Week 1: Physiological adaptation

A nurse is teaching a client about how to recognize when treatment for hypothyroidism is effective. Which statement from the client would indicate that the nurse's teaching has been effective?

"I will start feeling more energetic." Understanding of the treatment for hypothyroidism is shown when the client can identify what changes will signify improvement. An increase in energy will demonstrate that therapy has been effective and the thyroid levels are rising. The other choices are all examples of hyperthyroidism

A client has had hoarseness for more than 2 weeks. What should the nurse do?

Assess the client for dysphagia. Hoarseness occurring longer than 2 weeks is a warning sign of laryngeal cancer. The nurse should first assess other signs, such as a lump in the neck or throat, persistent sore throat or cough, earache, pain, and difficulty swallowing (dysphagia). Gargling with salt water may lead to increased irritation. There is no indication of infection warranting an antibiotic. An oral analgesic would provide only temporary relief of discomfort if hoarseness is accompanied by a sore throat.

The nurse finds a visitor unconscious with spontaneous breathing sitting in a chair in the waiting room. What priority action(s) will the nurse implement? Select all that apply.

Attempt to identify the visitor. Call a rapid response team. The nurse will need to attempt to identify the visitor and call a rapid response team. The visitor is breathing and sitting in a chair, so the team will change positions with care. The supervisor will be notified through the call of the rapid response team. Asking other visitors for help is not appropriate for the care of the unconscious person.

The nurse in the postanesthesia care unit notes that one of the client's pupils is larger than the other. What should the nurse do next?

Check the client's baseline data. The nurse should check the client's baseline data to ascertain whether the client's pupil has always been enlarged or this is a new finding. The preoperative assessment is valuable as the baseline for comparison of all subsequent assessments made throughout the perioperative period. The nurse may determine that a more involved neurologic examination is indicated or may choose to assess other signs using the Glasgow Coma Scale, administer oxygen, or call the surgeon, but the nurse still needs to know the baseline data before proceeding.

A nurse is assessing an adult who has been receiving chemotherapy. The client has a platelet count of 22,000 cells/mm3 (22 × 109/L) and has petechiae on the lower extremities. What should the nurse should instruct the client to do?

Consult the health care provider. Petechiae are tiny, purplish, hemorrhagic spots visible under the skin. Petechiae usually appear when platelets are depleted. Bleeding gums or oozing of blood may accompany the petechiae, and the client should seek medical assistance immediately. Increasing iron in the diet will not improve the platelet count. Lotion will not treat the petechiae. Elevating the legs will not cause the petechiae to disappear.

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

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

A client with aortic stenosis has increasing dyspnea and dizziness. Identify the area where the nurse would place the stethoscope to assess a murmur from aortic stenosis.

To assess a murmur from aortic stenosis, the stethoscope is placed at the second intercostal space right of sternum; (1). location, (2) the pulmonic valve area, (3) Erb's point, (4) tricuspid valve area, and (5) mitral valve area.

The nurse is establishing goals for the client with hepatitis A? Which goal is appropriate?

Verbalize the importance of reporting bleeding gums or bloody stools. The client should be able to verbalize the importance of reporting any bleeding tendencies that could be the result of a prolonged prothrombin time. Ascites is not typically a clinical manifestation of hepatitis; it is associated with cirrhosis. Alcohol use should be eliminated for at least 1 year after the diagnosis of hepatitis to allow the liver time to fully recover. There is no need for a client to be restricted to the home because hepatitis is not spread through casual contact between individuals.

While performing cardiopulmonary resuscitation (CPR) on a 5-year-old child, the nurse palpates for a pulse. Which site is best for checking the pulse during CPR in a 5-year-old child?

carotid artery Checking the carotid artery pulse in a child during CPR provides information about perfusion of the brain. The brachial pulse is checked in an infant because the infant's short and typically fat neck makes it difficult to palpate the carotid pulse. The femoral and radial arteries might indicate perfusion to the peripheral body sites, but the critical need is for adequate circulation to the brain.

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

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

A client is hospitalized with Guillain-Barré syndrome. Which nursing assessment finding is mostsignificant?

even, unlabored respirations A characteristic feature of Guillain-Barré syndrome is ascending weakness, which usually begins in the legs and progresses upward to the trunk, arms, and face. Respiratory muscle weakness, evidenced by even, unlabored respirations, is a particularly dangerous effect of this disease progression because it may lead to respiratory failure and death. Therefore, although warm, dry skin; urine output of 40 ml/hour; and a soft, nondistended abdomen are pertinent assessment data, those related to respiratory function and status are most significant.

The nurse is educating a client with systemic lupus erythematosus (SLE) about self-management. For what sign or symptom does the nurse tell the client to seek immediate medical attention?

having decreased urine output A serious complication of SLE is lupus nephritis, which presents with proteinuria, hematuria, and kidney dysfunction with a decline in glomerular filtration rate. The prognosis for preserving kidney function is best if the condition is detected and treated early, and the nurse ensures the client knows to seek immediate attention for urinary symptoms. Rash, fatigue, and painful joints are typical with SLE but do not pose an immediate threat to the client's health.

A primary health care provider prescribes regular insulin 10 units intravenously (I.V.) along with 50 ml of dextrose 50% for a client with acute renal failure. What electrolyte imbalance is this client most likely experiencing?

hyperkalemia Administering regular insulin I.V. concomitantly with 50 ml of dextrose 50% helps shift potassium from the extracellular fluid into the cell, which normalizes serum potassium levels in the client with hyperkalemia. This combination does not help reverse the effects of hypercalcemia, hypernatremia, or hypermagnesemia.

A 4-week-old infant admitted with the diagnosis of hypertrophic pyloric stenosis presents with a history of vomiting. The nurse should anticipate that the infant's vomitus would contain gastric contents and which other substances?

mucus and streaks of blood The vomitus of an infant with hypertrophic pyloric stenosis contains gastric contents, mucus, and streaks of blood. The vomitus does not contain bile or stool because the pyloric constriction is proximal to the ampulla of Vater.

A 10-month-old child with phenylketonuria (PKU) is being weaned from breast-feeding. When teaching the parents about the proper diet for their child, the nurse should stress the importance of restricting meats and dairy products because:

they contain high levels of phenylalanine. PKU is an inherited disorder characterized by the inability to metabolize phenylalanine, an essential amino acid. Phenylalanine accumulation in the blood results in central nervous system damage and progressive intellectual disability. However, early detection of PKU and dietary restriction of phenylalanine can prevent disease progression. Intake of high-protein foods, such as meats and dairy products, must be restricted throughout life because they contain large amounts of phenylalanine.

A nurse is helping a physician insert a subclavian central line. After the physician has gained access to the subclavian vein, the phyician connects a 10-ml syringe to the catheter and withdraws a sample of blood. The phyisician then disconnects the syringe from the port. Suddenly, the client becomes confused, disoriented, and pale. The nurse suspects an air embolus. The nurse should

turn the client on the left side and place the bed in Trendelenburg's position. A nurse who suspects an air embolism should place the client on their left side and in Trendelenburg's position. Doing so allows the air to collect in the right atrium rather than enter the pulmonary system. The supine position, high-Fowler's position, and the shock position are therapeutic for other situations but not for air embolism.

The nurse is caring for a 2-year-old child with cancer. The parents have been told that the child will need an allogeneic bone marrow transplant and want to know what this means. What is the bestresponse by the nurse?

"A donor is determined after testing for similar human leukocyte antigens." An allogeneic transplant is one in which the donor and the recipient are related or unrelated but share similar human leukocyte antigens (HLA).

A 10-month-old child with recurrent otitis media is brought to the clinic for evaluation. What is mostimportant for the nurse to ask the family about the baby's symptoms?

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

The nurse admits an 8-year-old child who is unconscious secondary to ketoacidosis. During the admission history, which parental statement is most consistent with the diagnosis of insulin-dependent diabetes?

"He started to wet his bed at night for the first time in 3 years." Bed-wetting in a previously continent child is a sign suggesting hyperglycemia. The enuresis is due to polyuria, one of the cardinal signs of insulin-dependent diabetes mellitus. Other signs include polydipsia (excessive thirst) and polyphagia (excessive hunger).Typically, the child with hyperglycemia secondary to insulin-dependent diabetes is slightly lethargic.Although the child with insulin-dependent diabetes experiences excessive hunger (polyphagia), the child loses weight even though he is eating more.

When determining the effectiveness of teaching a child's mother about sickle cell disease, which statement by the mother indicates the need for additional teaching?

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

A client diagnosed with hyperosmolar hyperglycemic nonketotic syndrome (HHNS) is stabilized and prepared for discharge. When preparing the client for discharge and home management, which statement indicates that the client understands the condition and how to control it?

"I can avoid getting sick by not becoming dehydrated and by paying attention to my need to urinate, drink, or eat more than usual." Stating the need to remain hydrated and pay attention to eating, drinking, and voiding needs indicates that the client understands HHNS. Inadequate fluid intake during hyperglycemic episodes commonly leads to HHNS. By recognizing the signs of hyperglycemia (polyuria, polydipsia, and polyphagia) and increasing fluid intake, the client may prevent HHNS. Drinking a glass of nondiet soda would be appropriate for hypoglycemia. Limiting fluids will exacerbate the development of HHNS; limiting food might be acceptable, but it may lead to ketosis. A high-carbohydrate diet would exacerbate the client's condition, particularly if fluid intake is low

In preparation for discharge, the nurse teaches the mother of an infant diagnosed with bronchiolitis about the condition and its treatment. Which statement by the mother indicates successful teaching?

"I need to wash my hands more often." Handwashing is the best way to prevent respiratory illnesses and the spread of disease. Bronchiolitis, a viral infection primarily affecting the bronchioles, causes swelling and mucus accumulation of the lumina and subsequent hyperinflation of the lung with air trapping. It is transmitted primarily by direct contact with respiratory secretions as a result of eye-to-hand or nose-to-hand contact or from contaminated fomites. Therefore, handwashing minimizes the risk for transmission. Taking the child's temperature is not appropriate in most cases. As long as the child is getting better, taking the temperature will not be helpful. The mother's statement that she hopes she does not get a cold from her child does not indicate understanding of what to do after discharge. For most parents, listening to the child's chest would not be helpful because the parents would not know what they were listening for. Rather, watching for an increased respiratory rate, fever, or evidence of poor eating or drinking would be more helpful in alerting the parent to potential illness.

Which client statement indicates a need for further instruction about a duodenal ulcer?

"I will need to take an antacid before every meal." Antacids such as magnesium hydroxide provide short-term relief for gastric ulcers and reflux but do not exert effects in the small intestine. Medications used for ulcer treatment include histamine blockers such as ranitidine and proton pump inhibitors such as omeprazole for duodenal and gastric ulcers. Additional treatment for duodenal ulcers includes avoidance of irritants such as alcohol, caffeine, and tobacco. Clients should avoid foods that aggravate their symptoms, which commonly include foods that are highly spiced. Stress management is an important tool in ulcer treatment because stress increases release of cortisol, which can cause ulcers.

The nurse is caring for a client who has been diagnosed with pernicious anemia. Which statement by the client indicates an understanding of the treatment of pernicious anemia?

"I'll need to take vitamin B12 replacements for the rest of my life." Clients who have been diagnosed with pernicious anemia are lacking adequate amounts of the intrinsic factor (IF) that is secreted by the gastric mucosa. IF is necessary for the absorption of cobalamin (vitamin B12) in the distal ileum. Without the presence of IF, dietary intake of vitamin B12is useless because it cannot be absorbed. Treatment of pernicious anemia includes IM injections of cobalamin, at first daily for 2 weeks, then weekly until the anemia is corrected. A maintenance schedule of monthly injections is then implemented. The injections will need to be continued for the rest of the client's life.

An obese client, age 65, is diagnosed with type 2 diabetes. When educating this client about the diagnosis, the nurse knows that more education is needed when the client says which statement? Select all that apply.

"If I follow my diet and exercise, I won't have diabetes any more." "I can never eat a hot fudge sundae again." "I guess I will need to stop meeting my friends at the coffee shop." Patients with type 2 diabetes who follow a diet and exercise program will likely be able to achieve normal blood sugar levels, but cannot consider themselves "cured" of diabetes. Renal failure is a possible complication of uncontrolled diabetes. People with well controlled diabetes can modify their diet to include occasional treats like ice cream if they select sugar free versions. Meeting friends for coffee is fine as long as the client does not include high sugar items along with the beverage. Type 2 diabetes can often be controlled with oral hypoglycemics.

Which statement by the parent of a toddler diagnosed with nephrotic syndrome indicates that the parent has understood the nurse's teaching about this disease?

"My child really likes chips and bologna. I guess we will have to find something else." Children with nephrotic syndrome usually require sodium restriction. Because potato chips and bologna are high in sodium, the mother's statement about finding something else reflects understanding of this need. Although fluid intake is not restricted in children with nephrotic syndrome, 4 L is an excessive amount for a toddler. The typical fluid requirement for a toddler is 115 mL/kg. Surgical intervention and antibiotic therapy are not parts of the treatment plan for nephrotic syndrome.

The nurse is educating a group of parents about respiratory disorders in young children. One of the mothers tells the nurse that she has noticed her child's nostrils flaring when the child has a respiratory infection. The mother asks the nurse if she should be concerned. What is the mostappropriate response by the nurse?

"Nasal flaring occurs when a child has to work hard to breathe." Nasal flaring refers to the enlargement of the opening of the nostrils during breathing. Nasal flaring is seen primarily in infants and younger children. Any condition that causes the infant to work harder to obtain enough air can cause nasal flaring. Although many causes of nasal flaring are not serious, some can be life threatening. In young infants, nasal flaring can be a very important sign of respiratory distress.

When obtaining a health history from a client newly admitted to the hospital, which statement indicates the client's needs for further follow-up?

"No matter how much I drink, I'm still thirsty all the time." Polydipsia, or increased thirst, is a classic clinical manifestation of diabetes. The excessive loss of fluids is the result of the osmotic diuresis that occurs with glycosuria. Other clinical manifestations include hunger, fatigue, blurred vision, slow-healing wounds, and hyperglycemia. The report of shortness of breath is not an acute issue and can be followed up upon later. In addition, painful joints and having trouble urinating are a concern to the client and should be addressed after the acute health concern is addressed.

