SAUNDERS

The nurse notes documentation that a client is exhibiting Cheyne-Stokes respirations. On assessment of the client, the nurse should expect to note which finding? A. Rhythmic respirations with periods of apnea B. Regular rapid and deep, sustained respirations C. Totally irregular respiration in rhythm and depth D. Irregular respirations with pauses at the end of inspiration and expiration

A Cheyne-Stokes respirations are rhythmic respirations with periods of apnea and can indicate a metabolic dysfunction in the cerebral hemisphere or basal ganglia. Neurogenic hyperventilation is a regular, rapid and deep, sustained respiration that can indicate a dysfunction in the low midbrain and middle pons. Ataxic respirations are totally irregular in rhythm and depth and indicate a dysfunction in the medulla. Apneustic respirations are irregular respirations with pauses at the end of inspiration and expiration and can indicate a dysfunction in the middle or caudal pons.

The nurse is administering a cleansing enema to a client with a fecal impaction. Before administering the enema, the nurse should place the client in which position? A. Left Sims' position B. Right Sims' position C. On the left side of the body, with the head of the bed elevated 45 degrees D. On the right side of the body, with the head of the bed elevated 45 degrees

A For administering an enema, the client is placed in a left Sims' position so that the enema solution can flow by gravity in the natural direction of the colon. The head of the bed is not elevated in the Sims' position.

The nurse is providing instructions to a pregnant client with human immunodeficiency virus (HIV) infection regarding care to the newborn after delivery. The client asks the nurse about the feeding options that are available. Which response should the nurse make to the client? A. "You will need to bottle-feed your newborn." B. "You will need to feed your newborn by nasogastric tube feeding." C. "You will be able to breast-feed for 6 months and then will need to switch to bottle-feeding." D. "You will be able to breast-feed for 9 months and then will need to switch to bottle-feeding."

A Perinatal transmission of HIV can occur during the antepartum period, during labor and birth, or in the postpartum period if the mother is breast-feeding. Clients who have HIV will most likely be advised not to breast-feed; however, PHCPs recommendations regarding breast-feeding are always followed. There is no physiological reason why the newborn needs to be fed by nasogastric tube.

The nurse is teaching a client about coughing and deep-breathing techniques to prevent postoperative complications. Which statement is most appropriate for the nurse to make to the client at this time as it relates to these techniques? A. "Use of an incentive spirometer will help prevent pneumonia." B. "Close monitoring of your oxygen saturation will detect hypoxemia." C. "Administration of intravenous fluids will prevent or treat fluid imbalance." D. "Early ambulation and administration of blood thinners will prevent pulmonary embolism."

A Postoperative respiratory problems are atelectasis, pneumonia, and pulmonary emboli. Pneumonia is the inflammation of lung tissue that causes productive cough, dyspnea, and lung crackles and can be caused by retained pulmonary secretions. Use of an incentive spirometer helps prevent pneumonia and atelectasis. Hypoxemia is an inadequate concentration of oxygen in arterial blood. While close monitoring of the oxygen saturation will help detect hypoxemia, monitoring is not directly related to coughing and deep-breathing techniques. Fluid imbalance can be a deficit or excess related to fluid loss or overload, and surgical clients are often given intravenous fluids to prevent a deficit; however, this is not related to coughing and deep breathing. Pulmonary embolus occurs as a result of a blockage of the pulmonary artery that disrupts blood flow to 1 or more lobes of the lung; this is usually due to clot formation. Early ambulation and administration of blood thinners helps prevent this complication; however, it is not related to coughing and deep-breathing techniques.

The nurse has just reassessed the condition of a postoperative client who was admitted 1 hour ago to the surgical unit. The nurse plans to monitor which parameter most carefully during the next hour? A. Urinary output of 20 mL/hr B. Temperature of 37.6° C (99.6° F) C. Blood pressure of 100/70 mm Hg D. Serous drainage on the surgical dressing

A Urine output should be maintained at a minimum of 30 mm Hg, are usually considered reportable immediately. The client's preoperative or baseline blood pressure is used to make informed postoperative comparisons. Moderate or light serous drainage from the surgical site is considered normal.

Which car safety device should be used for a child who is 8 years old and 4 feet tall? A. Seat belt B. Booster seat C. Rear-facing convertible seat D. Front-facing convertible seat

B All children whose weight or height is above the forward-facing limit for their car safety seat should use a belt-positioning booster seat until the vehicle seat belt fits properly, typically when they have reached 4 feet, 9 inches in height (145 cm) and are between 8 and 12 years of age. Infants should ride in a car in a semireclined, rear-facing position in an infant-only seat or a convertible seat until they weigh at least 20 pounds (9 kg) and are at least 1 year of age. The transition point for switching to the forward-facing position is defined by the manufacturer of the convertible car safety seat but is generally at a body weight of 9 kilograms (20 pounds) and 1 year of age.

The nurse is caring for a client who is on a mechanical ventilator. Blood gas results indicate a pH of 7.50 and a Paco2 of 30 mm Hg (30 mm Hg). The nurse has determined that the client is experiencing respiratory alkalosis. Which laboratory value would most likely be noted in this condition? A. Sodium level of 145 mEq/L (145 mmol/L) B. Potassium level of 3.0 mEq/L (3.0 mmol/L) C. Magnesium level of 1.8 (0.74 mmol/L) D. Phosphorus level of 3.0 mg/dL (0.97 mmol/L)

B Respiratory alkalosis is defined as a deficit of carbonic acid or a decrease in hydrogen ion concentration that results from the accumulation of base or from a loss of acid without a comparable loss of base in the body fluids. This occurs in conditions that cause overstimulation of the respiratory system. Some clinical manifestations of respiratory alkalosis include lightheadedness, confusion, tachycardia, dysrhythmias related to hypokalemia, nausea, vomiting, diarrhea, epigastric pain, and numbness and tingling of the extremities. All three incorrect options identify normal laboratory values. The correct option identifies the presence of hypokalemia.

The nurse assesses a client's surgical incision for signs of infection. Which finding by the nurse would be interpreted as a normal finding at the surgical site? A. Red, hard skin B. Serous drainage C. Purulent drainage D. Warm, tender skin

B Serous drainage is an expected finding at a surgical site. The other options indicate signs of wound infection. Signs and symptoms of infection include warm, red, and tender skin around the incision. Wound infection usually appears 3 to 6 days after surgery. The client also may have a fever and chills. Purulent material may exit from drains or from separated wound edges. Infection may be caused by poor aseptic technique or a contaminated wound before surgical exploration; existing client conditions such as diabetes mellitus or immunocompromise may place the client at risk.

The nurse is testing the extraocular movements in a client to assess for muscle weakness in the eyes. The nurse should implement which assessment technique to assess for muscle weakness in the eye? A. Test the corneal reflexes. B. Test the 6 cardinal positions of gaze. C. Test visual acuity, using a Snellen eye chart. D. Test sensory function by asking the client to close the eyes and then lightly touching the forehead, cheeks, and chin.

B Testing the 6 cardinal positions of gaze (diagnostic positions test) is done to assess for muscle weakness in the eyes. The client is asked to hold the head steady, and then to follow movement of an object through the positions of gaze. The client should follow the object in a parallel manner with the 2 eyes. A Snellen eye chart assesses visual acuity and cranial nerve II (optic). Testing sensory function by having the client close his or her eyes and then lightly touching areas of the face and testing the corneal reflexes assess cranial nerve V (trigeminal).

The nurse is monitoring a 3-month-old infant for signs of increased intracranial pressure. On palpation of the fontanels, the nurse notes that the anterior fontanel is soft and flat. On the basis of this finding, which nursing action is most appropriate? A. Increase oral fluids. B. Document the finding. C. Notify the pediatrician. D. Elevate the head of the bed to 90 degrees.

B The anterior fontanel is diamond-shaped and located on the top of the head. The fontanel should be soft and flat in a normal infant, and it normally closes by 12 to 18 months of age. The nurse would document the finding because it is normal. There is no useful reason to increase oral fluids, notify the pediatrician, or elevate the head of the bed to 90 degrees.

The nurse assesses the vital signs of a 12-month-old infant with a respiratory infection and notes that the respiratory rate is 35 breaths per minute. On the basis of this finding, which action is most appropriate? A. Administer oxygen. B. Document the findings. C. Notify the pediatrician. D. Reassess the respiratory rate in 15 minutes.

