence of active TB? Sputum culture for cytology White blood cell count Chest x-ray anterior/posterior and lateral Tuberculin skin testing

Sputum culture for cytology The sputum culture is the method for the determination if active TB is present. This test takes one to two weeks to get the results. Thus, these clients would need to be in isolation or on medication and not coughing during the wait.

An older adult client, admitted after a fall at home, begins to seize and loses consciousness. What action by a nurse is appropriate to do next? Announce a cardiac arrest and plan to assist with intubation Place an oral airway in the mouth and suction Collect pillows and pad the side rails of the bed Stay with client and monitor the condition

Stay with client and monitor the condition For the client's safety, remain at the bedside and observe respirations, the movements of the extremities and level of consciousness. Prepare to clear the airway or suction if obstructed. If suction equipment is not at the bedside, request that someone else get it for you, rather than leaving the client. Do not place anything in the client's mouth. For safety, do not leave the client unattended. A cardiac arrest should only be announced if pulse or respirations are absent after the seizure.

A nurse is caring for a client who is receiving a blood transfusion and develops urticaria one-half hour after the transfusion has begun. What is the first action the nurse should take? Take vital signs and observe for further deterioration Administer Benadryl and continue the infusion Slow the rate of infusion Stop the infusion

Stop the infusion This is an indication of an allergy to the plasma protein. The priority action of the nurse is to stop the transfusion by disconnecting at the IV insertion site. The nurse should then start a saline line at the IV insertion site and notify the health care provider.

A client with anemia has a new prescription for ferrous sulfate. When teaching the client about diet and iron supplements, what should the nurse emphasize about taking an iron supplement? Lie down for about 10 minutes after taking the pill Take the iron tablet with a glass of low-fat milk Take the iron tablet with a glass of orange juice Take an antacid with the iron supplement to reduce stomach upset

Take the iron tablet with a glass of orange juice Iron is best taken on an empty stomach, one hour before or two hours after meals, with a full glass of water or orange juice (ascorbic acid enhances the absorption of iron.) The client should not take the medication with antacids, dairy products, coffee or tea because these will decrease the effectiveness of the medicine. The client should not lie down for at least 10 minutes after taking the medicine.

The nurse is teaching the parents of a child with sickle cell disease about ways to prevent complications and crises. What information would be a priority for the nurse to emphasize to the family? The child may not be able to follow routine immunization schedules The child should be cautious of being exposed to people with a cold or fever The child should avoid becoming overheated or dehydrated during physical activity and exercise The child can maintain normal activity with some restrictions

The child should avoid becoming overheated or dehydrated during physical activity and exercise The goal of sickle cell treatment is to manage and control symptoms and to prevent sickle cell crisis. Fluid loss caused by overheating and dehydration can trigger a sickle cell crisis. People with sickle cell anemia need to keep their immunizations up-to-date, treat infections quickly, and avoid too much sun exposure.

During a 12-hour night shift, the nurse has a "near miss" and catches an error before giving a new medication. Which statement might explain the reason for the near miss? (Select all that apply.) The unit is short-staffed The nurse is interrupted when preparing the medication The nurse is sleep-deprived The nurse works in the intensive care unit (ICU) The nurse has worked on the same unit for 5 years

The unit is short-staffed Correct response The nurse is interrupted when preparing the medication Correct response The nurse is sleep-deprived This is a part of the correct response The nurse works in the intensive care unit (ICU) This is a part of the correct response There are a number of reasons for near misses and making medication errors, including heavy workload and inadequate staffing, distractions, interruptions, and inexperience. Fatigue and sleep loss are also factors, especially for nurses working in units with high acuity clients.

The nurse is working with victims of domestic abuse. The nurse should understand which of these factors is a reason why domestic violence or emotional abuse remains extensively undetected? Few people who have been battered seek medical care There are typically many series of minor, vague complaints The expenses due to police and court costs are prohibitive Little knowledge is known about batterers and battering relationships

There are typically many series of minor, vague complaints Signs of domestic violence or emotional abuse may not be clearly manifested and include many series of a minor complaints such as headache, abdominal pain, insomnia, back pain and dizziness. These may be covert indications of violence or abuse that go undetected. These complaints may be vague and reflect ambivalence about the disclosure of any violence or abuse.