A 7-month-old female infant is admitted to the hospital with a tentative diagnosis of Hirschsprung's disease. When obtaining the infant's initial health history from the parents, which statement made by the parent would be most consistent with the diagnosis of Hirschsprung's disease?

"She gets constipated often." Infants with Hirschsprung's disease typically have a history of abdominal distention, constipation, periodic diarrhea (when liquid stool leaks around the semiobstructed colon), and failure to thrive.Having an occasional cold is not unusual for an infant and is not related to Hirschsprung's disease.Spitting up once in a while is not unusual for an infant.A rectal temperature of 99.4° F (37.4° C) would be considered normal.

After teaching the parents of an infant diagnosed with Hirschsprung's disease, the nurse determines that the parents understand the diagnosis when the parent makes which statement?

"The nerves at the end of the large colon are missing." The primary defect in Hirschsprung's disease is an absence of autonomic parasympathetic ganglion cells in the distal portion of the colon. Thus, the nerves at the end of the large colon are missing. Constipation is caused by decreased peristalsis, not a physical obstruction like polyps. The colon typically enlarges giving rise to the name "megacolon" versus being constricted. Weakened areas of the colon are associated with diverticulosis.

A client presents to the clinic for a follow-up visit for hospitalization due to uncontrolled diabetes. Which of the following assessment findings indicates a complication of diabetes mellitus?

Blood pressure of 160/100 mm Hg The client with diabetes mellitus is especially prone to hypertension due to atherosclerotic changes, which leads to problems of the microvascular and macrovascular systems. This can result in complications in the heart, brain, and kidneys. Heart disease and stroke are twice as common among people with diabetes mellitus as among people without the disease. Painful, inflamed joints accompany rheumatoid arthritis. Pale yellow urine is not indicative of urinary complications. Diabetic nephropathy is diagnosed by evaluating for albuminuria and measuring albumin-to-creatinine ratio. A low hemoglobin concentration accompanies anemia, especially iron deficiency anemia and anemia of chronic disease.

The nurse is caring for a newborn with a large ventricular septal defect. The client has undergone pulmonary artery banding. Which assessment finding best indicates that the pulmonary artery band is functioning effectively?

Breath sounds are clear and equal bilaterally. Pulmonary artery banding is a palliative treatment used in pediatric clients with congenital cardiac defects with increased pulmonary blood flow. The pulmonary artery band reduces excessive pulmonary blood flow and protects the lungs from irreversible damage. When the pulmonary artery band is functioning properly, the lungs should no longer be receiving an increased amount of blood flow, which would be reflected in clear and equal breath sounds. A capillary refill of less than 3 seconds and a urine output greater than 1 ml/kg per hour reflect adequate peripheral perfusion. Bounding radial pulses and weak femoral pulses are indicative of a child with coarctation of the aorta.

A client who is prescribed by the health care provider (HCP) to take aspirin daily in order to prevent thrombus formation reports having ringing in the ears. The nurse advises the client to take which measure?

Contact the HCP. Because aspirin is ototoxic, the ringing in the ears is likely caused by long-term aspirin use. The nurse advises the client to contact the HCP; if the aspirin is to be discontinued, other drugs may be ordered. The client is not instructed to stop taking the drug without discussing the change with the HCP. Acetaminophen does not have the same antithrombotic properties as aspirin. Increasing fluid intake will not stop the ringing in the ears.

When caring for a client with a left radial arterial line, the nurse notes that the left hand is cool and the capillary refill time in the finger is 6 seconds. What is the appropriate action by the nurse?

Contact the health care provider. The nurse should contact the health care provider because a capillary refill time greater than 5 seconds is indicative of impaired circulation and should be brought to the attention of the health care provider. The arterial line may need to be relocated, but this action would not be performed by the nurse. Hyperextension of the wrist would be appropriate if the client had tingling or numbness in the fingers. There is no indication that the client might be bleeding at the insertion site.

A client from a Mediterranean country is admitted with thalassemia, jaundice, splenomegaly, and hepatomegaly. Which should be the primary focus of nursing care for this client?

Decrease cardiac demands by promoting rest. This client has clinical manifestations of thalassemia major, a disease found in descendants from the Mediterranean Sea area whose mother and father both possess a gene for thalassemia (i.e., the client is homozygous for the gene). The severe hemolytic anemia causes sequestration of red blood cells in the spleen and liver, which leads to engorgement of the organs and chronic bone marrow hyperplasia. Rest will decrease the demands on the heart due to the diminished hemoglobin level, a physiologic concern. The nurse should follow the time schedule of the area in which the client is now living. The nurse can help the client prescribe preferred foods and listen to concerns, but the main priority is to decrease oxygen demands.

Which would be the most appropriate measure for preventing the development of a paralytic ileus in a client who had renal surgery yesterday?

Encourage the client to ambulate every 2 to 4 hours. Ambulation stimulates peristalsis. A client with paralytic ileus is kept on nothing-by-mouth status until peristalsis returns. Carbonated beverages will increase gas and distention but will not stimulate peristalsis. A stool softener will not stimulate peristalsis. IV fluid infusion is a routine postoperative prescription that does not have any effect on preventing paralytic ileus.

A nurse is teaching the parents of an infant with clubfeet about cast care. Which statement by the parent indicates the need for further teaching?

Immunizations will have to be delayed until the casts come off." The parent's statement about delaying immunizations indicates the need for further teaching. Immunizations can be administered in the thighs because the casts cover only the lower legs and feet. The other responses are correct statements, indicating effective teaching.

When caring for a client with myasthenia gravis who is receiving anticholinesterase drug therapy, the nurse must be able to distinguish cholinergic crisis from myasthenic crisis. Which of the following symptoms is not present in cholinergic crisis?

Improved muscle strength after I.V. administration of edrophonium chloride. Extreme muscle weakness is present in both cholinergic crisis and myasthenic crisis. In cholinergic crisis, I.V. edrophonium chloride, a cholinergic agent, does not improve muscle weakness; in myasthenic crisis, it does. Diaphoresis and increased salivation are not present in cholinergic crises.

A client with diabetes is found unconscious after the morning dose of insulin. What would be a priority nursing intervention at this time?

Initiate treatment for hypoglycemia as a result of insulin. During treatment for diabetes, the client may develop hypoglycemia. Careful observation for this complication should be made by the nurse, and the nurse would begin treatment for hypoglycemia immediately to prevent it from progressing. The client would not be able to take fluids while unconscious. Withholding glucose will contribute to worsening hypoglycemia. The healthcare provider should be contacted after the client has stabilized.

n which order should the nurse perform actions for a newborn receiving phototherapy who breastfeeds and presents with numerous loose watery stools, a decrease in urine output, and delayed capillary refill? All options must be used.

Insert a peripheral IV. Administer intravenous fluid bolus. Monitor strict intake and output. Educate family on the need for the infant to breastfeed frequently. One of the side effects of standard phototherapy is frequent, loose stools. Frequent, loose stools in an infant who is not breastfeeding sufficiently may cause dehydration. Decreased urinary output (UOP) and delayed capillary refill time may indicate dehydration and hypovolemia. The nurse should first start a peripheral IV. Then the nurse should administer IV fluids to rehydrate the infant. Monitoring the intake and output would be a form of evauation of the intervention of the IV fluid bolus. The last thing would be to educate the family about the need to feed frequently.

A client with chronic hepatitis C is experiencing nausea, anorexia, and fatigue. During the health history the client states that he is homosexual, drinks one to two glasses of wine with dinner, is taking St. John's Wort for a "bit of depression," and takes acetaminophen for frequent headaches. What should the nurse do? Select all that apply.

Instruct the client to ask the health care provider (HCP) about taking any other medications as they may interact with medications the client is currently taking. Advise the client of the need for additional testing for HIV. Encourage the client to obtain sufficient rest. Clients with chronic hepatitis C should abstain from alcohol as it can speed cirrhosis and end-stage liver disease. Clients should also check with their HCPs before taking any nonprescription or prescription medications, or herbal supplements. It is also important that clients who are infected with HCV be tested for HIV, as clients who have both HIV and HCV have a more rapid progression of liver disease than those who have HCV alone. Clients with HCV and nausea should be instructed to eat four to five times a day to help reduce anorexia and nausea. The client should obtain sufficient rest to manage the fatigue.

A client has a routine Papanicolaou (Pap) test during a yearly gynecologic examination. The result reveals a class V finding. What should the nurse tell the client about this finding?

It calls for a biopsy as soon as possible. A class V finding in a Pap test suggests probable cervical cancer; the client should have a biopsy as soon as possible. Only a class I finding, which is normal, requires no action. A class II finding, which indicates inflammation, calls for a repeat Pap test in 3 months. A class III finding, which indicates mild to moderate dysplasia, calls for a repeat Pap test in 6 weeks to 3 months. A class IV finding indicates possible cervical cancer; like a class V finding, it warrants a biopsy as soon as possible.

A client is to have sclerotherapy to treat varicose veins. What information about the procedure should the nurse include in the teaching plan for this client?

It causes the veins to fade and disappear. Sclerotherapy involves injecting small- and medium-sized varicose veins with a solution that scars and closes those veins. In a few weeks, the veins should fade and disappear. This procedure does not require anesthesia and can be done in a health care provider's (HCP's) office. Varicose veins can reoccur regardless of the procedure. Bruising is more likely following vein stripping or catheter assisted procedures.

The nurse is caring for a client with peripheral vascular disease (PVD). Which action would the nurse do to ensure an accurate assessment?

Keep the client warm. Vasodilation or vasoconstriction will affect the assessment findings in a client with PVD, so the nurse would keep the client warm. The nurse would keep the client covered and expose only the portion of the client's body that the nurse is assessing. The nurse would also keep the client warm by maintaining the room temperature between 68°F and 74°F (20° and 23.3°C). Extreme temperatures have a negative effect on clients with PVD. Keeping the client uncovered would cause the client to become chilled. Matching the room temperature to the client's body temperature is inappropriate.

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

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

mmediately on return to the nursing unit after surgical repair of a cleft palate, in which of the following positions should the nurse place the child?

Lying on the abdomen with the head turned to the side. Immediately after a surgical repair of a cleft palate, the child is placed on the abdomen with the head turned to the side to lessen the chance of aspiration by allowing secretions to drain out. Positioning the child on the back places the child at risk for aspiration should any regurgitation or vomiting occur, even in low Fowler's position with the head to the side or in reverse Trendelenburg position with the head tilted forward.

The nurse is caring for an alert 2-month-old child and assesses a sunken fontanelle. Which action would be most appropriate for the nurse to take based on the assessment?

Monitor fluid intake and output. A sunken fontanelle in an alert child would most commonly suggest a concern with dehydration. Monitoring intake and output can help determine whether the child is receiving adequate hydration and can lead to planning further actions that could correct the situation.

A client with rheumatoid arthritis arrives at the clinic for a checkup. Which statement by the client refers to the most overt clinical manifestation of rheumatoid arthritis?

My finger joints are oddly shaped." Joint abnormalities are the most obvious manifestations of rheumatoid arthritis. A systemic disease, rheumatoid arthritis attacks all connective tissue. Although muscle weakness may occur from limited use of the joint where the muscle attaches, such weakness isn't the most obvious sign of rheumatoid arthritis; also, it occurs only after joint abnormalities arise. Subcutaneous nodules in the hands, although common in rheumatoid arthritis, are painless. The disease may cause gait disturbances, but these follow joint abnormalities.

While caring for a client who has sustained a myocardial infarction (MI), the nurse notes eight premature ventricular contractions (PVCs) in 1 minute on the cardiac monitor. The client is receiving an IV infusion of 5% dextrose in water (D5W) at 125 mL/h and oxygen at 2 L/min. What should the nurse do first?

Notify the health care provider (HCP). PVCs are often a precursor of life-threatening arrhythmias, including ventricular tachycardia and ventricular fibrillation. An occasional PVC is not considered dangerous, but if PVCs occur at a rate greater than five or six per minute in the post-MI client, the HCP should be notified immediately. More than six PVCs per minute is considered serious and usually calls for decreasing ventricular irritability by administering medications such as lidocaine hydrochloride. Increasing the IV infusion rate would not decrease the number of PVCs. Increasing the oxygen concentration should not be the nurse's first course of action; rather, the nurse should notify the HCP promptly. Administering a prescribed analgesic would not decrease ventricular irritability.

A school-age child with glomerulonephritis reports a headache and blurred vision. What immediate action should the nurse take?

Obtain the child's blood pressure. Hypertension occurs with acute glomerulonephritis. The symptoms of headache and blurred vision may indicate an elevated blood pressure. Hypertension in acute glomerulonephritis occurs due to the inability of the kidneys to remove fluid and sodium; the fluid is reabsorbed, causing fluid volume excess. The nurse must verify that these symptoms are due to hypertension. Calling the HCP before confirming the cause of the symptoms would not facilitate his treatment. Putting the client to bed may help treat an elevated blood pressure, but first the nurse must establish that high blood pressure is the cause of the symptoms. Administering acetaminophen for high blood pressure is not recommended.

A nurse must apply a wet-to-damp dressing over an ulcer on a client's left ankle. How should the nurse proceed?

Pack the moistened fine-mesh gauze dressings into all depressions and grooves of the wound. The nurse should pack the moistened fine-mesh gauze dressings into all depressions and grooves of the wound because necrotic tissue is usually more prevalent in those areas. The nurse should wring out excess moisture from saturated fine-mesh gauze dressings because saturated dressings won't dry properly. The nurse shouldn't apply an occlusive dressing or elastic bandage because these products can prevent air circulation and hinder drying of the fine-mesh gauze.

A 3-year-old client is admitted to the pediatric unit with pneumonia. The child has a productive cough and appears to have difficulty breathing. The parents tell the nurse that the child has not been eating or drinking much and has been very inactive. Which interventions to improve airway clearance should the nurse include in the care plan? Select all that apply.

Perform chest physiotherapy as ordered. Encourage coughing and deep breathing. Perform postural drainage. Maintain humidification with a cool mist humidifier. Chest physiotherapy and postural drainage work together to break up congestion and then drain secretions. Coughing and deep breathing are also effective to remove congestion. A cool mist humidifier helps loosen thick mucous and relax airway passages. Fluids should be encouraged, not limited. The child should be placed in semi-Fowler's to high Fowler's position to facilitate breathing and promote optimal lung expansion.