B The normal respiratory rate in a 12-month-old infant is 20 to 40 breaths per minute. The normal apical heart rate is 90 to 130 beats per minute, and the average blood pressure is 90/56 Hg. The nurse would document the findings.

The nurse is providing medication instructions to an older client who is taking digoxin daily. The nurse explains to the client that decreased lean body mass and decreased glomerular filtration rate, which are age-related body changes, could place the client at risk for which complication with medication therapy? A. Decreased absorption of digoxin B. Increased risk for digoxin toxicity C. Decreased therapeutic effect of digoxin D. Increased risk for side effects related to digoxin

B The older client is at risk for medication toxicity because of decreased lean body mass and an age-associated decreased glomerular filtration rate. This age-related change is not specifically associated with decreased absorption, decreased therapeutic effect, or increased risk for side effects. Toxicity, or toxic effects, occurs as a result of excessive accumulation of the medication in the body.

The nurse obtains a prescription from a primary health care provider to restrain a client and instructs an assistive personnel (AP) to apply the safety device to the client. Which observation of unsafe application of the safety device would indicate that further instruction is required for the AP? A. Placing a safety knot in the safety device straps B. Safely securing the safety device straps to the side rails C. Applying safety device straps that do not tighten when force is applied against them D. Securing so that 2 fingers can slide easily between the safety device and the client's skin

B The safety device straps are secured to the bed frame and never to the side rails to avoid accidental injury in the event that the side rails are released. A half-bow or safety knot or device with a quick release buckle should be used to apply a safety device because it does not tighten when force is applied against it and it allows quick and easy removal of the safety device in case of an emergency. The safety device should be secure, and 1 or 2 fingers should slide easily between the safety device and the client's skin.

A client is being prepared for a thoracentesis. The nurse should assist the client to which position for the procedure? A. Lying in bed on the affected side B. Lying in bed on the unaffected side C. Sims' position with the head of the bed flat D. Prone with the head turned to the side and supported by a pillow

B To facilitate removal of fluid from the chest, the client is positioned sitting at the edge of the bed leaning over the bedside table, with the feet supported on a stool; or lying in bed on the unaffected side with the head of the bed elevated 30 to 45 degrees. The prone and Sims' positions are inappropriate positions for this procedure.

The nurse is conducting a dietary assessment on a client who is on a vegan diet. The nurse provides dietary teaching and should focus on foods high in which vitamin that may be lacking in a vegan diet? A. Vitamin A B. Vitamin B12 C. Vitamin C D. Vitamin E

B Vegans do not consume any animal products. Vitamin B12 is found in animal products and therefore would most likely be lacking in a vegan diet. Vitamins A, C, and E are found in fresh fruits and vegetables, which are consumed in a vegan diet.

The home care nurse is visiting an older client whose spouse died 6 months ago. Which behaviors by the client indicates effective coping? Select all that apply. A. Neglecting personal grooming B. Looking at old snapshots of family C. Participating in a senior citizens program D. Visiting the spouse's grave once a month E. Decorating a wall with the spouse's pictures and awards received

B, C, D, E Coping mechanisms are behaviors used to decrease stress and anxiety. In response to a death, ineffective coping is manifested by an extreme behavior that in some cases may be harmful to the individual physically or psychologically. Neglecting personal grooming is indicative of a behavior that identifies ineffective coping in the grieving process. The remaining options identify appropriate and effective coping mechanisms.

The clinic nurse is assessing a child who is scheduled to receive a live virus vaccine (immunization). What are the general contraindications associated with receiving a live virus vaccine? Select all that apply. A. The child has symptoms of a cold. B. The child had a previous anaphylactic reaction to the vaccine. C. The mother reports that the child is having intermittent episodes of diarrhea. D. The mother reports that the child has not had an appetite and has been fussy. E. The child has a disorder that caused a severely deficient immune system. F. The mother reports that the child has recently been exposed to an infectious disease.

B, E The general contraindications for receiving live virus vaccines include a previous anaphylactic reaction to a vaccine or a component of a vaccine. In addition, live virus vaccines generally are not administered to individuals with a severely deficient immune system, individuals with a severe sensitivity to gelatin, or pregnant women. A vaccine is administered with caution to an individual with a moderate or severe acute illness, with or without fever. Options 1, 3, 4, and 6 are not contraindications to receiving a vaccine.

A client who is recovering from surgery has been advanced from a clear liquid diet to a full liquid diet. The client is looking forward to the diet change because he has been "bored" with the clear liquid diet. The nurse should offer which full liquid item to the client? A. Tea B. Gelatin C. Custard D. Ice pop

C A client who is recovering from surgery has been advanced from a clear liquid diet to a full liquid diet. The client is looking forward to the diet change because he has been "bored" with the clear liquid diet. The nurse should offer which full liquid item to the client? Rationale:Full liquid food items include items such as plain ice cream, sherbet, breakfast drinks, milk, pudding and custard, soups that are strained, refined cooked cereals, and strained vegetable juices. A clear liquid diet consists of foods that are relatively transparent. The food items in the incorrect options are clear liquids.

The nurse has conducted preoperative teaching for a client scheduled for surgery in 1 week. The client has a history of arthritis and has been taking acetylsalicylic acid. The nurse determines that the client needs additional teaching if the client makes which statement? A. "Aspirin can cause bleeding after surgery." B. "Aspirin can cause my ability to clot blood to be abnormal." C. "I need to continue to take the aspirin until the day of surgery." D. "I need to check with my doctor about the need to stop the aspirin before the scheduled surgery."

C Antiplatelets alter normal clotting factors and increase the risk of bleeding after surgery. Aspirin has properties that can alter platelet aggregation and should be discontinued at least 48 hours before surgery. However, the client should always check with his or her surgeon regarding when to stop taking the aspirin when a surgical procedure is scheduled. Options 1, 2, and 4 are accurate client statements.

The nurse is providing an educational session to new employees, and the topic is abuse of the older client. The nurse helps the employees identify which client as most typically a victim of abuse? A. A man who has moderate hypertension B. A man who has newly diagnosed cataracts C. A woman who has advanced Parkinson's disease D. A woman who has early diagnosed Lyme disease

C Elder abuse includes physical, sexual, or psychological abuse; misuse of property; and violation of rights. The typical abuse victim is a woman of advanced age with few social contacts and at least 1 physical or mental impairment that limits her ability to perform activities of daily living. In addition, the client usually lives alone or with the abuser and depends on the abuser for care.

A preoperative client expresses anxiety to the nurse about upcoming surgery. Which response by the nurse is most likely to stimulate further discussion between the client and the nurse? A. "If it's any help, everyone is nervous before surgery." B. "I will be happy to explain the entire surgical procedure to you." C. "Can you share with me what you've been told about your surgery?" D. "Let me tell you about the care you'll receive after surgery and the amount of pain you can anticipate."

C Explanations should begin with the information that the client knows. By providing the client with individualized explanations of care and procedures, the nurse can assist the client in handling anxiety and fear for a smooth preoperative experience. Clients who are calm and emotionally prepared for surgery withstand anesthesia better and experience fewer postoperative complications. Option 1 does not focus on the client's anxiety. Explaining the entire surgical procedure may increase the client's anxiety. Option 4 avoids the client's anxiety and is focused on postoperative care.

The nurse creates a plan of care for a client with deep vein thrombosis. Which client position or activity in the plan should be included? A. Out-of-bed activities as desired B. Bed rest with the affected extremity kept flat C. Bed rest with elevation of the affected extremity D. Bed rest with the affected extremity in a dependent position

C For the client with deep vein thrombosis, elevation of the affected leg facilitates blood flow by the force of gravity and also decreases venous pressure, which in turn relieves edema and pain. A flat or dependent position of the leg would not achieve this goal. Bed rest is indicated to prevent emboli and to prevent pressure fluctuations in the venous system that occur with walking.