The nurse is caring for a client diagnosed with a spontaneous pneumothorax. The nurse expects the client will have a chest tube inserted for which of the reasons listed below? To prevent an accumulation of blood and other tissue drainage in the pleural cavity To drain air out of the thorax with a restoration of normal intrathoracic pressure To increase the intrathoracic pressure with a restoration back to a normal pressure To drain the purulent drainage from the empyema that caused the problem

To drain air out of the thorax with a restoration of normal intrathoracic pressure With a spontaneous pneumothorax, which is not the result of a surgical procedure, normal intrathoracic pressure increases as a result of the opening in the thorax, which allows outside air to rush in and "collapse" the lung. Therefore, draining the air out of the thoracic cage reduces that increased intrathoracic pressure and restores the lung to its inflated normal. The collapsed lung is essentially reinflated.

A Hispanic couple confide in the nurse about their concern with staff giving their newborn the "evil eye." What should the nurse communicate to the other personnel who are involved in the care of this family? Avoid touching the infant above the waist Look only at the parents and not the newborn Touch the baby after looking at him Talk very slowly while speaking to him

Touch the baby after looking at him In many cultures, an "evil eye" is cast when looking at a person without touching. Thus, the spell is broken by touching while looking or assessing. Remember that quotations in the stem of the question are often the most important content in the question (evil eye). You should make the association between the words "looking" and "seeing"(eye). Also note that the answer needs to refer to the newborn, not the parents ("give the newborn the evil eye"). To only look at the parents is an unrealistic approach.

A nurse is assigned to care for a client who has been diagnosed with an intracranial aneurysm that has now stopped leaking. To minimize the risk of another bleeding episode, or rupture, the nurse should plan to take which of these actions? Avoid arousal of the client except for family visits Treat any elevation in blood pressure Apply a warming blanket for temperatures of 98 F (36.6 C) or less Keep the client in a upright sitting position

Treat any elevation in blood pressure Treating any blood pressure elevation and reducing stress by maintaining a quiet environment, including during family visits, will assist in minimizing the risk of a cerebral bleed. An upright sitting position with the pressure on the hip area can lead to increased intracranial pressure; this position should be avoided. A warming blanket is inappropriate to use.

The nurse is to review the topic of caring for clients with Guillain-Barré syndrome with other staff members at a monthly meeting. Which of these findings should the nurse include in the discussion? (Select all that apply.) Weakness, tingling or loss of sensation in legs and feet occur first Difficulty with eye movement, facial movement, speaking, chewing or swallowing Rapidly progressive ascending paralysis of the legs, arms, respiratory muscles and face Numbness, tingling, prickling sensation or moderate pain throughout the body Difficulty with bladder control or intestinal functions Hypertension

Weakness, tingling or loss of sensation in legs and feet occur first This is a part of the correct response Difficulty with eye movement, facial movement, speaking, chewing or swallowing Correct response Rapidly progressive ascending paralysis of the legs, arms, respiratory muscles and face Correct response Numbness, tingling, prickling sensation or moderate pain throughout the body This is a part of the correct response Difficulty with bladder control or intestinal functions This is a part of the correct response Guillian-Barré is an autoimmune disease. The symptoms of weakness or tingling sensation begins in the legs and progresses to the arms and upper body, resulting in almost complete paralysis. The client is often put on a ventilator during the worst part of the disease to assist breathing. The client may have low blood pressure or poor blood pressure control.

A nurse is assessing the growth of children during their school-age years. What would the nurse expect to see during this assessment? Yearly weight gain of about 5 1/2 pounds per year Little change in body appearance from year to year Decreasing amounts of body fat and muscle mass Progressive height increase of 4 inches each year

Yearly weight gain of about 5 1/2 pounds per year School-age children gain about 5 1/2 pounds each year and increase about 2 inches in height.