A client with metastatic cancer of the liver tells the nurse about being concerned about the prognosis. How should the nurse respond to the client?

Place emphasis on providing symptomatic and comfort measures. There is no cure for metastatic cancer of the liver; palliative nursing care is required. Liver transplants are not recommended for the client with widespread malignant disease. Prescribed medications will not make metastatic lesions shrink. There is nothing to indicate that the client is receiving chemotherapy; therefore, explaining its effects would not be helpful.

A client diagnosed with an empyema is scheduled for a thoracentesis. The nurse should prepare the client for this procedure with which action?

Position the client sitting upright on the edge of the bed and leaning forward. This procedure can be done at the bedside. The nurse should help to position the client correctly. The best position for the procedure is to place the client in a sitting position with arms raised and resting on an overbed table. This position helps to spread out the spaces between the ribs for needle insertion. It is not necessary for the client to receive a sedative or be sent to the catheterization lab. The client does not have to be NPO for this procedure.

A client with Crohn's disease has concentrated urine, decreased urinary output, dry skin with decreased turgor, hypotension, and weak, thready pulses. What should the nurse should do first?

Provide parenteral rehydration therapy as prescribed. Initially, the extracellular fluid volume with isotonic IV fluids until adequate circulating blood volume and renal perfusion are achieved. Vital signs should be monitored as parenteral and oral rehydration are achieved. Oral fluid intake should be greater than 1,000 mL/day. Turning and repositioning the client at regular intervals aids in the prevention of skin breakdown, but it is first necessary to rehydrate this client.

Which intervention should the nurse anticipate using when caring for a term neonate diagnosed with transient tachypnea at 2 hours after birth

Provide warm, humidified oxygen in a warm environment Symptoms of transient tachypnea include respirations as high as 150 breaths/minute, retractions, flaring, and cyanosis. Treatment is supportive and includes provision of warm, humidified oxygen in a warm environment. The nurse should continuously monitor the neonate's respirations, color, and behaviors to allow for early detection and prompt intervention should problems arise. Feedings are given by gavage rather than bottle to decrease respiratory stress. Obtaining extracorporeal membrane oxygenation equipment is not necessary but may be used for the neonate diagnosed with meconium aspiration syndrome.

A client who has apnea during sleep would require which of the following interventions? Select all that apply.

Refer to primary healthcare provider Assess sleep routine/hours Have client keep a sleep diary The client with periods of apnea may require a more thorough assessment including a sleep routine/hour and sleep diary as well as a referral to a primary healthcare provider. Pursed-lip breathing has no influence on sleep apnea. Family may sleep in the same room.

Which discharge instructions would the nurse give to the client with acute pancreatitis? Select all that apply.

Report any twitching or muscle spasms. Eat a high-carbohydrate, low-protein, low-fat diet. Twitching and muscle spasms are signs of hypocalcemia, which may signal reoccurrence of pancreatitis. A high-carbohydrate, low-protein, low-fat diet will increase caloric intake without overstimulating the pancreas. Tea and coffee will increase pancreatic and gastric secretions. Over-the-counter medications contain alcohol, which can precipitate attacks of pancreatitis. A period of rest for several months may be required before energy level returns.

The nurse is observing the electrocardiogram (EKG) rhythm of a client with a permanent pacemaker and determines there is not a QRS complex that follows the pacemaker spike. Which follow-up action is most appropriate?

Report to the health care provider that the pacemaker is failing to capture. Failure to capture is observed when the pacemaker fails to generate a complex; in this case the pacemaker fails to generate a ventricular complex with the QRS. This needs to be reported to the health care provider and the client should be assessed to determine any clinical manifestations of low blood flow due to this. The client's electrolyte levels would not have an effect on pacemaker function. Having the client take deep breaths and cough or lay on the right side with head of bed elevated would not have an effect on pacemaker function with failing to capture.

Which nursing intervention should be done first when managing a pediatric client admitted to the emergency department with severe diabetic ketoacidosis (DKA)?

Secure the client's airway to ensure adequate ventilation. Treating pediatric clients with severe DKA is a medical emergency; therefore, attending to the airway, breathing, and circulation is the first priority. Once the airway is secured, the health care team should estimate the level of dehydration and begin replacement fluids of normal saline. An insulin drip should be started after the initial 1 to 2 hours of treatment at a rate of 0.1 units/kg per hour. Blood glucose should be tested every 1 to 2 hours until the client is stable, then it should be every 6 hours. Additionally, serum electrolytes should be drawn every 1 to 2 hours until the client is stable, then every 4 to 6 hours.

The nurse is conducting a health assessment of an older adult. The client tells the nurse about cramping leg pain that occurs when walking for 15 minutes; the pain is relieved with rest. The lower extremities are slightly cool to touch, and pedal pulses are palpable +1. What should the nurse instruct the client to do?

Seek consultation from the health care provider. This client has indications of peripheral artery disease and needs additional follow-up. Increasing walking or exercising the legs and feet likely will not be sufficient to improve peripheral circulation. Muscle cramping is a result of inadequate arterial circulation. Increasing potassium will not decrease the cramping.

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

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

A client with an esophageal stricture is about to undergo esophageal dilatation. As the bougies are passed down the esophagus, the nurse should instruct the client to do which action to minimize the vomiting urge?

Take long, slow breaths During passage of the bougies used to dilate the esophagus, the client should take long, slow breaths to minimize the vomiting urge. Having the client hold the breath, bear down as if having a bowel movement, or pant like a dog is neither required nor helpful.

The nurse is performing an admission assessment on a neonate and finds the femoral pulses to be weaker than the brachial and radial pulses. What nursing action should the nurse take next?

Take the neonate's blood pressure in all four extremities. The next nursing action in this situation would be to assess the blood pressure in all four extremities and compare the findings. A difference of 15 mm Hg in the systolic blood pressure between the arms and legs is an indication of a narrowed aorta. This could be an emergency, and the HCP needs to be notified as soon as the blood pressure data has been collected. Generally, prescribing a HCP consult is not a nursing function. Placing the neonate in reverse Trendelenburg will only decrease the perfusion to the lower extremities.

A nurse is documenting a health assessment when the client states having problems with balance, as well as fine and gross motor function. When collaborating with the health team, which area on the illustration of the brain would the nurse highlight as an area of concern?

The cerebellum is the portion of the brain that controls balance and fine and gross motor function. The cerebellum is located at the base of the skull and above the brain stem.

One month following a subtotal gastrectomy for cancer, the nurse is evaluating the nursing care goal related to nutrition. What indicates that the client has attained the goal? The client has:

The client has achieved adequate nutritional status through oral or parenteral feedings An appropriate expected outcome is for the client to achieve optimal nutritional status through the use of oral feedings or total parenteral nutrition (TPN). TPN may be used to supplement oral intake, or it may be used alone if the client cannot tolerate oral feedings. The client would not be expected to regain lost weight within 1 month after surgery or to tolerate a normal dietary intake of three meals a day. Nausea and vomiting would not be considered an expected outcome of gastric surgery, and regular use of antiemetics would not be anticipated.

The nurse develops a teaching plan for a client scheduled for a spinal fusion. What should the nurse tell the client?

The client will typically experience more pain at the donor site than at the fusion site. Typically, the donor site causes more pain than the fused site does because inflammation, swelling, and venous oozing around the nerve endings in the donor site, where the subcutaneous tissue was removed, occur during the first 24 to 48 hours postoperatively. After surgery, the surgeon applies a pressure dressing to the donor site to compress the veins that were transected for the removal of subcutaneous tissue but that did not stop oozing blood after surgical cauterization. Pressure on a transected vein, which is low pressure, stops the oozing and loss of blood from the venous site. When the donor site is the fibula, neurovascular checks must be performed every hour to ensure adequate neurologic function of and circulation to the area. The surgeon, not the degree or amount of pain, specifies activity restrictions.

A client arrives at a public health clinic worried that she has breast cancer after finding a lump in her breast. When assessing the breast, which assessment finding provides an indication that the lump is more typical of fibrocystic breast disease?

The lump is round and movable. When assessing a breast with fibrocystic disease, the lumps typically are different from cancerous lumps. The characteristic breast mass of fibrocystic disease is soft to firm, circular, movable, and unlikely to cause nipple retraction. A cancerous mass is typically irregular in shape, firm, and nonmovable. Lumps typically do not make one breast larger than the other. Nipple retractions are suggestive of cancerous masses.

The nurse assesses the client's stoma during the initial postoperative period. What observation should the nurse report to the health care provider (HCP) immediately?

The stoma is dark red to purple. A dark red to purple stoma indicates inadequate blood supply. Mild edema and slight oozing of blood are normal in the early postoperative period. The colostomy would typically not begin functioning until 2 to 4 days after surgery.

A 24-year old client who has diabetes mellitus accidentally cut themself while preparing dinner and has sustained a large laceration on the left wrist. After the laceration is sutured, the client asks the nurse, "How long will it take for my scars to disappear?" Which statement is the nurse's bestresponse?

With your history and the type and location of your injury, it's hard to say." In a client with diabetes, wound healing will be delayed. Providing a specific time frame could give the client false information.

A nurse is caring for 4 clients on the cardiac unit. Which client has the greatest risk for contracting infective endocarditis?

a client 4 days postoperative after mitral valve replacement Having prosthetic cardiac valves places the client at high risk for infective endocarditis. Hypertrophic cardiomyopathy and repaired ventricular septal defects are moderate risks for infective endocarditis. Coronary stent placement isn't a risk factor for infective endocarditis.

The charge nurse is working on a medical-surgical unit and must rearrange room assignments for several clients. Which clients should the nurse put in the same room? Select all that apply.

a client who underwent cholecystectomy today a client with pain related to pancreatitis The client who underwent a cholecystectomy and the client with pain related to pancreatitis both show no signs of infection, but will need frequent pain assessments and medications; these two clients can be roomed together. Clients with diarrhea and vomiting may need enteric isolation, cancer clients receiving chemotherapy are at risk for immunosuppression, and the client that has neutropenia may need to be in reverse isolation. These clients should not be roomed with any clients showing no sign of infection.

The nurse assesses that a client who has had a partial gastrectomy has a decreased hemoglobin and hematocrit. The nurse explains to the client that the partial gastrectomy has most likely contributed to which deficiency?

a vitamin B12 deficiency Vitamin B12 (extrinsic factor) combines with intrinsic factor, a substance secreted by the parietal cells of the gastric mucosa, forming a hemopoietic factor. Hemopoietic factor stimulates erythropoiesis. A decrease in vitamin B12 absorption, such as that caused by a partial gastrectomy, results in anemia.

A mother states that a health care provider (HCP) described her daughter as having 20/60 vision, and she asks the nurse what this means. The nurse responds based on the interpretation that the child is experiencing which condition?

ability to see at 20 feet what she should see at 60 feet A child with 20/60 vision sees at 20 feet what those with 20/20 vision see at 60 feet. A visual acuity of 20/200 is considered to be the boundary of legal blindness.

A client at 36 weeks' gestation, begins to exhibit signs of labor after an eclamptic seizure. The nurse should assess the client for:

abruptio placentae After an eclamptic seizure, the client is at risk for abruptio placentae due to severe vasoconstriction resulting in hemorrhage into the decidua basalis. Abruptio placentae is manifested by a board-like abdomen and an abnormal fetal heart rate tracing. Transverse lie or shoulder presentation, placenta accreta, and uterine atony are not related to eclampsia. Causes of a transverse lie may include relaxation of the abdominal wall secondary to grand multiparity, preterm fetus, placenta previa, abnormal uterus, contracted pelvis, and excessive amniotic fluid. Placenta accreta, a rare phenomenon, refers to a condition in which the placenta abnormally adheres to the uterine lining. Uterine atony, or relaxed uterus, may occur after childbirth, leading to postpartum hemorrhage.

Which intervention is the highest priority for the therapeutic management of a child with congestive heart failure (CHF) resulting from pulmonary stenosis?

administering furosemide to decrease systemic venous congestion Pulmonary stenosis can cause right-sided CHF, resulting in venous congestion. Removing accumulated fluid is a primary goal of treatment in right-sided CHF. Furosemide is used to reduce venous congestion. It is important to educate the family about signs and symptoms of CHF, but treating the client's CHF is the priority. Enoxaparin is an anticoagulant and will not help improve left ventricular contractility. It is important to assess vital signs frequently in the child with CHF, but assessments do not treat the problem.

When assessing a client with left-sided heart failure, the nurse expects to note

air hunger. With left-sided heart failure, the client typically has air hunger and other signs of pulmonary congestion. Ascites, jugular vein distention, and pitting edema of the legs are signs of right-sided heart failure.

Twelve hours after cardiac surgery, the nurse is assessing a 3-year-old who weighs 15 kg. The nurse should notify the surgeon about which clinical finding?

alterations in levels of consciousness Clinical signs of low cardiac output and poor tissue perfusion include pale, cool extremities, cyanosis or mottled skin, delayed capillary refill, weak, thready pulses, oliguria, and alterations in level of consciousness. An adequate urine output for a child over 1 year should be 1 mL/kg/h. Therefore 60 mL/4 h is satisfactory. Strong peripheral pulses indicate adequate cardiac output. Drainage from the chest tube should show fluctuation in the drainage compartment of the chest drainage system. The fluid level normally fluctuates as proof that the apparatus is airtight. On about the 3rd postoperative day, the fluctuation ceases indicating the lungs have fully expanded.

A 9-month-old, well-nourished boy who lives with his extensive extended family tests positive for tuberculosis. What is a risk factor for tuberculosis in this child?

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

When evaluating the effectiveness of airway suctioning, the nurse should use which criterion?

breath sounds clear on auscultation Auscultating for clear breath sounds is the most accurate way to evaluate the effectiveness of tracheobronchial suctioning. Auscultation should also be done to determine whether or not the client needs suctioning.Assessing for labored respirations is not as accurate in evaluating the effectiveness of tracheobronchial suctioning. A client may have labored breathing that is not affected by the presence or absence of tracheobronchial secretions.Percussion of the chest is useful for detecting masses or dense consolidation of lung tissue. It is not an accurate method for assessing the effectiveness of suctioning.Suctioning clears mucus but does not decrease its production.