The nurse is performing a neurological assessment on a client and notes a positive Romberg's test. The nurse makes this determination based on which observation? A. An involuntary rhythmic, rapid, twitching of the eyeballs B. A dorsiflexion of the great toe with fanning of the other toes C. A significant sway when the client stands erect with feet together, arms at the side, and the eyes closed D. A lack of normal sense of position when the client is unable to return extended fingers to a point of reference

C In Romberg's test, the client is asked to stand with the feet together and the arms at the sides, and to close the eyes and hold the position; normally the client can maintain posture and balance. A positive Romberg's sign is a vestibular neurological sign that is found when a client exhibits a loss of balance when closing the eyes. This may occur with cerebellar ataxia, loss of proprioception, and loss of vestibular function. A lack of normal sense of position coupled with an inability to return extended fingers to a point of reference is a finding that indicates a problem with coordination. A positive gaze nystagmus evaluation results in an involuntary rhythmic, rapid twitching of the eyeballs. A positive Babinski's test results in dorsiflexion of the great toe with fanning of the other toes; if this occurs in anyone older than 2 years it indicates the presence of central nervous system disease.

The nurse is performing an assessment on an older client who is having difficulty sleeping at night. Which statement by the client indicates the need for further teaching regarding measures to improve sleep? A. "I swim 3 times a week." B. "I have stopped smoking cigars." C. "I drink hot chocolate before bedtime." D. "I read for 40 minutes before bedtime."

C Many nonpharmacological sleep aids can be used to influence sleep. However, the client should avoid caffeinated beverages and stimulants such as tea, cola, and chocolate. The client should exercise regularly, because exercise promotes sleep by burning off tension that accumulates during the day. A 20- to 30-minute walk, swim, or bicycle ride 3 times a week is helpful. Smoking and alcohol should be avoided. Reading is also a helpful measure and is relaxing.

The nurse is providing instructions to the assistive personnel (AP) regarding care of an older client with hearing loss. What should the nurse tell the AP about older clients with hearing loss? A. They are often distracted. B. They have middle ear changes. C. They respond to low-pitched tones. D. They develop moist cerumen production.

C Presbycusis refers to the age-related irreversible degenerative changes of the inner ear that lead to decreased hearing ability. As a result of these changes, the older client has a decreased response to high-frequency sounds. Low-pitched voice tones are heard more easily and can be interpreted by the older client. Options 1, 2, and 4 are not accurate characteristics related to aging.

A Spanish-speaking client arrives at the triage desk in the emergency department and states to the nurse that an interpreter is needed. Which is the best action for the nurse to take? A. Have one of the client's family members interpret. B. Have the Spanish-speaking triage receptionist interpret. C. Page an interpreter from the hospital's interpreter services. D. Obtain a Spanish-English dictionary and attempt to triage the client.

C The best action is to have a professional hospital-based interpreter translate for the client. English-speaking family members may not appropriately understand what is asked of them and may paraphrase what the client is actually saying. Also, client confidentiality as well as accurate information may be compromised when a family member or a non-health care provider acts as interpreter.

The nurse is caring for a client with heart failure who is receiving high doses of a diuretic. On assessment, the nurse notes that the client has flat neck veins, generalized muscle weakness, and diminished deep tendon reflexes. The nurse suspects hyponatremia. What additional signs would the nurse expect to note in a client with hyponatremia? A. Muscle twitches B. Decreased urinary output C. Hyperactive bowel sounds D. Increased specific gravity of the urine

C The normal serum sodium level is 135 to 145 mEq/L (135 to 145 mmol/L). Hyponatremia is evidenced by a serum sodium level lower than 135 mEq/L (135 mmol/L). Hyperactive bowel sounds indicate hyponatremia. The remaining options are signs of hypernatremia. In hyponatremia, muscle weakness, increased urinary output, and decreased specific gravity of the urine would be noted.

The registered nurse is planning the client assignments for the day. Which is the most appropriate assignment for an assistive personnel (AP)? A. A client requiring a colostomy irrigation B. A client receiving continuous tube feedings C. A client who requires urine specimen collections D. A client with difficulty swallowing food and fluids

C The nurse must determine the most appropriate assignment based on the skills of the staff member and the needs of the client. In this case, the most appropriate assignment for the AP would be to care for the client who requires urine specimen collections. The AP is skilled in this procedure. Colostomy irrigations and tube feedings are not performed by APs because these are invasive procedures. The client with difficulty swallowing food and fluids is at risk for aspiration.

The nurse is creating a plan of care for a client scheduled for surgery. The nurse should include which activity in the nursing care plan for the client on the day of surgery? A. Avoid oral hygiene and rinsing with mouthwash. B. Verify that the client has not eaten for the last 24 hours. C. Have the client void immediately before going into surgery. D. Report immediately any slight increase in blood pressure or pulse.

C The nurse would assist the client to void immediately before surgery so that the bladder will be empty. Oral hygiene is allowed, but the client should not swallow any water. The client usually has a restriction of food and fluids for 6 to 8 hours (or longer as prescribed) before surgery instead of 24 hours. A slight increase in blood pressure and pulse is common during the preoperative period and is usually the result of anxiety.

The nurse enters a client's room and finds that the wastebasket is on fire. The nurse immediately assists the client out of the room. What is the next nursing action? A. Call for help. B. Extinguish the fire. C. Activate the fire alarm. D. Confine the fire by closing the room door.

C The order of priority in the event of a fire is to rescue the clients who are in immediate danger. The next step is to activate the fire alarm. The fire then is confined by closing all doors and, finally, the fire is extinguished.

The nurse is preparing to care for a dying client, and several family members are at the client's bedside. Which therapeutic techniques should the nurse use when communicating with the family? Select all that apply. A. Discourage reminiscing. B. Make the decisions for the family. C. Encourage expression of feelings, concerns, and fears. D. Explain everything that is happening to all family members. E. Touch and hold the client's or family member's hand if appropriate. F. Be honest and let the client and family know they will not be abandoned by the nurse.

C, E, F The nurse must determine whether there is a spokesperson for the family and how much the client and family want to know. The nurse needs to allow the family and client the opportunity for informed choices and assist with the decision-making process if asked. The nurse should encourage expression of feelings, concerns, and fears and reminiscing. The nurse needs to be honest and let the client and family know they will not be abandoned. The nurse should touch and hold the client's or family member's hand, if appropriate.

What are some assessment findings of a patient with hypernatremia?

CARDIOVASCULAR Heart rate and BP respond to vascular volume status RESPIRATORY Pulmonary edema if hypovolemia is present NEUROMUSCULAR Early: Spontaneous muscle twitches; irregular muscle contractions Late: Skeletal muscle weakness; deep tendon reflexes diminished or absent CENTRAL NERVOUS SYSTEM Altered cerebral function is the most common manifestation of hypernatremia Normovolemia or hypovolemia: Agitation, confusion, seizures Hypervolemia: Lethargy, stupor, coma GASTROINTESTINAL Extreme thirst INTEGUMENTARY Dry and flushed skin Dry and sticky tongue and mucous membranes Presence or absence of edema, depending on fluid volume changes LABORATORY FINDINGS Serum sodium level that exceeds 145 Increased urinary specific gravity (page 101)

What are some assessment findings of a patient with hyponatremia?

CARDIOVASCULAR Symptoms vary with changes in vascular volume Normovolemic: Rapid pulse rate, normal BP Hypovolemic: Thready, weak, rapid pulse rate; hypotension; flat neck veins; normal or low central venous pressure Hypervolemic: Rapid, bounding pulse; BP normal or elevated; normal or elevated central venous pressure RESPIRATORY Shallow, ineffective respiratory movement is a late manifestation related to skeletal muscle weakness NEUROMUSCULAR Generalized skeletal muscle weakness that is worse in the extremities Diminished deep tendon reflexes CENTRAL NERVOUS SYSTEM Headache Personality changes Confusion Seizures Coma GASTROINTESTINAL Increased motility and hyperactive bowel sounds Nausea Abdominal cramping and diarrhea RENAL Increased urinary output INTEGUMENTARY Dry mucous membranes LABORATORY FINDINGS Serum sodium level less than 135 Decreased urinary specific gravity (Page 101)

What are some assessment findings in a patient with fluid volume deficit?