Which outcome criterion would be most appropriate for a client with a nursing diagnosis of Ineffective airway clearance?

breath sounds clear on auscultation The expected outcome for a client with Ineffective airway clearance is for the lungs to be clear of secretions (or congestion) on auscultation. Congestion on X-ray, continued use of and need for oxygen, and a respiratory rate of 28 breaths/minute indicate that the client is still experiencing airway problems.

While attending a support group, the parents of a child with hemophilia become concerned because they heard stories about how many children with hemophilia have died from acquired immunodeficiency syndrome (AIDS). They ask the nurse how these children got the AIDS virus. The nurse bases the response on which as the most likely route of transmission of AIDS to these children?

contamination of the factor VIII replacement received during bleeding episodes The acquired immune deficiency syndrome (AIDS) virus is spread by direct contact with blood or blood products and by sexual contact. Children with hemophilia were at risk for AIDS in the 1980s because the factor VIII concentrate infusions were made from pooled plasma. However, factor VIII is now a recombinant synthesized factor product, which virtually eliminates the risk of contacting HIV with an infusion.There is no evidence that casual contact between infected and uninfected people transmits the human immunodeficiency virus (HIV). Exposure to others in a waiting room is considered casual contact.All venipunctures for blood specimens in hospitals and clinics are performed with sterile disposable needles. Because the needles are sterile, they cannot be a source of HIV transmission.

A client has sustained a head injury and is to receive mannitol by I.V. push. In evaluating the effectiveness of the drug, the nurse should expect to find:

decreased cerebral edema. Mannitol, an osmotic diuretic, is used to decrease cerebral edema in clients with head injuries. The other choices are not correct results of mannitol.

A client has chronic open-angle glaucoma. What should the nurse ask the client about when conducting a focused assessment?

decreasing peripheral vision Although COAG is usually asymptomatic in the early stages, peripheral vision gradually decreases as the disorder progresses. Eye pain is not a feature of COAG but is common in clients with angle-closure glaucoma. Excessive lacrimation is not a symptom of COAG; it may indicate a blocked tear duct. Flashes of light are a common symptom of retinal detachment.

The nurse is caring for an elderly client who has experienced a sensorineural hearing loss. The nurse anticipates that the client will exhibit which symptom?

difficulty hearing high-pitched sounds The client with sensorineural hearing loss has difficulty hearing high-pitched sounds. Aging and ototoxicity are two causes of sensorineural hearing loss. The client's ability to speak is not affected. The client who cannot assign meaning to sound has central hearing loss. Vertigo is commonly an indication of an inner ear problem.

A 10-year-old child is admitted with a brain tumor. Which assessment made by the nurse is mostcritical to report to the child's health care provider (HCP)?

difficulty in recalling the day of the week A decrease or change in the level of consciousness is an early indication of increased intracranial pressure (ICP) and should be reported to the child's HCP as soon as possible to try and control the pressure so that it does not increase further. Vomiting can be a sign of increased ICP that occurs with a brain tumor, but it usually occurs unrelated to food and in the morning upon arising. Blood pressure increases with a brain tumor due to pressure on the brain stem. Concentrated urine is a sign of dehydration and is not related to the signs of a brain tumor.

A nurse is caring for a client who underwent a subtotal gastrectomy. To manage dumping syndrome, the nurse should advise the client to

drink liquids only between meals. A client who experiences dumping syndrome after a subtotal gastrectomy should be advised to ingest liquids between meals rather than with meals. Taking fluids between meals allows for adequate hydration, reduces the amount of bulk ingested with meals, and aids in the prevention of rapid gastric emptying. There is no need to restrict the amount of fluids, just the time when the client drinks fluids. Drinking liquids with meals increases the risk of dumping syndrome by increasing the amount of bulk and stimulating rapid gastric emptying. Small amounts of water are allowable before meals.

After undergoing a left thoracotomy, a client has a chest tube in place. When caring for this client, the nurse must

encourage coughing and deep breathing. When caring for a client who's recovering from a thoracotomy, the nurse should encourage coughing and deep breathing to prevent pneumonia. Fluctuations in the water-seal chamber are normal. Clamping the chest tube could cause a tension pneumothorax. Chest tube milking is controversial and should be done only to remove blood clots that obstruct the flow of drainage

Which should be the nursing priority of care for a client exhibiting signs and symptoms of coronary artery disease?

enhance myocardial oxygenation Enhancing myocardial oxygenation is always the first priority when a client exhibits signs or symptoms of cardiac compromise. Without adequate oxygen, the myocardium suffers damage. A nurse administers sublingual nitroglycerin to treat acute angina pectoris, but its administration is not the first priority. Although educating the client and decreasing anxiety are import in care delivery, neither is a priority when a client is compromised.

Which information obtained during a health history is most consistent with the diagnosis of failure to thrive in an infant?

fussiness during feedings Infants who have failure to thrive are typically fussy during feedings. This fussiness may be related to the caretaker not recognizing cues about what the infant needs or wants.Typically infants with failure to thrive are unafraid of strangers.Although they protest being put down, infants with failure to thrive are typically not content while being held because they are not used to it.Infants with failure to thrive typically have difficulty sleeping for any length of time. They often awaken because they are hungry.

A client at 24 weeks gestation comes to the clinic for a prenatal check-up and reports that she has been "seeing double." The nurse checks the urine and determines that there is 3+ proteinuria. What does the nurse determine is the potential priority problem?

gestational hypertension A client with gestational hypertension typically presents with headaches, double vision, and sudden weight gain. Additional findings include proteinuria. The client with gestational diabetes would have elevated glucose levels. The client with hyperemesis gravidarum would present with intractable vomiting and signs of dehydration. Placenta previa is the covering of the cervical os with the placenta and would be demonstrated by painless vaginal bleeding.

A nurse is caring for a client with multiple myeloma. Which laboratory value is the nurse most likely to see?

hypercalcemia Calcium is released when bone is destroyed, causing hypercalcemia. Multiple myeloma doesn't affect potassium, sodium, or magnesium levels.

When assessing a neonate 1 hour after birth, the nurse notes acrocyanosis of both feet and hands, measures an axillary temperature of 95.5°F (35.3°C), an apical pulse of 110 beats/minute, and a respiratory rate of 64 breaths/minute. Which assessment would be the most concerning for the nurse?

hypothermia The neonate's normal axillary temperature should range from approximately 97.7°F to 99.5°F (36.5°C to 37.5°C). A temperature of 95.5°F (35.3°C) is very low. When the temperature drops, the neonate is at risk for hypothermia, respiratory distress, and hypoglycemia. The normal respiratory rate for a newborn is 30 to 60 breaths/minute while resting. It can increase with crying, and it will increase if hypothermia develops. This neonate would have tachypnea instead of bradypnea. The normal heart rate for a newborn is 110 to 160 beats/minute, so 110 beats/minute would be a normal finding and not tachycardia. All neonates have acrocyanosis of the hands and feet in the first few hours of life; this would not indicate hypoxia.

Which finding would be expected in a client with chest trauma, rib fractures, and respiratory acidosis?"

hypoventilation due to inability to take deep breaths because of pain Hypoventilation causes a buildup of CO2 in the blood. Kussmaul respirations are related to abnormal respiratory patterns and are characterized by rapid, deep breathing. They are often seen in clients with metabolic acidosis, and hyperventilation would not cause acidosis. The choice rib fractures does not represent any information in the scenario.

In a 3-month-old infant, fluid and electrolyte imbalance can occur quickly, primarily because an infant has:

immature kidney function. Because of immature kidneys, an infant's glomerular filtration and absorption are inadequate, not reaching adult levels until age 1 to 2 years. An infant actually has a greater percentage of body water as well as higher daily fluid requirements than an adult. Although the infant's respiratory rate is higher, causing insensible water loss, immature kidney function is more responsible for fluid balance in an infant.

A child is in the emergency department with suspected epiglottitis and has been ordered an X-ray to confirm the diagnosis. The nurse would prepare the child for X-ray by which methods?

in the emergency department, by portable X-ray The child is at risk for obstruction related to the swollen epiglottis. The nurse should not move the child, keep a careful watch, and get a portable X-ray in the emergency department.

When obtaining the vital signs of a client with multiple traumatic injuries, a nurse detects bradycardia, bradypnea, and systolic hypertension. The nurse must notify the physician immediately because these findings may reflect which complication?

increased intracranial pressure (ICP) When ICP increases, Cushing's triad may develop, which involves decreased heart and respiratory rates and increased systolic blood pressure. Shock typically causes tachycardia, tachypnea, and hypotension. In encephalitis, the temperature rises and the heart and respiratory rates may increase from the effects of fever on the metabolic rate. (If the client doesn't maintain adequate hydration, hypotension may occur.) Status epilepticus causes unceasing seizures, not changes in vital signs.

Which assessment finding is an early sign of heart failure in a client?

increased respiratory rate increased respiratory and heart rates are the earliest signs of heart failure. Decreased urine output and increased weight are later signs.

A client was brought to the emergency department following a motor vehicle accident and has phrenic nerve involvement. The nurse should assess the client for which nursing problem?

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

Which lab values should the nurse report to the health care provider (HCP) when the client has anemia?

intrinsic factor, absent The defining characteristic of pernicious anemia, a megaloblastic anemia, is lack of the intrinsic factor which results from atrophy of the stomach wall. Without the intrinsic factor, vitamin B cannot be absorbed in the small intestine and folic acid needs vitamin B for deoxyribonucleic acid synthesis of RBCs. The gastric analysis is done to determine the primary cause of the anemia. An elevated excretion of the injected radioactive vitamin B, which is protocol for the first and second stage of the Schilling test, indicates that the client has the intrinsic factor and can absorb vitamin B in the intestinal tract. A sedimentation rate of 16 mm/hour is normal for both men and women and is a nonspecific test to detect the presence of inflammation; it is not specific to anemias. An RBC value within the normal range does not indicate an anemia.

A client undergoes hip-pinning surgery to treat an intertrochanteric fracture of the right hip. The nurse should include which intervention in the postoperative care plan?

keeping a pillow between the client's legs at all times After hip pinning, the client must keep the affected leg abducted at all times; placing a pillow between the legs reminds the client not to cross the legs and to keep the leg abducted. Passive or active ROM exercises shouldn't be performed on the affected leg during the postoperative period because this could damage the operative site and cause hip dislocation. Most clients should be turned to the unaffected side, not from side to side. After hip pinning, the client must avoid acute flexion of the affected hip to prevent possible hip dislocation; therefore, semi-Fowler's position should be avoided.

A nurse is working with a student nurse who is caring for a client with an acute bleeding cerebral aneurysm. Which action by the student nurse requires further intervention?

keeping the client in one position to decrease bleeding The student nurse shouldn't keep the client in one position.The student nurse should carefully reposition the client often (at least every hour). The client needs to be positioned so that a patent airway can be maintained. Fluid administration must be closely monitored to prevent complications such as increased intracranial pressure. The client must be maintained in a quiet environment to decrease the risk of rebleeding.

The nurse is caring for a client in a diabetic coma. The nurse is aware that this is caused by an excess of which substance in the blood?

ketones from rapid fat breakdown, causing acidosis Ketones are released when fat is broken down for energy. In diabetic coma, the client is admitted with dehydration and ketoacidosis. The other choices do not define diabetic coma.

A client with multiple sclerosis (MS) is experiencing bowel incontinence and is starting a bowel retraining program. Which strategy is not appropriate?

limiting fluid intake to 1,000 mL/day Limiting fluid intake is likely to aggravate rather than relieve symptoms when a bowel retraining program is being implemented. Furthermore, water imbalance, as well as electrolyte imbalance, tends to aggravate the signs and symptoms of MS. A diet high in fiber helps keep bowel movements regular. Setting a regular time each day for elimination helps train the body to maintain a schedule. Using an elevated toilet seat facilitates transfer of the client from the wheelchair to the toilet or from a standing to a sitting position.

The nurse should assess an older adult with macular degeneration for:

loss of central vision. Macular degeneration generally involves loss of central vision. Gradual blurring of vision can occur as the disease progresses and may result in blindness; however, loss of central vision is the most common finding. Tiny yellowish spots, known as drusen, develop beneath the retina. Loss of peripheral vision is characteristic of glaucoma.

Which finding will the nurse observe in the client in the ictal phase of a generalized tonic-clonic seizure?

loss of consciousness, body stiffening, and violent muscle contractions A generalized tonic-clonic seizure involves both a tonic phase and a clonic phase. The tonic phase consists of loss of consciousness, dilated pupils, and muscular stiffening or contraction, which lasts about 20 to 30 seconds. The clonic phase involves repetitive movements. The seizure ends with confusion, drowsiness, and resumption of respiration. A partial seizure starts in one region of the cortex and may stay focused or spread (e.g., jerking in the extremity spreading to other areas of the body). An absence seizure usually occurs in children and involves a vacant stare with a brief loss of consciousness that often goes unnoticed. A complex partial seizure involves facial grimacing with patting and smacking.

A physician is assessing a client's ear and notes excess bone formation around the oval window. Which additional assessment finding should the nurse anticipate?

low-frequency hearing loss Excess bone formation around the oval window indicates otosclerosis, which is characterized by low-frequency hearing loss. The tympanic membrane is normal, not sclerosed, with this disorder, and bone conduction usually occurs longer than air conduction. Chronic ear infections aren't a characteristic of otosclerosis.

A client with weakness and tingling in both legs is admitted to the medical-surgical unit with a tentative diagnosis of Guillain-Barré syndrome. On admission, which assessment is most important for this client?

lung auscultation and measurement of vital capacity and tidal volume In Guillain-Barré syndrome, polyneuritis commonly causes weakness and paralysis, which may ascend to the trunk and involve the respiratory muscles. Lung auscultation and measurement of vital capacity, tidal volume, and negative inspiratory force are crucial in detecting and preventing respiratory failure — the most serious complication of polyneuritis. A peripheral nerve disorder, polyneuritis doesn't cause increased ICP. Although the nurse must evaluate the client for pain and discomfort and must assess the nutritional status and metabolic state, these aren't priorities.

Which statement indicates that the client with diabetes insipidus understands how to manage care? The client will:

maintain normal fluid and electrolyte balance. Because diabetes insipidus involves excretion of large amounts of fluid, maintaining normal fluid and electrolyte balance is a priority for this client. Special dietary programs or restrictions are not indicated in treatment of diabetes insipidus. Serum glucose levels are priorities in diabetes mellitus but not in diabetes insipidus.

Four clients injured in an automobile accident enter the emergency department at the same time. The triage nurse evaluates them immediately. The nurse should assign the highest priority to the client with the:

maxillofacial injury and gurgling respirations. Emergency department triage involves employing the Emergency Severity Index (ESI) as the triage tool to assess which clients should be seen first and what resources they will need; it is a 5-level algorithm with 1 given the highest priority. Clients with poor prognoses are given a lesser priority. The client with the maxillofacial injury and gurgling respirations needs immediate attention because of an impaired airway which would be considered a Level 1. The spinal cord injury client doesn't exhibit immediate airway needs and would be considered a Level 2. The client with the severe head injury and no blood pressure has a grave prognosis. Although the client is in early labor, early labor doesn't surpass airway compromise in importance and would be assigned a level 2.

While assessing the skin of a 45-year-old, fair-skinned female client, the nurse notes a lesion on the medial aspect of her lower leg. It has irregular borders, with various shades of black and brown. The client states that the lesion itches occasionally and bled slightly a few weeks ago. She also reveals a history of sunburns. Based on these signs and symptoms, the nurse suspects

melanoma. The "ABCDs" of melanoma are Asymmetry of the lesion, Borders that are irregular, Colors that vary in shades, and increased Diameter. Fair skin with a history of sunburn and the location of the lesion on the leg (the most common site in women) suggest melanoma. Squamous cell carcinoma commonly develops on the skin of the face, the ears, the dorsa of the hands and forearms, and other sun-damaged areas. Early lesions appear as opaque, firm nodules with indistinct borders, scaling, and ulceration. Actinic keratosis is a premalignant skin lesion. Basal cell carcinoma presents as lesions that are lightly pigmented. As they enlarge, their centers become depressed and their borders become firm and elevated.

A client in the emergency department reports that they have been vomiting excessively for the past 2 days. The client's arterial blood gas analysis shows a pH of 7.50, partial pressure of arterial carbon dioxide (PaCO2) of 43 mm Hg, partial pressure of arterial oxygen (PaO2) of 75 mm Hg, and bicarbonate (HCO3-) of 42 mEq/L. Based on these findings, the nurse documents that the client is experiencing which type of acid-base imbalance?

metabolic alkalosis A pH over 7.45 with a HCO3- level over 26 mEq/L indicates metabolic alkalosis. Metabolic alkalosis is always secondary to an underlying cause and is marked by decreased amounts of acid or increased amounts of base HCO3-. The client isn't experiencing respiratory alkalosis because the PaCO2 is normal. The client isn't experiencing respiratory or metabolic acidosis because the pH is greater than 7.35.

A nurse is performing a respiratory assessment on a 5-year-old child diagnosed with pneumonia. Which assessment finding should be reported to the health care provider immediately?

moderate intercostal retractions Normally, children and men use the abdominal muscles to breathe, whereas women use the thoracic muscles. Use of the accessory or intercostal muscles would indicate a respiratory problem and should be immediately reported to the physician. Mouth breathing and a foul odor from the mouth aren't cause for concern. Irregular respirations while awake are not an unusual finding in a young child.

Creatine kinase-MB isoenzyme (CK-MB) can increase as a result of:

myocardial necrosis. An increase in CK-MB is related to myocardial necrosis. An increase in total CK might occur for several reasons, including brain injury, such as cerebral bleeding; skeletal muscle damage, which can result from I.M. injections or falls; muscular or neuromuscular disease; vigorous exercise; trauma; or surgery.

The nurse should conduct a focused assessment for the client with suspected bladder cancer for which common sign of the disease?

painless hematuria Painless hematuria is the most common clinical finding in bladder cancer. Other symptoms include urinary frequency, dysuria, and urinary urgency, but these are not as common as hematuria. Suprapubic pain and urine retention do not occur in bladder cancer.

A nurse in the telemetry unit is caring for a client with diagnosis of postoperative coronary artery bypass graft (CABG) surgery from 2 days ago. On assessment, the nurse notes a paradoxical pulse of 88. Which surgical complication would the nurse suspect?

pericardial tamponade A paradoxical pulse (a palpable decrease in pulse amplitude on quiet inspiration) signals pericardial tamponade, a complication of CABG surgery. Left-sided heart failure can cause pulsus alternans (a pulse amplitude alteration from beat to beat, with a regular rhythm). Aortic regurgitation may cause a bisferious pulse (an increased arterial pulse with a double systolic peak). Complete heart block may cause a bounding pulse (a strong pulse with increased pulse pressure).

When conducting a focused assessment of the respiratory system, what should the nurse note as an early sign of laryngeal cancer?

persistent mild hoarseness Hoarseness occurs early in the course of most laryngeal cancers because the tumor prevents accurate approximation of the vocal cords during phonation.Large tumors eventually produce difficulty and pain in swallowing, but this is not an early sign.Foul breath and expectoration of blood are late symptoms.A nagging cough has no direct relationship to laryngeal cancer.

A client is experiencing autonomic dysreflexia. The nurse should first:

place the client in Fowler's position. Autonomic dysreflexia is a medical emergency. The rising blood pressure can cause cerebrovascular accident, blindness, or even death. Placing the client in Fowler's position lowers blood pressure. Administering nitroprusside IV is appropriate if the conservative measures are ineffective. Although notifying the health care provider is important, it is more essential that the nurse intervene immediately in the situation. A urine sample for culture should be obtained if the client has an elevated temperature and no other cause for the dysreflexia is found. A urinary tract infection may be causing symptoms

A nurse is caring for a client with acute pulmonary edema. To immediately promote oxygenation and relieve dyspnea, the nurse should

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

A nurse is caring for a 2-year-old child with tetralogy of Fallot (TOF) who is scheduled for surgery in 24 hours. What intervention is the most important for the nurse to include in the plan of care?

positioning the child with knees to the chest TOF consists of four congenital anomalies: pulmonic stenosis, intraventricular septal defect, overriding aorta, and right ventricular hypertrophy. Interventions for care include high flow oxygen, morphine, beta-blockers and positioning with knees to chest.

A 9-year-old child is admitted to the pediatric unit for treatment of cystic fibrosis. A nurse assessing the child's respiratory status should expect to identify:

production of thick, sticky mucus. Cystic fibrosis is associated with the production of thick, sticky mucus. Cystic fibrosis isn't associated with harsh, nonproductive coughing or with stridor or unilateral decrease in breath sounds.

A nurse is caring for a client who has suffered a severe stroke. During routine assessment, the nurse notices Cheyne-Stokes respirations. Cheyne-Stokes respirations are

progressively deeper breaths followed by shallower breaths with apneic periods. Cheyne-Stokes respirations are breaths that become progressively deeper followed by shallower respirations with apneic periods. Biot's respirations are rapid, deep breaths with abrupt pauses between each breath, and equal depth between each breath. Kussmaul's respirations are rapid, deep breaths without pauses. Tachypnea is abnormally rapid respirations.

The nurse should assess a client for which complications associated with disseminated intravascular coagulation (DIC)?

pulmonary embolism Pulmonary embolism is an indication of intravascular clotting due to the fact that platelets have been significantly decreased and there is clotting and bleeding. Low prothrombin levels will also show that there is a delay in clotting, so the person will bleed for a longer time. The other conditions are not associated with DIC.

A client who was diagnosed with type 1 diabetes 14 years ago is admitted to the medical-surgical unit with abdominal pain. On admission, the client's blood glucose level is 470 mg/dl (26.1 mmol/L). Which finding is most likely to accompany this blood glucose level?

rapid, thready pulse This client's abnormally high blood glucose level indicates hyperglycemia, which typically causes polyuria, polyphagia, and polydipsia. Because polyuria leads to fluid loss, the nurse should expect to assess signs of deficient fluid volume, such as a rapid, thready pulse; decreased blood pressure; and rapid respirations. Cool, moist skin and arm and leg trembling are associated with hypoglycemia. Rapid respirations — not slow, shallow ones — are associated with hyperglycemia.

A client is at risk for developing a pressure ulcer. The first warning of an impending pressure ulcer is when the nurse applies pressure and observes for color change when pressure is released and the skin color changes to:

reddish. When pressure is applied to the skin, the area first becomes blanched, or whitish. When pressure is relieved, the circulation tends to carry excess blood to the area to make up for the temporary decrease in blood supply. This effect, called reactive hyperemia, causes the skin to redden. Such a reddened area is a precursor of a pressure ulcer.Bluish skin indicates a lack of oxygen in the tissues, not the development of a pressure ulcer.Whitish skin may be indicative of arterial insufficiency to an area.A yellowish cast when blanched suggests jaundice, which indicates a liver or biliary tract disorder.

A client who suffered a stroke has a nursing diagnosis of ineffective airway clearance. The goal of care for this client is to mobilize pulmonary secretions. Which intervention helps meet this goal?

repositioning the client every 2 hours Repositioning the client every 2 hours helps prevent secretions from pooling in dependent lung areas. Restricting fluids would make secretions thicker and more tenacious, thereby hindering their removal. Administering oxygen and keeping the head of the bed at a 30-degree angle might ease respirations and make them more effective but wouldn't help mobilize secretions.

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

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

When caring for a client with preeclampsia during labor, the nurse should:

restrict the amount of fluid administered. The volume of fluids administered during labor to a client with preeclampsia should be restricted. Clients usually receive between 60 and 150 ml/hour.

The client is to have surgery on the fourth metatarsal. Identify the place on the illustration below where the client should confirm the operative site to the health care provider.

second smallest toe, upper foot

When developing the postoperative plan of care for an adolescent who has undergone an appendectomy for a ruptured appendix, in which position should the nurse expect to place the client during the early postoperative period?

semi-Fowler's position After an appendectomy for a ruptured appendix, assuming the semi-Fowler's or a right side-lying position helps localize the infection. These positions promote drainage from the peritoneal cavity and decrease the incidence of subdiaphragmatic abscess.

A client has an intracapsular hip fracture. The nurse should conduct a focused assessment to detect which change near the fracture?

shortening of the affected leg With an intracapsular hip fracture, the affected leg is shorter than the unaffected leg because of the muscle spasms and external rotation. The client also experiences severe pain in the region of the fracture.

Which position is best for a client with heart failure who has orthopnea?

sitting upright (high Fowler's position) with legs resting on the mattress Sitting almost upright in bed with the feet and legs resting on the mattress decreases venous return to the heart, thus reducing myocardial workload. Also, the sitting position allows maximum space for lung expansion. Low Fowler's position would be used if the client could not tolerate high Fowler's position for some reason. Lying on the right side would not be a good position for the client in heart failure. The client in heart failure would not tolerate Trendelenburg position.

A nurse is changing a client's surgical incision dressing on post-op day three. For which observation would the nurse take immediate action?

small amount of creamy yellow drainage Yellow, creamy drainage describes purulent dischage and suggests infection; the nurse must report this finding to the healthcare provider immediately and obtain a culture as ordered. Clear pink to red watery discharge describes serosanguinous dischage, which is evidence of some edema at the site; it does not warrant immediate intervention. Reddended wound edges are expected as healing occurs, and epithelizing tissue represent normal findings for a wound.

When teaching the mother of an infant who has received a temporary colostomy for treatment of Hirschsprung's disease about how the stoma should normally appear, the nurse should include which description about the stoma's appearance in the teaching?

staying deep red in color Typically, the stoma should remain deep red in color as long as the infant has the colostomy. A dark red to purplish color may indicate impaired circulation to the stoma.

The nurse is caring for a 3-month-old infant, who had a cleft palate and cleft lip surgical repair. Which assessment data would indicate a postoperative complication from the surgery?

suture line surrounded by erythema There is a risk for infection in the suture line if it is not kept clean and dry. Signs of infection would include erythema or foul drainage from the suture line and fever. Crying intermittently is a normal assessment finding and the nurse should be prepared with liquids or formula. A suture line may be swollen in the immediate postoperative period, but its appearance will improve with time. A Logan bar may be used to hold the suture line in place.

Which signs or symptoms suggest that an infant with diarrhea is dehydrated? Select all that apply.

tacky mucous membranes sunken anterior fontanel restlessness Diarrhea in infants is a serious condition as it can proceed rapidly to dehydration. Clinical signs of dehydration are irritability and restlessness, weakness, stupor, loss of body weight, poor skin turgor, and sunken fontanels. The urine output is decreased in dehydrated infants. The saliva decreases with dehydration and is not salty.

A client is recovering from an abdominal-perineal resection. To promote wound healing after the perineal drains have been removed the nurse should encourage the client to:

take sitz baths. Sitz baths are an effective way to clean the operative area after an abdominal-perineal resection. Sitz baths bring warmth to the area, improve circulation, and promote healing and cleanliness. Most clients find them comfortable and relaxing. Between sitz baths, the area should be kept clean and dry. A shower will not adequately clean the perineal area. Moist dressings may promote wound contamination and delay healing. A heating pad applied to the area for longer than 20 minutes may cause excessive vasodilation, leading to congestion and discomfort.

A client undergoing chemotherapy has a white blood cell count of 2,300/mm3 (2.3 X 109/L); hemoglobin of 9.8 g/dL (98 g/L); platelet count of 80,000/mm3 (80 X 109/L); and potassium of 3.8. Which finding should take priority?

temperature 101° F (38.3° C). The client has a low white blood cell count from the chemotherapy and has a temperature. Signs and symptoms of infection may be diminished in a client receiving chemotherapy; therefore, the temperature elevation is significant. Early detection of the source of infection facilitates early intervention. Surveillance for bleeding is important with the low hemoglobin and platelet count; however, the high blood pressure does not indicate bleeding. Vomiting is a side effect of chemotherapy and should be treated. The urine output and potassium are within normal limits.