CARDIOVASCULAR Thready, increased pulse rate Decreased BP and orthostatic hypotension Flat neck and hand veins in dependent positions Diminished peripheral pulses Decreased central venous pressure Dysrhythmias RESPIRATORY Increased rate & depth of respirations Dyspnea NEUROMUSCULAR Decreased central nervous system activity, from lethargy to coma Fever, depending on the amount of fluid loss Skeletal muscle weakness RENAL Decreased urine output INTEGUMENTARY Dry skin Poor turgor, tenting Dry mouth GASTROINTESTINAL Decreased motility and diminished bowel sounds Constipation Thirst Decreased body weight LABORATORY FINDINGS Increased serum osmolality Increased hematocrit Increased BUN Increased serum sodium Increased urinary specific gravity

A child is receiving a series of the hepatitis B vaccine and arrives at the clinic with his parent for the second dose. Before administering the vaccine, the nurse should ask the child and parent about a history of a severe allergy to which substance? A. Eggs B. Penicillin C. Sulfonamides D. A previous dose of hepatitis B vaccine or component

D A contraindication to receiving the hepatitis B vaccine is a previous anaphylactic reaction to a previous dose of hepatitis B vaccine or to a component (aluminum hydroxide or yeast protein) of the vaccine. An allergy to eggs, penicillin, and sulfonamides is unrelated to the contraindication to receiving this vaccine.

On review of the clients' medical records, the nurse determines that which client is at risk for fluid volume excess? A. The client taking diuretics who has tenting of the skin B. The client with an ileostomy from a recent abdominal surgery C. The client who requires intermittent gastrointestinal suctioning D. The client with kidney disease and a 12-year history of diabetes mellitus

D A fluid volume excess is also known as overhydration or fluid overload and occurs when fluid intake or fluid retention exceeds the fluid needs of the body. The causes of fluid volume excess include decreased kidney function, heart failure, use of hypotonic fluids to replace isotonic fluid losses, excessive irrigation of wounds and body cavities, and excessive ingestion of sodium. The client taking diuretics, the client with an ileostomy, and the client who requires gastrointestinal suctioning are at risk for fluid volume deficit.

The nurse is reviewing a plan of care for a client with an internal radiation implant. Which intervention, if noted in the plan, indicates the need for revision of the plan? A. Wearing gloves when emptying the client's bedpan B. Keeping all linens in the room until the implant is removed C. Wearing a lead apron when providing direct care to the client D. Placing the client in a semiprivate room at the end of the hallway

D A private room with a private bath is essential if a client has an internal radiation implant. This is necessary to prevent accidental exposure of other clients to radiation. The remaining options identify accurate interventions for a client with an internal radiation implant and protect the nurse from exposure.

The nurse is preparing to care for a client who has returned to the nursing unit after cardiac catheterization performed through the femoral vessel. The nurse checks the primary health care provider's (PHCP's) prescription and plans to allow which client position or activity after the procedure? A. Bed rest in high-Fowler's position B. Bed rest with bathroom privileges only C. Bed rest with head elevation at 60 degrees D. Bed rest with head elevation no greater than 30 degrees

D After cardiac catheterization, the extremity into which the catheter was inserted is kept straight for 4 to 6 hours. The client is maintained on bed rest for 4 to 6 hours (time for bed rest may vary depending on the primary health care provider's (PHCPs) preference and on whether a vascular closure device was used), and the client may turn from side to side. The head is elevated no more than 30 degrees (although some PHCPs prefer a lower position or the flat position) until hemostasis is adequately achieved.

The nurse is assigned to care for four clients. In planning client rounds, which client should the nurse assess first? A. A postoperative client preparing for discharge with a new medication B. A client requiring daily dressing changes of a recent surgical incision C. A client scheduled for a chest x-ray after insertion of a nasogastric tube D. A client with asthma who requested a breathing treatment during the previous shift

D Airway is always the highest priority, and the nurse would attend to the client with asthma who requested a breathing treatment during the previous shift. This could indicate that the client was experiencing difficulty breathing. The clients described in options 1, 2, and 3 have needs that would be identified as intermediate priorities.

The visiting nurse observes that the older male client is confined by his daughter-in-law to his room. When the nurse suggests that he walk to the den and join the family, he says, "I'm in everyone's way; my daughter-in-law needs me to stay here." Which is the most important action for the nurse to take? A. Say to the daughter-in-law, "Confining your father-in-law to his room is inhumane." B. Suggest to the client and daughter-in-law that they consider a nursing home for the client. C. Say nothing, because it is best for the nurse to remain neutral and wait to be asked for help. D. Suggest appropriate resources to the client and daughter-in-law, such as respite care and a senior citizens center.

D Assisting clients and families to become aware of available community support systems is a role and responsibility of the nurse. Observing that the client has begun to be confined to his room makes it necessary for the nurse to intervene legally and ethically, so option 3 is not appropriate and is passive in terms of advocacy. Option 2 suggests committing the client to a nursing home and is a premature action on the nurse's part. Although the data provided tell the nurse that this client requires nursing care, the nurse does not know the extent of the nursing care required. Option 1 is incorrect and judgmental.

The nurse is caring for an older client in a long-term care facility. Which action contributes to encouraging autonomy in the client? A. Planning meals B. Decorating the room C. Scheduling haircut appointments D. Allowing the client to choose social activities

D Autonomy is the personal freedom to direct one's own life as long as it does not impinge on the rights of others. An autonomous person is capable of rational thought. This individual can identify problems, search for alternatives, and select solutions that allow continued personal freedom as long as others and their rights and property are not harmed. Loss of autonomy, and therefore independence, is a real fear of older clients. The correct option is the only one that allows the client to be a decision maker.

The nurse is conducting preoperative teaching with a client about the use of an incentive spirometer. The nurse should include which piece of information in discussions with the client? A. Inhale as rapidly as possible. B. Keep a loose seal between the lips and the mouthpiece. C. After maximum inspiration, hold the breath for 15 seconds and exhale. D. The best results are achieved when sitting up or with the head of the bed elevated 45 to 90 degrees.

D For optimal lung expansion with the incentive spirometer, the client should assume the semi-Fowler's or high-Fowler's position. The mouthpiece should be covered completely and tightly while the client inhales slowly, with a constant flow through the unit. The breath should be held for 5 seconds before exhaling slowly.

The nurse employed in an emergency department is assigned to triage clients coming to the emergency department for treatment on the evening shift. The nurse should assign priority to which client? A. A client complaining of muscle aches, a headache, and history of seizures B. A client who twisted her ankle when rollerblading and is requesting medication for pain C. A client with a minor laceration on the index finger sustained while cutting an eggplant D. A client with chest pain who states that he just ate pizza that was made with a very spicy sauce

D In an emergency department, triage involves brief client assessment to classify clients according to their need for care and includes establishing priorities of care. The type of illness or injury, the severity of the problem, and the resources available govern the process. Clients with trauma, chest pain, severe respiratory distress or cardiac arrest, limb amputation, and acute neurological deficits and those who have sustained chemical splashes to the eyes are classified as emergent and are the highest priority. Clients with conditions such as a simple fracture, asthma without respiratory distress, fever, hypertension, abdominal pain, or a renal stone have urgent needs and are classified as a second priority. Clients with conditions such as a minor laceration, sprain, or cold symptoms are classified as nonurgent and are a third priority.

An infant receives a diphtheria, tetanus, and acellular pertussis (DTaP) immunization at a well-baby clinic. The parent returns home and calls the clinic to report that the infant has developed swelling and redness at the site of injection. Which intervention should the nurse suggest to the parent? A. Monitor the infant for a fever. B. Bring the infant back to the clinic. C. Apply a hot pack to the injection site. D. Apply a cold pack to the injection site.

D On occasion, tenderness, redness, or swelling may occur at the site of the DTaP injection. This can be relieved with cold packs for the first 24 hours, followed by warm or cold compresses if the inflammation persists. Bringing the infant back to the clinic is unnecessary. Option 1 may be an appropriate intervention but is not specific to the subject of the question, a localized reaction at the injection site. Hot packs are not applied and can be harmful by causing burning of the skin.

A client who is found unresponsive has arterial blood gases drawn and the results indicate the following: pH is 7.12, Paco2 is 90 mm Hg (90 mmol/L), and HCO3- is 22 mEq/L (22 mmol/L). The nurse interprets the results as indicating which condition? A. Metabolic acidosis with compensation B. Respiratory acidosis with compensation C. Metabolic acidosis without compensation D. Respiratory acidosis without compensation

D The acid-base disturbance is respiratory acidosis without compensation. The normal pH is 7.35 to 7.45. The normal Paco2 is 35 to 45 mm Hg. In respiratory acidosis the pH is decreased and the Pco2 is elevated. The normal bicarbonate HCO3- level is 21 to 28 mEq/L (21 to 28 mmol/L). Because the bicarbonate is still within normal limits, the kidneys have not had time to adjust for this acid-base disturbance. In addition, the pH is not within normal limits. Therefore, the condition is without compensation. The remaining options are incorrect interpretations.