When performing the nursing history, which information would be most important for the nurse to obtain from the mother of an infant with suspected colic?

the infant's crying pattern Information on the crying pattern of the infant is most helpful in confirming the diagnosis of colic. Typically the colic attack begins abruptly, with the infant crying loudly and continuously, possibly for hours. The attack may end when the child becomes exhausted. The child also may attain some relief after passing stool or flatus. Often, in an attempt to alleviate the infant's crying, parents try to feed the infant, resulting in overfeeding leading to discomfort and distention. Asking about the type of formula, sleep position, or position for burping will not provide sufficient information to confirm the diagnosis of colic. However, the nurse can obtain additional information after determining the nature of the crying pattern.

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

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

A client who is 10 weeks pregnant develops spotting; however, the cervix remains closed. What should the nurse should suspect?

threatened abortion Spotting in the first trimester may indicate that the pregnancy is in jeopardy. Bed rest and avoidance of physical and emotional stress are recommended. Abortion is usually inevitable if the bleeding is accompanied by pain with dilation and effacement of the cervix. An inevitable abortion is associated with cervical dilation. An ectopic pregnancy is in the fallopian tubes, and a false positive pregnancy could reflect a missed abortion.

A client who had a left thoracoscopy sustained an injury secondary to the surgery position. The nurse should assess the client for which sign?

tingling in the arm A client who had a left thoracoscopy is placed in the lateral position, in which the most common injury is an injury to the brachial plexus. Numbness and tingling in the arm suggests a brachial plexus injury. There is no undue pressure on the ankles or knees during thoracic surgery.

When teaching the child with scoliosis being treated with a Boston brace about exercises, the nurse explains that the exercises are performed primarily for what reason?

to strengthen the back and abdominal muscles Exercises are prescribed for the child with scoliosis wearing a Boston brace to help strengthen spinal and abdominal muscles and provide support. Typically, children wearing a Boston brace do not have muscle spasms. Performing exercises provides no effect on the brace's traction ability. Spinal contractures do not occur when a Boston brace is worn.

A client is returned to the hospital room after a subtotal thyroidectomy. Which piece of equipment is most important for the nurse to keep at the client's bedside?

tracheostomy set After a subtotal thyroidectomy, swelling of the surgical site (the tracheal area) may obstruct the airway. Therefore, the nurse would keep a tracheostomy set at the client's bedside in case of a respiratory emergency. Although an automated vital signs machine and a cardiac monitor may be used for a client after a thyroidectomy, the tracheostomy set is more important. A humidifier isn't indicated for this client.

The nurse is administering 5,000 units heparin subcutaneously to a client (see the accompanying image). The nurse should:

use a shorter needle. Heparin should be administered into subcutaneous tissue at a 90-degree angle using a 27-gauge 5/8-inch (1.6-cm) needle. The medication should not be administered into the muscle. In order to prevent hematoma formation, the nurse should not rotate the tip of the needle or aspirate before injecting the heparin.

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

"This condition can result from irritation and inflammation from sexual activity." Cystitis is a lower urinary tract infection. It is sometimes seen among young adolescent females after the first sexual intercourse experience. The urinary tract infections occur because of inflammation and local irritation caused by sexual activity. Bladder infections can lead to complications, so they are not minor or harmless. A bladder or uretheral infection is not the result of vaginal cleanses such as douches.

Three days after surgery, a client continues to take hydrocodone 7.5 mg and acetaminophen 500 mg for postoperative pain. What should the nurse ask the client before administering the pain medication?

"When did you last have a bowel movement?" The nurse should ask the client about having a bowel movement because acetaminophen with hydrocodone is an opioid, which can be constipating. By the third day, many clients become constipated and are feeling distended, with sharp, cramping pain due to gas, which is treated with ambulation, not more opioids. The client's emptying the bladder should not affect the pain level. The nurse should look at the client's medical record to determine when the client's last dose of pain medication was administered, rather than asking the client. The client's statement regarding the pain level before the surgery is not relevant to whether the nurse should administer the acetaminophen and hydrocodone

What information should a nurse plan to teach a client newly diagnosed with an infection who has acquired-immune deficiency syndrome (AIDS)?

"You are more susceptible to infection due to damage to your immune system." The nurse should provide accurate information to this client. There is no information in the question to indicate that the disease is rapidly progressing. Opportunistic infections are common but are not considered normal, and may occur at any stage of this disease.

he nurse performs a routine prenatal assessment on a client at 35 weeks' gestation and finds vital signs: blood pressure 138/88 mm Hg, pulse 82/min, respirations 18/min, temperature 99.1° F (37.3° C). Which statement is most appropriate for the nurse to make at this time?

"Your blood pressure is slightly high. I will check it again before you leave." A blood pressure reading of 138/88 mm Hg is nearing hypertension range and could be a sign of developing gestational hypertension. Conversely, the client may be experiencing "white coat" syndrome or could be anxious during the prenatal visit. In order to obtain an accurate blood pressure reading, the nurse should allow the woman to rest for a period of time and recheck the blood pressure in the same arm and while the woman is in the same position. This blood pressure is considered approaching high. All other vital signs are within normal range.

The physician prescribes furosemide, 2 mg/kg P.O., as a one-time dose for an infant with fluid overload. The infant's documented weight is 14 lb (6.4 kg). The oral solution contains 10 mg/mL. How many milliliters of solution should the nurse administer? Record your answer using one decimal place.

1.3 Perform the calculation to determine the total dose prescribed: 2 mg/kg = X/6.4 kg X = 12.8 mg. Then set up the proportion to determine the volume of medication to administer: 10 mg/mL = 12.8 mg/X X = 1.3 mL.

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

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

A nurse has found a client unconscious and not breathing. Arrange interventions in order of priority. All options must be used.

Activate emergency response system. Perform chest compressions at a rate of at least 100/minute. Provide 30 compressions. Perform head tilt-chin lift. Provide two ventilations. After determining that the client is not breathing, the emergency response system should be the first action. Chest compressions should be rapid (at least 100 per minute) to provide circulation; after 30 compressions, the client's jaw should be positioned to open the airway and two breaths should be provided.

The nurse caring for a 7-year-old child who has undergone a cardiac catheterization 2 hours ago finds the dressing and bed saturated with blood. What should the nurse do first?

Apply pressure just above the catheter insertion site. Direct pressure is the first measure that should be used to control bleeding. Taking the vital signs will not control the bleeding. This should be done while another person is being sent to notify the HCP. The dressing can be reinforced after the bleeding has been contained.

A client is admitted to the telemetry unit following a ST segment-elevation myocardial infarction (STEMI). The electrocardiogram (EKG) tracing shows a run of sustained ventricular tachycardia. What is the first action that the nurse should take?

Assess the client's airway, breathing, pulses, and level of conciseness. If the client is experiencing ventricular tachycardia, the priority for the nurse is to assess the client's airway, breathing, and level of consciousness before any further action is taken.

The nurse notices redness, swelling, and induration at a surgical wound site. What is the nurse's next action?

Assess the client's temperature. Infection produces signs of redness, swelling, induration, warmth, and possibly drainage. Since there could be a worsening situation occurring, further evaluation of the client is needed to determine the urgency of the situation. Assessment of the temperature should be the next step to determine how the client is responding to the infection. The white blood cells can also determine patient's response, but the priority should be the temperature. The wound needs to be re-dressed, but this would occur after speaking with the health care provider in case a culture may be ordered, which would be inaccurate if the wound was cleaned first.

An enterostomy nurse is providing an in-service session on caring for colostomies. Which statement by a nurse indicates the need for further teaching?

"I can make a small pin hole in the bag to let the gas out, so I don't have to change the appliance frequently." The nurse requires additional teaching if stateing that they can make a hole in the drainage bag to let gas out. Any hole in the drainage bag, no matter how small, will destroy the odor-proof seal. Removing or unclamping the bag is the only appropriate method for releasing the gas accumulated in the bag. Odor-relieving tablets, usually made of charcoal, can be placed in the bag to help with the odor.

A nurse is teaching the parent of a 5-month-old infant diagnosed with bronchiolitis. Which statement by the mother indicates that teaching has been effective?

"I know that this disease is serious and can lead to asthma." By saying that bronchiolitis places the child at risk for developing asthma, the parent demonstrates understanding of the infant's condition. If diagnosed and treated promptly, most infants recover from the illness and return home. Infants typically don't have recurrences of bronchiolitis. Infants diagnosed with bronchiolitis rarely require mechanical ventilation

The parent asks the nurse whether a child with hemiparesis due to spastic cerebral palsy will be able to walk normally because he can pull himself to a standing position. Which response by the nurse would be most appropriate?

"It is difficult to predict, but his ability to bear weight is a positive factor." The nurse needs to respond honestly to the mother. Most children with hemiparesis due to spastic cerebral palsy are able to walk because the motor deficit is usually greater in the upper extremity. There is no need to refer the mother to the HCP. Pulling to a stand requires both upper body and lower body strength. The will to walk is important, but without neurologic stability the child may be unable to do so.

An infant's death is deemed due to sudden infant death syndrome (SIDS). The parents want to know the cause of SIDS and if they could have done something to prevent it. What explanation should the nurse provide these parents?

"Unfortunately the cause of SIDS is unknown." Unfortunately, while there are many theories as what causes SIDS, no one specific cause has been identified. SIDS is more frequent in male than female infants. Although cigarette smoke may have an association with SIDS, exposure to respiratory infection has not been proven to be correlated with an increased incidence of SIDS. Although SIDS is more common in preterm infants, it is often associated with multiple births, infants with low Apgar scores, and infants born to mothers who smoked during pregnancy. SIDS can also occur in babies who sleep face down on soft surfaces. That is why back sleeping is now recommended.

Which statements would indicate that the parents of a child being treated with antibiotics for an ear infection understand the reason for a follow-up visit after the child completes the course of therapy?

"We need to make sure that her ear infection has completely cleared." Because ear infections are sometimes difficult to treat, determining if the antibiotic has resolved the infection is essential. If the child is not rechecked, it will be difficult to determine if another infection is a continuation of a previous infection or a separate, new infection.Although studies may be done to determine if an infection has impaired the child's hearing, they are not done routinely after each course of antibiotic therapy.A visit to the primary care provider's office cannot validate that all the medication was taken.A follow-up visit helps to determine if the infection has completely cleared. If the infection is resolved with one course of antibiotics, another course would not be prescribed.

The nurse is caring for a client receiving morphine in an intravenous infusion using a patient-controlled anesthesia pump (PCA) for relief of postoperative pain. On assessment, the client's vital signs are as follows: heart rate, 84 bpm; respirations, 8 breaths/min; blood pressure 104/56 mm Hg; and oxygen saturation of 88% on room air. What should the nurse do first?

Assist the client to sit and stimulate coughing/deep breathing. The client still has a respiratory rate of 8; the nurse should first assist the client to sit and stimulate the client to take deep breaths and cough. This action will also help the nurse to determine what the client's level of sedation is; if the client is too sedated to cooperate with coughing/deep breathing, it will be important to slow or stop the infusion of narcotics and to consider contacting the HCP for a prescription for naloxone. The client is still breathing, so it is not necessary to call the rapid response team.

A child with hemophilia is hospitalized after falling. Now the child complains of severe pain in the left wrist. What should the nurse do first?

Elevate the affected arm and apply ice to the injury site. Severe joint pain in a child with hemophilia indicates bleeding; therefore, the nurse should first elevate the affected extremity and apply ice to the injury site to promote vasoconstriction. ROM exercises may worsen discomfort and bleeding. Massage and warm compresses also may increase bleeding. The nurse should notify the physician only after taking measures to stop the bleeding.

When the client who has had a modified radical mastectomy returns from the operating room to the recovery room, what should the nurse do first?

Ensure that the client's airway is free of obstruction. The highest priority when a nurse receives a client from the operating room is to assess airway patency. If the airway is not clear, immediate steps should be taken so that the client is able to breathe.Vital signs can be assessed after airway patency is assured.Assessing the patency and functioning of drainage tubes can be done after the airway is assessed and vital signs are taken.The dressing can be assessed once airway patency has been determined

A preschooler has vomiting, diarrhea, and a potassium level of 3 mEq/L (3 mmol/L). Which prescribed order will the nurse implement first?

I.V. infusion of 500 ml of dextrose 5% in water and half-normal saline solution with 20 mEq (20 mmol/L) of potassium chloride at 100 ml/hr A child with vomiting and diarrhea loses excessive fluids and electrolytes, putting them at risk for dehydration and cardiac arhythmia. The first action by the nurse is to start the IV fluid replacement. The nurse would then adminster the promethazine to reduce nausea and vomiting and then place the nasogastric tube to low intermittent suction. Imodium is not recommended in children under age 6, therefore the nurse should seek clarification of this order.

When developing a care plan for a client newly diagnosed with scleroderma, which nursing diagnosis has the highest priority?

Impaired skin integrity Impaired skin integrity is a concern for the client with scleroderma in its earlier stages. Meticulous skin care is required to prevent complications. Although Risk for constipation may also be appropriate, this nursing diagnosis isn't the priority. Clients with scleroderma are at risk for Imbalanced nutrition: Less than body requirements. The client with advanced scleroderma, not newly diagnosed scleroderma, is at increased risk for developing respiratory complications.

A 10-year-old child falls, injures the left shoulder, and is taken to the emergency department. While the client waits to be seen by the physician, what intervention should the nurse perform first?

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

A client has just been transferred to the postanesthesia recovery room following a laparotomy. In addition to vital signs, what are the most important initial assessments that need to be completed?

Level of consciousness, pain level, and wound dressing Postoperatively vital signs are taken to ensure that vital systems are returning to normal after anesthesia. It is also important to check the level of consciousness, particularly postanesthesia and postanalgesia. Pain levels need to be monitored. Dressings need to be checked to detect abnormal increase in bleeding. The nurse would not check metabolic rate and reflexes, emotional response, or social support systems as an initial assessment after surgery.

The nurse is assessing a client's abdominal incision 48 hours after surgery. Which finding indicates that the wound is inflamed?

Localized warmth over the incisional area. Localized warmth over the incisional area indicates that inflammation is present and could indicate the presence of an infection.Serous-sanguineous drainage from a wound drain is normal in the early postoperative phase.Dried, bloody drainage is also considered to be a normal finding.A slightly pink skin color around staples or sutures is to be expected as the skin is irritated by the presence of the materials.

While assessing a client's spine for abnormal curvatures, the nurse notes lordosis. Identify the area of the spine that is affected by lordosis.

Lordosis is characterized by an accentuated curve of the lumbar area of the spine.

A client's arterial blood gas values are as shown on the accompanying chart. These findings indicate which of the following acid-base imbalances?

Metabolic acidosis. The pH of 7.24 indicates that the client is acidotic. The carbon dioxide level is normal, but the HCO3- level is decreased. These findings indicate that the client is in metabolic acidosis.

A client receiving continuous mandatory ventilation begins to experience cluster breathing after recent intracranial occipital bleeding. What should the nurse do?

Notify the health care provider (HCP) of the client's breathing pattern. Cluster breathing consists of clusters of irregular breaths followed by periods of apnea on an irregular basis. A lesion in the upper medulla or lower pons is usually the cause of cluster breathing. Because the client had a bleed in the occipital lobe, which is just superior and posterior to the pons and medulla, clinical manifestations that indicate a new lesion are monitored very closely in case another bleed ensues. The nurse should notify the HCP immediately so that treatment can begin before respirations cease. The client is not obtaining sufficient oxygen, and the depth of breathing is assisted by the ventilator. The HCP will determine changes in the ventilator settings.

An adult client is admitted to the hospital after vomiting bright red blood and is diagnosed with a bleeding duodenal ulcer. The client develops a sudden, sharp pain in the midepigastric region along with a rigid, board-like abdomen. After obtaining the client's vital signs, what should the nurse do next?

Notify the health care provider. The client is likely experiencing a perforation of the ulcer, and the nurse should notify the health care provider immediately. The body reacts to perforation of an ulcer by immobilizing the area as much as possible. This results in board-like abdominal rigidity, usually with extreme pain. Perforation is a medical emergency requiring immediate surgical intervention because peritonitis develops quickly after perforation.Administering pain medication is not the first action, although the nurse later should institute measures to relieve pain.Elevating the head of the bed will not minimize the perforation.A nasogastric tube may be used following surgery.

A nurse is caring for a client who had a thyroidectomy and is at risk for hypocalcemia. What should the nurse do?

Observe for muscle twitching and numbness or tingling of the lips, fingers, and toes. Muscle twitching and numbness or tingling of the lips, fingers, and toes are signs of hyperirritability of the nervous system due to hypocalcemia. The other options describe complications for which the nurse should also be observing; however, tetany and neurologic alterations are primary indications of hypocalcemia.

A client presents to the emergency room with abdominal pain and upper gastrointestinal bleeding. The client is sweating and appears to be in moderate distress. Which nursing action would be a priority at this time?

Obtain vital signs. The priority nursing action is vital signs. Vital signs provide valuable information on the internal body system. Symptoms of shock, such as low blood pressure, a rapid weak pulse, cold clammy skin, and restlessness, can be monitored. Assessing bowel sounds and abdominal tenderness can provide useful data but is not a priority. Documentation is a lower priority and a health care provider's order is needed for a nasogastric tube placement.

A nurse is assessing a full-term neonate and discovers a heart rate of 100 beats/minute and an axillary temperature of 97.3°F (36.3°C). What action should the nurse take?

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

Which item must the nurse consider when positioning a client for tracheal suctioning?

Position in a semi-Fowler's position. The semi-Fowler's position is the correct position for suctioning a client. The other answers are incorrect based on incorrect positioning of client for suctioning. The neck should be in neutral position.

The nurse explains to the client that a biopsy of the enlarged lymph node is important because, if Hodgkin's disease is present, the histologic examination will reveal which of the following?

Reed-Sternberg cells. A definitive diagnosis of Hodgkin's disease is made if Reed-Sternberg cells are found in the histologic examination of the excisional lymph node biopsy. Tay-Sachs disease is an inherited disease carried by an autosomal recessive gene. Sarcoidosis is an inflammatory granulomatous disease. Duchenne's disease is a type of muscular disorder.

A school nurse is examining a student at an elementary school and notes vesicular lesions that ooze, forming crusts on the face and extremities. Which actions by the nurse are most appropriate?

Sending the child home and encourage evaluation by physician. The nurse should send the child home due to possible impetigo and encourage the parents to have the child evaluated by the physician. Impetigo is contagious until the child has been on antibiotics for 24-48 hours, which is why the child should be sent home to be seen by the physician. Impetigo starts as papulovesicular lesions surrounded by redness. The lesions become purulent and begin to ooze, forming crusts. Impetigo occurs most commonly on the face and extremities. Small red lesions on the trunk and in the skin folds are characteristic of scarlet fever. A discrete pink-red maculopapular rash that starts on the face and progresses down to the trunk and extremities is characteristic o

While the nurse is assisting a client to ambulate as part of a cardiac rehabilitation program, the client has midsternal burning. What should the nurse do next?

Stop and assess the client further. The nurse should stop and assess the client further. A chair should be available for the client to sit down. Obtaining the client's blood pressure and heart rate are important when exercising. These values can be used to predict when the oxygen demand becomes greater than the oxygen supply. Calling for help is not necessary for the midsternal burning. If the health care provider (HCP) has prescribed nitroglycerin, the nurse can administer it; however, stopping the activity may restore the oxygen balance.

A nurse is planning to assess a client's apical heart rate. Identify the area where the nurse should place the stethoscope to assess the apical heart rate.

The apical heart rate is best heard at the point of maximal impulse at the left ventricular area of the thorax. It is the fifth intercostal space, midclavicular line.

A nurse is caring for a client who has experienced an acute exacerbation of Crohn's disease. Which assessment best indicates that the disease is under control?

The client exhibits signs of adequate GI perfusion with normal bowel sounds. Adequate GI perfusion can be maintained only if Crohn's disease is controlled. If the client experiences acute, uncontrolled episodes of Crohn's disease, impaired GI perfusion may lead to a bowel infarction. Positive self-image, a manageable level of discomfort, and intact skin integrity are expected client outcomes, but aren't related to control of the disease.

During a teaching session, a nurse demonstrates to a client how to change a tracheostomy dressing. Then the nurse watches as the client returns the demonstration. Which client action indicates an accurate understanding of the procedure?

The client rinses around the clean incision site, using gauze squares moistened with normal saline. o change a tracheostomy dressing effectively, the client should rinse around the clean incision site, using gauze squares moistened with normal saline. If crusts are difficult to remove, the client may use a solution of 50% hydrogen peroxide and 50% sterile saline — not full-strength hydrogen peroxide. The client shouldn't use tap water, which may contain chemicals and other harmful substances. To prevent lint or fiber aspiration and subsequent tracheal abscess, the client should use sterile dressings made of nonraveling material instead of cotton-filled gauze squares.

A client with diabetes mellitus has a foot ulcer. The physician orders bed rest, a wet-to-damp dressing change every shift, and blood glucose monitoring before meals and at bedtime. Why are wet-to-damp dressings used for this client?

They debride the wound and promote healing by secondary intention For this client, wet-to-damp dressings are most appropriate because they clean the foot ulcer by debriding exudate and necrotic tissue, thus promoting healing by secondary intention. Moist, transparent dressings contain exudate and provide a moist wound environment. Dry, sterile dressings protect the wound from mechanical trauma and promote healing. Hydrocolloid dressings prevent the entrance of microorganisms and minimize wound discomfort.

A nurse is changing a dressing and providing wound care. Place the following activities in the correct order. All options must be used.

Wash hands thoroughly. Put on latex gloves. Slowly remove the soiled dressing. Assess the drainage in the dressing. The correct order for a dressing change involves the nurse washing her hands, putting on gloves, removing the dressing, and observing the drainage.

A with a pediatric client with scoliosis has to wear a brace. The nurse should develop a teaching plan with the client to include which instruction?

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

Parents bring a 10-month-old boy with myelomeningocele and hydrocephalus with a ventriculoperitoneal shunt to the emergency department. His symptoms include vomiting, poor feeding, lethargy, and irritability. What interventions by the nurse are appropriate? Select all that apply.

Weigh the child. Listen to bowel sounds. Obtain vital signs. Assess pitch and quality of the child's cry. common shunt complications are obstruction, infection, and disconnection of the tubing. The signs presented by the child indicate increased intracranial pressure from a shunt malfunction, which could be caused by an infection, such as peritonitis or meningitis. By listening to bowel sounds, the nurse will note if peritonitis might be a possibility. Intracranial pressure manifests as a bulging or taut anterior fontanel, but the posterior fontanel is typically closed. Obtaining vital signs would assess for signs of infection, such as elevated temperature or, possibly, Cushing's triad (elevated blood pressure, slow pulse, and depressed respirations). A high-pitched cry is a sign of increased intracranial pressure. Weighing the child, while it would not help identify the cause of the problem, would help determine the severity of the dehydration from vomiting

A client who has tested positive for the human immunodeficiency virus (HIV) gives birth. When she asks whether her baby has acquired immunodeficiency syndrome (AIDS), how should the nurse respond?

Your child may have acquired HIV in utero, but we won't know for sure until the child is older." The nurse should explain to the mother that the neonate might have acquired HIV in utero, but that a diagnosis can't be made until the neonate is older. Diagnosing AIDS in neonates is difficult because all neonates of women with HIV receive maternal antibodies and therefore initially test positive for HIV antibodies. Saying, "Don't worry. It's too soon to tell" minimizes the mother's concern and doesn't provide specific information. Saying that chances are the neonate will be okay could promote false hope. Stating that all neonates born to HIV-positive women are infected isn't true. Neonates of HIV-positive mothers have a 25% to 30% chance of developing HIV.

During the admission assessment of a female neonate, a nurse notes a large lump on the neonate's head. Concerned about making the correct assessment, the nurse differentiates between caput succedaneum and a cephalohematoma based on the knowledge that

a cephalohematoma doesn't cross the suture lines. Cephalohematomas don't cross the suture lines and are the result of blood vessels rupturing in the neonate's scalp during labor. Blood outside the vasculature in a neonate increases the possibility of jaundice as the neonate's body tries to reabsorb the blood. Caput succedaneum, which is soft tissue edema of the scalp, can occur in any labor and isn't limited to a prolonged second stage of labor.

A client with suspected rheumatic fever is admitted to the pediatric unit. When obtaining the client's history, the nurse considers which information to be most important?

a recent episode of pharyngitis A recent episode of pharyngitis is the most important factor in establishing the diagnosis of rheumatic fever. Although the client may have a history of fever or vomiting or lack interest in food, these findings are not specific to rheumatic fever.

While auscultating the heart sounds of a client with heart failure, the nurse hears an extra heart sound immediately after the second heart sound (S2). The nurse should document this as

a third heart sound (S3). An S3 is heard following an S2, which commonly occurs in clients experiencing heart failure and results from increased filling pressures. An S1 is a normal heart sound made by the closing of the mitral and tricuspid valves. An S4 is heard before an S1 and is caused by resistance to ventricular filling. A murmur is heard when there is turbulent blood flow across the valves

A nurse is teaching a new mother about intussusception. Which signs and symptoms should the nurse include?

abdominal distension and vomiting Intussusception occurs when a portion of the bowel slides into the next, like the pieces of a telescope. When this occurs it can create a blockage in the bowel, with the walls of the intestines pressing against one another. This leads to abdominal swelling, inflammation, and decreased blood flow to the part of the intestines involved. Additional symptoms include vomiting, passing of stools mixed with blood and mucus, and grunting due to pain.

Which outcome would the nurse identify as the priority to achieve when developing the plan of care for a primigravid client at 38 weeks' gestation who is hospitalized with severe preeclampsia and receiving intravenous magnesium sulfate?

absence of any seizure activity during the first 48 hours The highest priority for a client with severe preeclampsia is to prevent seizures, thereby minimizing the possibility of adverse effects on the mother and fetus, and then to facilitate safe childbirth. Efforts to decrease edema, reduce blood pressure, increase urine output, limit kidney damage, and maintain sedation are desirable but are not as important as preventing seizures. It would take several days or weeks for the edema to be decreased. Sedation and decreased reflex excitability can occur with the administration of intravenous magnesium sulfate, which peaks in 30 minutes, much sooner than 48 hours.

While caring for a just born female term neonate, the nurse observes that the neonate's clitoris is enlarged and there is some fusion of the posterior labia majora. The nurse should notify the health care provider because these findings are associated with which problem?

ambiguous genitalia An enlarged clitoris with fusion of the posterior labia majora is associated with ambiguous genitalia. Ultrasound examination will reveal whether ovaries are present.Renal disorders are associated with absence of a kidney and oliguria.Potter's syndrome is a fatal condition involving renal agenesis and facial deformities.Turner's syndrome is an autosomal anomaly in which there are 45 chromosomes. This syndrome also involves intellectual disabilities, a long spine, and delayed or absent sexual maturity.

When teaching the mother of a child diagnosed with phenylketonuria (PKU) about its transmission, the nurse should use knowledge of which factor as the basis for the discussion?

autosomal recessive gene PKU is caused by an inborn error of metabolism. It is an autosomal recessive disorder that inhibits the conversion of phenylalanine to tyrosine. A form of Down syndrome, trisomy 21, is an example of a disorder caused by chromosomal translocation. Cri du chat is an example of a disorder caused by chromosomal deletion. Hemophilia A is an example of a disorder caused by an X-linked recessive gene.

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

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

A client is admitted with hyperosmolar hyperglycemic nonketotic syndrome (HHNS). Which laboratory finding should the nurse expect in this client?

blood glucose level 1,100 mg/dl (61.05 mmol/L) HHNS occurs most frequently in older clients. It can occur in clients with either type 1 or type 2 diabetes mellitus but occurs most commonly in those with type 2. The blood glucose level rises to above 600 mg/dl (33.33 mmol/L) in response to illness or infection. As the blood glucose level rises, the body attempts to rid itself of the excess glucose by producing urine. Initially, the client produces large quantities of urine. If fluid intake isn't increased at this time, the client becomes dehydrated, causing BUN levels to rise. Arterial pH and plasma bicarbonate levels typically remain within normal limits.

A client is admitted with a diagnosis of ulcerative colitis. The nurse should assess the client for:

bloody, diarrheal stools. Diarrhea is the primary symptom of ulcerative colitis. It is profuse and severe; the client may pass as many as 15 to 20 watery stools per day. Stools may contain blood, mucus, and pus. The frequent diarrhea is often accompanied by anorexia and nausea.Constipation is not a sign or symptom of ulcerative colitis.Steatorrhea (fatty stools) is more typical of pancreatitis and cholecystitis.Alternating diarrhea and constipation is associated with irritable bowel syndrome.