A client brought to the emergency department states that he has accidentally been taking 2 times his prescribed dose of warfarin for the past week. After noting that the client has no evidence of obvious bleeding, the nurse plans to take which action? A. Prepare to administer an antidote. B. Draw a sample for type and crossmatch and transfuse the client. C. Draw a sample for an activated partial thromboplastin time (aPTT) level. D. Draw a sample for prothrombin time (PT) and international normalized ratio (INR).

D The action that the nurse should take is to draw a sample for PT and INR level to determine the client's anticoagulation status and risk for bleeding. These results will provide information as to how to best treat this client (e.g., if an antidote such as vitamin K or a blood transfusion is needed). The aPTT monitors the effects of heparin therapy.

A client has just returned to a nursing unit after an above-knee amputation of the right leg. The nurse should place the client in which position? A. Prone B. Reverse Trendelenburg's C. Supine, with the residual limb flat on the bed D. Supine, with the residual limb supported with pillows

D The residual limb is usually supported on pillows for the first 24 hours after surgery to promote venous return and decrease edema. After the first 24 hours, the residual limb usually is placed flat on the bed to reduce hip contracture. Edema also is controlled by limb-wrapping techniques. In addition, it is important to check the primary health care provider's or surgeon's prescriptions regarding positioning after amputation, because there are often differences in preference in terms of positioning after the procedure related to risks associated with hip and knee contracture

A prescription reads morphine sulfate, 8 mg stat. The medication ampule reads morphine sulfate, 10 mg/mL. The nurse prepares how many milliliters (mL) to administer the correct dose? Fill in the blank.

0.8 Use the formula to calculate the correct dose.Desired--------- × Volume = mL/doseAvailable8 mg----- × 1 mL = 0.8 mL10 mg

The nurse reviews the blood gas results of a client with atelectasis. The nurse analyzes the results and determines that the client is experiencing respiratory acidosis. Which result validates the nurse's findings? A. pH 7.25, Paco2 50 mm Hg B. pH 7.35, Paco2 40 mm Hg C. pH 7.50, Paco2 52 mm Hg D. pH 7.52, Paco2 28 mm Hg

1 Atelectasis is a condition characterized by the collapse of alveoli, preventing the respiratory exchange of oxygen and carbon dioxide in a part of the lungs. The normal pH is 7.35 to 7.45. The normal Paco2 is 35 to 45 mm Hg. In respiratory acidosis, the pH is decreased and the Paco2 is elevated. Option 2 identifies normal values. Option 3 identifies an alkalotic condition, and option 4 identifies respiratory alkalosis.

The nurse notes that a client's arterial blood gas (ABG) results reveal a pH of 7.50 and a Paco2 of 30 mm Hg (30 mm Hg). The nurse monitors the client for which clinical manifestations associated with these ABG results? Select all that apply. A. Nausea B. Confusion C. Bradypnea D. Tachycardia E. Hyperkalemia F. Lightheadedness

1, 2, 4, 6 Respiratory alkalosis is defined as a deficit of carbonic acid or a decrease in hydrogen ion concentration that results from the accumulation of base or from a loss of acid without a comparable loss of base in the body fluids. This occurs in conditions that cause overstimulation of the respiratory system. Clinical manifestations of respiratory alkalosis include lethargy, lightheadedness, confusion, tachycardia, dysrhythmias related to hypokalemia, nausea, vomiting, epigastric pain, and numbness and tingling of the extremities. Hyperventilation (tachypnea) occurs. Bradypnea describes respirations that are regular but abnormally slow. Hyperkalemia is associated with acidosis.

Several laboratory tests are prescribed for a client, and the nurse reviews the results of the tests. Which laboratory test results should the nurse report? Select all that apply. A. Platelets 35,000 mm3 (35 × 109/L) B. Sodium 150 mEq/L (150 mmol/L) C. Potassium 5.0 mEq/L (5.0 mmol/L) D. Segmented neutrophils 40% (0.40) E. Serum creatinine, 1 mg/dL (88.3 mcmol/L) F. White blood cells, 3000 mm3 (3.0 × 109/L)

1, 2, 4, 6 The normal values include the following: platelets 150,000 to 400,000 mm3 (5.0 to 10.0 × 109/L). The platelet level noted is low; the sodium level noted is high; the potassium level noted is normal; the segmented neutrophil level noted is low; the serum creatinine level noted is normal; and the white blood cell level is low.

A prescription reads to administer an intravenous (IV) dose of 400,000 units of penicillin G benzathine. The label on the 10-milliliters (mL) ampule sent from the pharmacy reads penicillin G benzathine, 300,000 units/mL. The nurse prepares how much medication to administer the correct dose? Fill in the blank. Record your answer using 1 decimal place.

1.3 Use the medication dose formula.Desired--------- × Volume = mL/doseAvailable400,000 units------------- × 1 mL = 1.33 mL300,000 units

A prescription reads levothyroxine, 150 mcg orally daily. The medication label reads levothyroxine, 0.1 mg/tablet. The nurse administers how many tablet(s) to the client? Fill in the blank.

1.5 You must convert 150 mcg to milligrams. In the metric system, to convert smaller to larger, divide by 1000 or move the decimal 3 places to the left. Therefore, 150 mcg equals 0.15 mg. Next, use the formula to calculate the correct dose.Desired--------- × Tablet(s) = Tablet(s) per doseAvailable0.15 mg------- × 1 tablet = 1.5 tablets0.1 mg

A prescription reads to infuse 1 unit of packed red blood cells over 4 hours. The unit of blood contains 250 mL. The drop factor is 10 drops (gtt)/1 mL. The nurse prepares to set the flow rate at how many drops per minute? Fill in the blank. Record your answer to the nearest whole number.

10 Use the intravenous (IV) flow rate formula.Total volume × Drop factor-------------------------- = gtt/minTime in minutes250 mL × 10 gtt 2500--------------- = --- = 10.4 gtt/min240 minutes 240= 10 gtt/min (rounded)

A prescription reads 3000 mL of D5W to be administered over a 24-hour period. The nurse determines that how many milliliters (mL) per hour will be administered to the client? Fill in the blank.

125 Use the intravenous (IV) formula to determine milliliters per hour.Total volume in mL------------------ = mL/hrNumber of hours3000 mL-------- = 125 mL/hr24 hours

A prescription reads heparin sodium, 1300 units/hr by continuous intravenous (IV) infusion. The pharmacy prepares the medication and delivers an IV bag labeled heparin sodium 20,000 units/250 mL D5W. An infusion pump must be used to administer the medication. The nurse sets the infusion pump at how many milliliters (mL) per hour to deliver 1300 units/hour? Fill in the blank. Record your answer to the nearest whole number.

16 Calculation of this problem can be done using a 2-step process. First, you need to determine the amount of heparin sodium in 1 mL. The next step is to determine the infusion rate, or milliliters per hour.Step 1: Determine the amount of heparin sodium in 1 mL.Known amount of medication-------------------------- = Medication/mLTotal volume of diluent20,000 units------------ = 80 units/mL250 mLStep 2: Calculate mL per hour.Dose per hour desired--------------------- = Milliliters per hourConcentration per mL1300 units---------- = 16.25 mL/hour80 units= 16 mL/hour (rounded)

A prescription reads phenytoin 0.2 g orally twice daily. The medication label states that each capsule is 100 mg. The nurse prepares how many capsule(s) to administer 1 dose? Fill in the blank.

2 You must convert 0.2 mg. After conversion from grams to milligrams, use the formula to calculate the correct dose.Desired--------- × Capsule(s) = capsule(s)/doseAvailable200 mg------ × 1 capsule = 2 capsules100 mg

A prescription reads clindamycin phosphate 0.3 g in 50 mL normal saline (NS) to be administered intravenously over 30 minutes. The medication label reads clindamycin phosphate 900 mg in 6 mL. The nurse prepares how many milliliters (mL) of the medication to administer the correct dose? Fill in the blank.

2 You must convert 0.3 mg. After conversion from grams to milligrams, use the formula to calculate the correct dose.Desired--------- × Volume = mL/doseAvailable300 mg------ × 6 mL = 2 mL900 mg

A prescription reads 1000 mL of normal saline (NS) to infuse over 12 hours. The drop factor is 15 drops (gtt)/1 mL. The nurse prepares to set the flow rate at how many drops per minute? Fill in the blank. Record your answer to the nearest whole number.

21 Use the intravenous (IV) flow rate formula.Total volume × Drop factor-------------------------- = gtt/minTime in minutes1000 mL × 15 gtt 15000---------------- = ----- = 20.8 gtt/min720 minutes 720= 21 gtt/min (rounded)

Cefuroxime sodium, 1 g in 50 mL normal saline (NS), is to be administered over 30 minutes. The drop factor is 15 drops (gtt)/1 mL. The nurse sets the flow rate at how many drops per minute? Fill in the blank.

25 Use the intravenous (IV) flow rate formula.Total volume × Drop factor-------------------------- = gtt/minTime in minutes50 mL × 15 gtt 750-------------- = --- = 25 gtt/min30 minutes 30

A prescription reads 1000 mL of normal saline 0.9% to infuse over 8 hours. The drop factor is 15 drops (gtt)/1 mL. The nurse sets the flow rate at how many drops per minute? Fill in the blank. Record your answer to the nearest whole number.

31 Use the intravenous (IV) flow rate formula.Total volume × Drop factor-------------------------- = gtt/minTime in minutes1000 mL × 15 gtt 15000---------------- = ----- = 31.2 gtt/min480 minutes 480= 31 gtt/min (rounded)

Gentamicin sulfate, 80 mg in 100 mL normal saline (NS), is to be administered over 30 minutes. The drop factor is 10 drops (gtt)/1 mL. The nurse sets the flow rate at how many drops per minute? Fill in the blank. Record your answer to the nearest whole number.

33 Use the intravenous (IV) flow rate formula.Total volume × Drop factor-------------------------- = gtt/minTime in minutes100 mL × 10 gtt 1000--------------- = ---- = 33.3 gtt/min30 minutes 30= 33 gtt/min (rounded)

What electrocardiographic changes could be seen in a patient with hypercalcemia?

Shortened ST segment Widened T wave Heart block (Page 99)

A prescription reads regular insulin, 8 units/hr by continuous intravenous (IV) infusion. The pharmacy prepares the medication and then delivers an IV bag labeled 100 units of regular insulin in 100 mL normal saline (NS). An infusion pump must be used to administer the medication. The nurse sets the infusion pump at how many milliliters (mL) per hour to deliver 8 units/hr? Fill in the blank.

8 Calculation of this problem can be done using a 2-step process. First, you need to determine the amount of regular insulin in 1 mL. The next step is to determine the infusion rate, or milliliters per hour.Step 1:Known amount of medication-------------------------- = Medication/mLTotal volume of diluent100 units--------- = 1 units/mL100 mLStep 2:Dose per hour desired--------------------- = mL/hrConcentration per mL8 units---------- = 8 mL/hr1 units/mL

A prescription reads 1000 mL D5W to infuse at a rate of 125 mL/hr. The nurse determines that it will take how many hours for 1 L to infuse? Fill in the blank.

8 You must determine that 1 L = 1000 mL. Next, use the formula for determining infusion time in hours.Total volume to infuse---------------------- = Infusion timemL/hr being infused1000 mL------- = 8 hours125 mL

The nurse caring for a client who has been receiving intravenous (IV) diuretics suspects that the client is experiencing a fluid volume deficit. Which assessment finding would the nurse note in a client with this condition? A. Weight loss and poor skin turgor B. Lung congestion and increased heart rate C. Decreased hematocrit and increased urine output D. Increased respirations and increased blood pressure

A A fluid volume deficit occurs when the fluid intake is not sufficient to meet the fluid needs of the body. Assessment findings in a client with a fluid volume deficit include increased respirations and heart rate, decreased central venous pressure (CVP), weight loss, poor skin turgor, dry mucous membranes, decreased urine volume, increased specific gravity of the urine, increased hematocrit, and altered level of consciousness. Lung congestion, increased urinary output, and increased blood pressure are all associated with fluid volume excess.

A client who has had abdominal surgery complains of feeling as though "something gave way" in the incisional site. The nurse removes the dressing and notes the presence of a loop of bowel protruding through the incision. Which interventions should the nurse take? Select all that apply. A. Contact the surgeon. B. Instruct the client to remain quiet. C. Prepare the client for wound closure. D. Document the findings and actions taken. E. Place a sterile saline dressing and ice packs over the wound. F. Place the client in a supine position without a pillow under the head.

A, B, C, D Wound dehiscence is the separation of the wound edges. Wound evisceration is protrusion of the internal organs through an incision. If wound dehiscence or evisceration occurs, the nurse should call for help, stay with the client, and ask another nurse to contact the surgeon and obtain needed supplies to care for the client. The nurse places the client in a low-Fowler's position, and the client is kept quiet and instructed not to cough. Protruding organs are covered with a sterile saline dressing. Ice is not applied because of its vasoconstrictive effect. The treatment for evisceration is usually immediate wound closure under local or general anesthesia. The nurse also documents the findings and actions taken.

What electrocardiographic changes could be seen in a patient with hypomagnesemia?

Tall T waves Depressed ST segment (Page 99)

The nurse is reviewing laboratory results and notes that a client's serum sodium level is 150 mEq/L (150 mmol/L). The nurse reports the serum sodium level to the primary health care provider (PHCP), and the PHCP prescribes dietary instructions based on the sodium level. Which acceptable food items does the nurse instruct the client to consume? Select all that apply. A. Peas B. Nuts C. Cheese D. Cauliflower E. Processed oat cereals

1, 2, 4 The normal serum sodium level is 135 to 145 mEq/L (135 to 145 mmol/L). A serum sodium level of 150 mEq/L (150 mmol/L) indicates hypernatremia. On the basis of this finding, the nurse would instruct the client to avoid foods high in sodium. Peas, nuts, and cauliflower are good food sources of phosphorus and are not high in sodium (unless they are canned or labeled salted). Peas and cauliflower are also a good source of magnesium. Processed foods such as cheese and processed oat cereals are high in sodium content.

The nurse is monitoring the status of a postoperative client in the immediate postoperative period. The nurse would become most concerned with which sign that could indicate an evolving complication? A. Increasing restlessness B. A pulse of 86 beats per minute C. Blood pressure of 110/70 mm Hg D. Hypoactive bowel sounds in all 4 quadrants

A Increasing restlessness is a sign that requires continuous and close monitoring because it could indicate a potential complication such as hemorrhage, shock, or pulmonary embolism. A blood pressure of 110/70 mm Hg with a pulse of 86 beats per minute is within normal limits. Hypoactive bowel sounds heard in all 4 quadrants are a normal occurrence in the immediate postoperative period.

The nurse is providing instructions to a client and the family regarding home care after right eye cataract removal. Which statement by the client would indicate an understanding of the instructions? A. "I should sleep on my left side." B. "I should sleep on my right side." C. "I should sleep with my head flat." D. "I should not wear my glasses at any time."

A After cataract surgery, the client should not sleep on the side of the body that was operated on to prevent edema formation and intraocular pressure. The client also should be placed in a semi-Fowler's position to assist in minimizing edema and intraocular pressure. During the day, the client may wear glasses or a protective shield; at night, the protective shield alone is sufficient.

The nurse reviews a client's laboratory report and notes that the client's serum phosphorus (phosphate) level is 1.8 mg/dL (0.58 mmol/L). Which condition most likely caused this serum phosphorus level? A. Malnutrition B. Renal insufficiency C. Hypoparathyroidism D. Tumor lysis syndrome

A The normal serum phosphorus (phosphate) level is 3.0 to 4.5 mg/dL (0.97 to 1.45 mmol/L). The client is experiencing hypophosphatemia. Causative factors relate to malnutrition or starvation and the use of aluminum hydroxide-based or magnesium-based antacids. Renal insufficiency, hypoparathyroidism, and tumor lysis syndrome are causative factors of hyperphosphatemia.

A 2-year-old child is treated in the emergency department for a burn to the chest and abdomen. The child sustained the burn by grabbing a cup of hot coffee that was left on the kitchen counter. The nurse reviews safety principles with the parents before discharge. Which statement by the parents indicates an understanding of measures to provide safety in the home? A. "We will be sure not to leave hot liquids unattended." B. "I guess our children need to understand what the word hot means." C. "We will be sure that the children stay in their rooms when we work in the kitchen." D. "We will install a safety gate as soon as we get home so the children cannot get into the kitchen."

A Toddlers, with their increased mobility and development of motor skills, can reach hot water or hot objects placed on counters and stoves and can reach open fires or stove burners above their eye level. The nurse should encourage parents to remain in the kitchen when preparing a meal, use the back burners on the stove, and turn pot handles inward and toward the middle of the stove. Hot liquids should never be left unattended or within the child's reach, and the toddler should always be supervised. The statements in options 2, 3, and 4 do not indicate an understanding of the principles of safety.

The mother of a 3-year-old asks a clinic nurse about appropriate and safe toys for the child. The nurse should tell the mother that the most appropriate toy for a 3-year-old is which? A. A wagon B. A golf set C. A farm set D. A jack set with marbles

A Toys for the toddler must be strong, safe, and too large to swallow or place in the ear or nose. Toddlers need supervision at all times. Push-pull toys, large balls, large crayons, large trucks, and dolls are some of the appropriate toys. A farm set, a golf set, and jacks with marbles may contain items that the child could swallow.

The nurse reviews a client's record and determines that the client is at risk for developing a potassium deficit if which situation is documented? A. Sustained tissue damage B. Requires nasogastric suction C. Has a history of Addison's disease D. Uric acid level of 9.4 mg/dL (557 mcmol/L)

B The normal serum potassium level is 3.5 to 5.0 mEq/L (3.5 to 5.0 mmol/L). A potassium deficit is known as hypokalemia. Potassium-rich gastrointestinal fluids are lost through gastrointestinal suction, placing the client at risk for hypokalemia. The client with tissue damage or Addison's disease and the client with hyperuricemia are at risk for hyperkalemia. The normal uric acid level for a female is 2.7 to 7.3 mg/dL (160 to 430 mcmol/L) and for a male is 4.0 to 8.5 mg/dL (240 to 501 mcmol/L).

The nurse is preparing to insert a nasogastric tube into a client. The nurse should place the client in which position for insertion? A. Right side B. Low-Fowler's C. High-Fowler's D. Supine with the head flat

C During insertion of a nasogastric tube, the client is placed in a sitting or high-Fowler's position to facilitate insertion of the tube and reduce the risk of pulmonary aspiration if the client should vomit. The right side and low-Fowler's and supine positions place the client at risk for aspiration; in addition, these positions do not facilitate insertion of the tube.

The nurse is caring for a client with a severe burn who is scheduled for an autograft to be placed on the lower extremity. The nurse creates a postoperative plan of care for the client and should include which intervention in the plan? A. Maintain the client in a prone position. B. Elevate and immobilize the grafted extremity. C. Maintain the grafted extremity in a flat position. D. Keep the grafted extremity covered with a blanket.

B Autografts placed over joints or on lower extremities are elevated and immobilized after surgery for 3 to 7 days, depending on the surgeon's preference. This period of immobilization allows the autograft time to adhere and attach to the wound bed, and the elevation minimizes edema. Keeping the client in a prone position and covering the extremity with a blanket can disrupt the graft site.

The nurse employed in a long-term care facility is planning assignments for the clients on a nursing unit. The nurse needs to assign four clients and has a licensed practical nurse and 3 assistive personnel (APs) on a nursing team. Which client would the nurse most appropriately assign to the licensed practical nurse? A. A client who requires a bed bath B. An older client requiring frequent ambulation C. A client who requires hourly vital sign measurements D. A client requiring abdominal wound irrigations and dressing changes every 3 hours

D

The nurse is giving report to an assistive personnel (AP) who will be caring for a client in hand restraints (safety devices). How frequently should the nurse instruct the AP to check the tightness of the restrained hands? A. Every 2 hours B. Every 3 hours C. Every 4 hours D. Every 30 minutes

D

What electrocardiographic changes could be seen in a patient with hypermagnesemia?

Prolonged PR interval Widened QRS complexes (Page 99)

What electrocardiographic changes could be seen in a patient with hypocalcemia?

Prolonged ST segment Prolonged QT interval (Page 99)

What electrocardiographic changes could be seen in a patient with hyperkalemia?

Tall peaked T waves Flat P waves Widened QRS complexes Prolonged QR interval (Page 99)

The nurse reviews a client's electrolyte laboratory report and notes that the potassium level is 2.5 mmol/L). Which patterns should the nurse watch for on the electrocardiogram (ECG) as a result of the laboratory value? Select all that apply. A. U waves B. Absent P waves C. Inverted T waves D. Depressed ST segment E. Widened QRS complex

1, 3, 4 The normal serum potassium level is 3.5 to 5.0 mEq/L (3.5 to 5.0 mmol/L). A serum potassium level lower than 3.5 mEq/L (3.5 mmol/L) indicates hypokalemia. Potassium deficit is an electrolyte imbalance that can be potentially life-threatening. Electrocardiographic changes include shallow, flat, or inverted T waves; ST segment depression; and prominent U waves. Absent P waves are not a characteristic of hypokalemia but may be noted in a client with atrial fibrillation, junctional rhythms, or ventricular rhythms. A widened QRS complex may be noted in hyperkalemia and in hypermagnesemia.

The nurse is preparing to initiate an intravenous (IV) line containing a high dose of potassium chloride using an IV infusion pump. While preparing to plug the pump cord into the wall, the nurse finds that no receptacle is available in the wall socket. The nurse should take which action? A. Initiate the IV line without the use of a pump. B. Contact the electrical maintenance department for assistance. C. Plug in the pump cord in the available plug above the room sink. D. Use an extension cord from the nurses' lounge for the pump plug.

B Electrical equipment must be maintained in good working order and should be grounded; otherwise, it presents a physical hazard. An IV line that contains a dose of potassium chloride should be administered by an infusion pump. The nurse needs to use hospital resources for assistance. A regular extension cord should not be used because it poses a risk for fire. Use of electrical appliances near a sink also presents a hazard.

The emergency department (ED) nurse receives a telephone call and is informed that a tornado has hit a local residential area and that numerous casualties have occurred. The victims will be brought to the ED. The nurse should take which initial action? A. Prepare the triage rooms. B. Activate the emergency response plan specific to the facility. C. Obtain additional supplies from the central supply department. D. Obtain additional nursing staff to assist in treating the casualties.

B In an external disaster (a disaster that occurs outside of the institution or agency), many victims may be brought to the ED for treatment. The initial nursing action must be to activate the emergency response plan specific to the facility. Once the emergency response plan is activated, the actions in the other options will occur.

The nurse is caring for a client who is 1 day postoperative for a total hip replacement. Which is the best position in which the nurse should place the client? A. Head elevated lying on the operative side B. On the nonoperative side with the legs abducted C. Side-lying with the affected leg internally rotated D. Side-lying with the affected leg externally rotated

B Positioning after a total hip replacement depends on the surgical techniques used, the method of implantation, the prosthesis, and the primary health care provider's (PHCP's) preference. Abduction is maintained when the client is in a supine position or positioned on the nonoperative side. Internal and external rotation, adduction, or lying on the operative side (unless specifically prescribed by the PHCP) is avoided to prevent displacement of the prosthesis.

Which client is at risk for the development of a potassium level of 5.5 mEq/L (5.5 mmol/L)? A. The client with colitis B. The client with Cushing's syndrome C. The client who has been overusing laxatives D. The client who has sustained a traumatic burn

D The normal potassium level is 3.5 to 5.0 mEq/L (3.5 to 5.0 mmol/L). A serum potassium level higher than 5.0 mEq/L (5.0 mmol/L) indicates hyperkalemia. Clients who experience cellular shifting of potassium in the early stages of massive cell destruction, such as with trauma, burns, sepsis, or metabolic or respiratory acidosis, are at risk for hyperkalemia. The client with Cushing's syndrome or colitis and the client who has been overusing laxatives are at risk for hypokalemia.

The nurse is caring for a client following a craniotomy, in which a large cancerous tumor was removed from the left side. In which position can the nurse safely place the client? Refer to the figure. 1 2 3 4

1 Clients who have undergone craniotomy should have the head of the bed elevated 30 to 45 degrees to promote venous drainage from the head. The client is positioned to avoid extreme hip or neck flexion and the head is maintained in a midline neutral position. The client should not be positioned on the site that was operated on, especially if the bone flap was removed, because the brain has no bony covering on the affected site. A flat position or Trendelenburg's position would increase intracranial pressure. A reverse Trendelenburg's position would not be helpful and may be uncomfortable for the client.

A postoperative client has been placed on a clear liquid diet. The nurse should provide the client with which items that are allowed to be consumed on this diet? Select all that apply. A. Broth B. Coffee C. Gelatin D. Pudding E. Vegetable juice F. Pureed vegetables

1, 2, 3 A clear liquid diet consists of foods that are relatively transparent to light and are clear and liquid at room and body temperature. These foods include items such as water, bouillon, clear broth, carbonated beverages, gelatin, hard candy, lemonade, ice pops, and regular or decaffeinated coffee or tea. The incorrect food items are items that are allowed on a full liquid diet.

A prescription reads potassium chloride 30 mEq to be added to 1000 mL normal saline (NS) and to be administered over a 10-hour period. The label on the medication bottle reads 40 mEq/20 mL. The nurse prepares how many milliliters (mL) of potassium chloride to administer the correct dose of medication? Fill in the blank.

15 In most facilities, potassium chloride is premixed in the intravenous solution and the nurse will need to verify the correct dose before administration. In some cases the nurse will need to add the potassium chloride and will use the medication calculation formula to determine the mL to be added.Desired--------- × Volume = mL/doseAvailable30 mEq------ × 20 mL = 15 mL40 mEq

The nurse provides instructions to a client with a low potassium level about the foods that are high in potassium and tells the client to consume which foods? Select all that apply. A. Peas B. Raisins C. Potatoes D. Cantaloupe E. Cauliflower F. Strawberries

2, 3, 4, 6 The normal potassium level is 3.5 to 5.0 mEq/L (3.5 to 5.0 mmol/L). Common food sources of potassium include avocado, bananas, cantaloupe, carrots, fish, mushrooms, oranges, potatoes, pork, beef, veal, raisins, spinach, strawberries, and tomatoes. Peas and cauliflower are high in magnesium.

The nurse notes that a 6-year-old child does not recognize that objects exist when the objects are outside of the visual field. Based on this observation, which action should the nurse take? A. Report the observation to the pediatrician. B. Move the objects in the child's direct field of vision. C. Teach the child how to visually scan the environment. D. Provide additional lighting for the child during play activities.

A According to Jean Piaget's theory of cognitive development, it is normal for the infant or toddler not to recognize that objects continue to be in existence if out of the visual field; however, this is abnormal for the 6-year-old. If a 6-year-old child does not recognize that objects still exist even when outside the visual field, the child is not progressing normally through the developmental stages. The nurse should report this finding to the pediatrician. Options 2, 3, and 4 delay necessary follow-up and treatment.

The nurse is reviewing a surgeon's prescription sheet for a preoperative client that states that the client must be nothing by mouth (NPO) after midnight. The nurse should call the surgeon to clarify that which medication should be given to the client and not withheld? A. Prednisone B. Ferrous sulfate C. Cyclobenzaprine D. Conjugated estrogen

A Prednisone is a corticosteroid. With prolonged use, corticosteroids cause adrenal atrophy, which reduces the ability of the body to withstand stress. When stress is severe, corticosteroids are essential to life. Before and during surgery, dosages may be increased temporarily and may be given parenterally rather than orally. Ferrous sulfate is an oral iron preparation used to treat iron deficiency anemia. Cyclobenzaprine is a skeletal muscle relaxant. Conjugated estrogen is an estrogen used for hormone replacement therapy in postmenopausal women. These last 3 medications may be withheld before surgery without undue effects on the client.

A client who has undergone preadmission testing has had blood drawn for serum laboratory studies, including a complete blood count, coagulation studies, and electrolytes and creatinine levels. Which laboratory result should be reported to the surgeon's office by the nurse, knowing that it could cause surgery to be postponed? A. Hemoglobin, 8.0 g/dL (80 mmol/L) B. Sodium, 145 mEq/L (145 mmol/L) C. Serum creatinine, 0.8 mg/dL (70.6 mcmol/L) D. Platelets, 210,000 cells/mm3 (210 × 109/L)

A Routine screening tests include a complete blood count, serum electrolyte analysis, coagulation studies, and a serum creatinine test. The complete blood count includes the hemoglobin analysis. All of these values are within normal range except for hemoglobin. If a client has a low hemoglobin level, the surgery likely could be postponed by the surgeon.

The nurse receives a telephone call from the postanesthesia care unit stating that a client is being transferred to the surgical unit. The nurse plans to take which action first on arrival of the client? A. Assess the patency of the airway. B. Check tubes or drains for patency. C. Check the dressing to assess for bleeding. D. Assess the vital signs to compare with preoperative measurements.

A The first action of the nurse is to assess the patency of the airway and respiratory function. If the airway is not patent, the nurse must take immediate measures for the survival of the client. The nurse then takes vital signs followed by checking the dressing and the tubes or drains. The other nursing actions should be performed after a patent airway has been established.

Which client is at risk for the development of a sodium level at 130 mEq/L (130 mmol/L)? A. The client who is taking diuretics B. The client with hyperaldosteronism C. The client with Cushing's syndrome D. The client who is taking corticosteroids

A The normal serum sodium level is 135 to 145 mEq/L (135 to 145 mmol/L). A serum sodium level of 130 mEq/L (130 mmol/L) indicates hyponatremia. Hyponatremia can occur in the client taking diuretics. The client taking corticosteroids and the client with hyperaldosteronism or Cushing's syndrome are at risk for hypernatremia.

The home health nurse is visiting a client for the first time. While assessing the client's medication history, it is noted that there are 19 prescriptions and several over-the-counter medications that the client has been taking. Which intervention should the nurse take first? A. Check for medication interactions. B. Determine whether there are medication duplications. C. Determine whether a family member supervises medication administration. D. Call the prescribing primary health care provider (PHCP) and report polypharmacy.

B Polypharmacy is a concern in the older client. Duplication of medications needs to be identified before medication interactions can be determined, because the nurse needs to know what the client is taking. Asking about medication administration supervision may be part of the assessment but is not a first action. The phone call to the PHCP is the intervention after all other information has been collected.

The nurse is giving a bed bath to an assigned client when an assistive personnel (AP) enters the client's room and tells the nurse that another assigned client is in pain and needs pain medication. Which is the most appropriate nursing action? A. Finish the bed bath and then administer the pain medication to the other client. B. Ask the AP to find out when the last pain medication was given to the client. C. Ask the AP to tell the client in pain that medication will be administered as soon as the bed bath is complete. D. Cover the client, raise the side rails, tell the client that you will return shortly, and administer the pain medication to the other client.

D The nurse is responsible for the care provided to assigned clients. The appropriate action in this situation is to provide safety to the client who is receiving the bed bath and prepare to administer the pain medication. Options 1 and 3 delay the administration of medication to the client in pain. Option 2 is not a responsibility of the AP.

The nurse has received the assignment for the day shift. After making initial rounds and checking all of the assigned clients, which client should the nurse plan to care for first? A. A client who is ambulatory demonstrating steady gait B. A postoperative client who has just received an opioid pain medication C. A client scheduled for physical therapy for the first crutch-walking session D. A client with a white blood cell count of 14,000 mm3 (14 x 109/L) and a temperature of 38.4° C

D The nurse should plan to care for the client who has an elevated white blood cell count and a fever first, because this client's needs are the priority. The client who is ambulatory with steady gait and the client scheduled for physical therapy for a crutch-walking session do not have priority needs. Waiting for pain medication to take effect before providing care to the postoperative client is best.

The nurse is reading a primary health care provider's (PHCP's) progress notes in the client's record and reads that the PHCP has documented "insensible fluid loss of approximately 800 mL daily." The nurse makes a notation that insensible fluid loss occurs through which type of excretion? A. Urinary output B. Wound drainage C. Integumentary output D. The gastrointestinal tract

C Insensible losses may occur without the person's awareness. Insensible losses occur daily through the skin and the lungs. Sensible losses are those of which the person is aware, such as through urination, wound drainage, and gastrointestinal tract losses.