A toddler hospitalized with nephrotic syndrome has marked dependent edema and hypoalbuminemia. His urine is frothy. When assessing the child's vital signs, the nurse should report which finding to the health care provider?

body temperature of 102.8° F (39.3° C) Temperature of 102.8° F (39.3° C) is elevated, suggesting an infection. The nurse should notify the health care provider.The child is displaying signs and symptoms of nephrotic syndrome. With this disorder, blood pressure is characteristically normal or slightly low. The other vital signs are likely to be normal unless edema causes respiratory distress and respirations increase and become labored. The blood pressure reading, heart rate, and respiratory rate here are within the normal range for a toddler.A pulse rate of 85 bpm is normal for a toddler. In nephrotic syndrome, the pulse rate would be normal unless other problems arise.A respiratory rate of 28 is normal for a toddler. In nephrotic syndrome, the respiratory rate would be normal unless edema causes respiratory distress and the respirations increase and become labored

Which complication is common in neonates who receive prolonged mechanical ventilation at birth?

bronchopulmonary dysplasia Bronchopulmonary dysplasia commonly results from the high pressures that must sometimes be used to maintain adequate oxygenation. Esophageal atresia, a structural defect in which the esophagus and trachea communicate with each other, isn't related to mechanical ventilation. Hydrocephalus and renal failure don't typically occur in neonates who receive mechanical ventilation

What finding indicates that performing passive range-of-motion (ROM) exercises on an unconscious client has been successful?

maintenance of joint mobility The goal of performing passive ROM exercises is to maintain joint mobility. Active exercise is needed to preserve bone and muscle mass. Passive ROM movements do not prevent bone demineralization or have a positive effect on the client's muscle tone.

A client undergoes a biopsy of a suspicious lesion. The biopsy report classifies the lesion according to the TNM staging system as follows: TIS, N0, M0. What does this classification mean?

carcinoma in situ, no abnormal regional lymph nodes, and no evidence of distant metastasis TIS, N0, M0 denotes carcinoma in situ, no abnormal regional lymph nodes, and no evidence of distant metastasis. No evidence of primary tumor, no abnormal regional lymph nodes, and no evidence of distant metastasis is classified as T0, N0, M0. If the tumor and regional lymph nodes can't be assessed and no evidence of metastasis exists, the lesion is classified as TX, NX, M0. A progressive increase in tumor size, no demonstrable metastasis of the regional lymph nodes, and ascending degrees of distant metastasis is classified as T1, T2, T3, or T4; N0; and M1, M2, or M3.

A client is admitted for suspected GI disease. Assessment data reveal muscle wasting, a decrease in chest and axillary hair, and increased bleeding tendency. The nurse suspects the client has

cirrhosis. Muscle wasting, a decrease in chest and axillary hair, and increased bleeding tendencies are all symptoms of cirrhosis. The client may also have mild fever, edema, abdominal pain, and an enlarged liver. Clients with peptic ulcer disease complain of a dull, gnawing epigastric pain that's relieved by eating. Appendicitis is characterized by a periumbilical pain that moves to the right lower quadrant and rebound tenderness. Cholelithiasis is characterized by severe abdominal pain that presents several hours after a large meal.

A 22-year-old client reports substernal chest pain and states that their heart feels like "it's racing out of my chest." The client reports no history of cardiac disorders. The nurse attaches the client to a cardiac monitor and notes sinus tachycardia with a rate of 136 beats/minute. Breath sounds are clear, and the respiratory rate is 26 breaths/minute. When a cardiorespiratory basis is eliminated, which drug would the nurse question about usage?

cocaine Because of the client's age and negative medical history, the nurse would question about cocaine use. Barbiturate overdose may trigger respiratory depression and a slow pulse. Opioids can cause marked respiratory depression, while benzodiazepines can cause drowsiness and confusion. Cocaine increases myocardial oxygen consumption and can cause coronary artery spasm, leading to tachycardia, ventricular fibrillation, myocardial ischemia, and MI.

For a client with a sucking stab wound in the chest wall, the nurse should first:

cover the wound with a petroleum-impregnated dressing. The first course of action for a client with a sucking chest wound is to stop air from entering the chest cavity. Air entry will cause the lung to collapse. Stopping air entry is best done in an emergency situation by applying an air-occlusive dressing over the wound.The nurse can next notify the health care provider. Starting oxygen therapy and preparing for endotracheal intubation may be necessary later, but neither has the same priority on admission as closing the wound.

For the client who is receiving intravenous magnesium sulfate for severe preeclampsia, which assessment findings would alert the nurse to suspect hypermagnesemia?

decreased deep tendon reflexes Typical signs of hypermagnesemia include decreased deep tendon reflexes, sweating or a flushing of the skin, oliguria, decreased respirations, and lethargy progressing to coma as the toxicity increases. The nurse should check the client's patellar, biceps, and radial reflexes regularly during magnesium sulfate therapy. Cool skin temperature may result from peripheral vasodilation, but the opposite—flushing and sweating—are usually seen. A rapid pulse rate commonly occurs in hypomagnesemia. Tingling in the toes may suggest hypocalcemia, not hypermagnesemia.

A client comes to the emergency department reporting pain in the right leg. When obtaining the history, the nurse learns that the client has a history of obesity and hypertension. Based on this information the nurse anticipates the client having which musculoskeletal disorder?

degenerative joint disease Obesity predisposes the client to degenerative joint disease. Obesity isn't a predisposing factor for muscular dystrophy, scoliosis, or Paget's disease.

A nurse is assessing a client with possible Cushing's syndrome. In a client with Cushing's syndrome, the nurse expects to find

deposits of adipose tissue in the trunk and dorsocervical area. Because of changes in fat distribution, adipose tissue accumulates in the trunk, face (moon face), and dorsocervical areas (buffalo hump). Hypertension is caused by fluid retention. Skin becomes thin and bruises easily because of a loss of collagen. Muscle wasting causes muscle atrophy and thin extremities.

A nurse is teaching a group of parents about otitis media. When discussing why children are predisposed to this disorder, the nurse should mention the significance of which anatomical feature?

eustachian tubes The nurse should mention the importance of the eustachian tubes because they're short in a child and lie in a horizontal plane, promoting entry of nasopharyngeal secretions into the tubes and thus setting the stage for otitis media. The nasopharynx, tympanic membrane, and external ear canal have no unusual features that would predispose a child to otitis media.

A fourth heart sound (S4) indicates a

failure of the ventricle to eject all blood during systole. An S4 occurs as a result of increased resistance to ventricular filling following atrial contraction. This increased resistance is related to decreased ventricular compliance. A dilated aorta doesn't cause an extra heart sound, though it does cause a murmur. A nurse hears decreased myocardial contractility as a third heart sound. A nurse doesn't hear an S4 in a normally functioning heart.

When instructing clients about self-breast examination, which finding should they report to their healthcare provider? Select all that apply.

fixed nodular mass with skin dimpling bloody discharge from one of the nipples round movable masses that enlarge with menses Slight consistent asymmetry of bilateral body parts such as extremities, eyes, ears, breasts, and testes is normal. Conditions that require further evaluation include any change, such as a nipple discharge that is anything other than milk. A fixed nodular mass with dimpling of the overlying skin is a common sign of breast cancer. Round, freely movable masses that change with the menstrual cycle may indicate fibrocystic breasts, which is a benign condition that should be monitored after diagnosis, as it is harder to identify cancerous changes in lumpy breasts.

A 5-year-old child is brought to the emergency department after being stung multiple times on the face by yellow jackets. Which symptom of anaphylaxis requires priority medical intervention?

heart rate less than 60 beats/minute Bradycardia, a slow but steady heartbeat at a rate less than 60 beats/minute, is an ominous sign in children. Older children experiencing anaphylaxis initially demonstrate tachycardia in response to hypoxemia. When tachycardia can no longer maintain tissue oxygenation, bradycardia follows. The development of bradycardia usually precedes cardiopulmonary arrest. The average systolic blood pressure of children ages 1 to 7 can be determined by this formula: age in years plus 90. Thus, an average blood pressure for a 5-year-old child is 95 mm Hg. Urticaria should be treated after airway control has been established. The normal respiratory rate for a 5-year-old is 20 to 25 breaths/minute.

A client tells the nurse he is experiencing dyspnea. Which position will the nurse place the client in?

high Fowler's position Dyspnea is an indicator of a problem with breathing. High Fowler's position — the posture assumed by the client when the head of the bed is elevated to 90 degrees — promotes breathing by allowing the thoracic cavity to expand. The Trendelenburg, Sims', and supine positions wouldn't facilitate breathing.

Which type of solution raises serum osmolarity and pulls fluid from the intracellular and intrastitial compartments into the intravascular compartment?

hypertonic The osmolarity of a hypertonic solution is higher than that of serum. A hypertonic solution draws fluid into the intravascular compartment from the intracellular and interstitial compartments. An isotonic solution's osmolarity is about equal to that of serum. It expands the intravascular and interstitial compartments. A hypotonic solution's osmolarity is lower than serum's. A hypotonic solution hydrates the intracellular and interstitial compartments by shifting fluid out of the intravascular compartment. Electrotonic solution is incorrect.

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

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

The nurse caring for a client on the cardiac unit notices that the client's cardiac monitor shows ventricular fibrillation. What is the priority action by the nurse?

immediate defibrillation When ventricular fibrillation is verified, the first intervention is defibrillation. It is the only intervention that will terminate this lethal dysrhythmia. Digoxin will not help in this situation. An I.V. line will need to be established, but it is not the priority. A pacemaker may be needed, but not until the client is stabilized.

An infant admitted to the hospital with an acute rotavirus infection is having frequent diarrheal stools. On assessment, the nurse notes 40 to 60 bowel sounds per minute. The child has poor skin turgor and dry mucous membranes. The nurse determines the infant's dehydration is related to which factor?

increased GI motility Rotavirus is a type of viral infection that affects the GI tract. It causes diarrhea, which results in fluid loss. This type of infection can be very serious in infants who, because of their immature kidneys, cannot adjust to fluid loss as readily as adults.Acute diarrheal infection results in increased gastric emptying.Insufficient production of antidiuretic hormone is not a consequence of acute diarrheal infection.Acute diarrheal infection results in malabsorption, not an inability to metabolize nutrients that are absorbed.

In a client with amyotrophic lateral sclerosis (ALS) and respiratory distress, which finding is the earliest sign of reduced oxygenation?

increased restlessness In ALS, an early sign of respiratory distress is increased restlessness, which results from inadequate oxygen flow to the brain. As the body tries to compensate for inadequate oxygenation, the heart rate increases and blood pressure drops. A decreased LOC is a later sign of poor tissue oxygenation in a client with respiratory distress.

A nurse notes that a client has kyphosis and generalized muscle atrophy. Which problem is a priority when the nurse develops a nursing plan of care?

ineffective coughing and deep breathing In kyphosis, the thoracic spine bends forward with convexity of the curve in a posterior direction, making effective coughing and deep breathing difficult. Although the client may develop other problems because respiratory status deteriorates when pulmonary secretions are not adequately cleared from airways, ineffective coughing and deep breathing should receive priority attention.

The nurse is inspecting the client's abdomen (see the accompanying image). The nurse should document that the client's abdomen:

is flat and symmetrical. The client's abdomen is flat and without abnormalities. There is no aortic pulsation (motion is client's breathing). There is no hernia; the umbilicus is normal. There are no markings or lines (striae) on this client's abdomen.

Which condition should the nurse assess when completing the history and physical examination of a client diagnosed with osteoarthritis?

local joint pain Osteoarthritis is a degenerative joint disease with local manifestations such as local joint pain. Rheumatoid arthritis has systemic manifestation such as anemia and osteoporosis. Weight loss occurs in rheumatoid arthritis, whereas most clients with osteoarthritis are overweight

A child with partial- and full-thickness burns is admitted to the pediatric unit. What should be the priority at this time?

maintaining fluid and electrolyte balance Although monitoring vital signs frequently is important, for the first few days the primary concern in burn care is fluid and electrolyte balance, with the goal being to replace fluid and electrolytes lost. With burns, fluid and electrolytes move from the interstitial spaces to the burn injury and are lost. These must be replaced. Once the child's fluid and electrolyte status has been addressed and fluid resuscitation has begun, preventing wound infection is a priority and efforts to control the child's pain can be initiated.

A nurse is caring for a multiparous client in the fourth stage of labor. Assessment reveals a boggy uterus. Which nursing intervention has the highest priority?

massaging the uterus If uterine atony is noted, uterine massage should be performed to decrease the risk of postpartum hemorrhage. This intervention takes priority. If the uterus is displaced from midline, assist the client to empty her bladder. Vital signs should be taken every 15-30 minutes but the priority action is to address the uterine atony. A position change is not indicated.

A nurse assesses a client who is 16 days postpartum. The nurse finds that the client's left nipple is cracked and bleeding slightly. Her left breast is sore to touch and an area under the breast is firm, painful, and red. The client is also experiencing chills. What is likely causing this breastfeeding problem?

mastitis Mastitis is a localized inflammation of the breast that occurs from milk that is not drained from the breast. It can progress to an infection fairly quickly and often presents with fever and chills. A plugged duct or engorged breasts can be uncomfortable but does not present as a systemic infection. A candidiasis (thrush) infection causes pain at the nipple but does not generalize to other areas of the breast.

A nurse at a community event is called to an unresponsive 3-year-old. The parent states the child was eating a hot dog. The nurse determines the child has an obstructed airway. After instructing an observer to call 911, what intervention should happen first?

performing chest compressions with the heel of one hand 30 times According to the American Heart Association (Heart and Stroke Foundation of Canada), when a child between 1-and 8-years-old is unconscious and believed to have an obstructed airway, the child should first be laid upon a hard surface, and 30 chest compressions should be given. Delivering five back blows followed by five chest thrusts is appropriate for an infant less than 1-year-old. Performing the Heimlich maneuver is appropriate when the child is still conscious. Attempting to give breaths should happen after the chest compressions. The chest compressions are believed to help expel the obstruction.

A 4-year-old child is having a sickle cell crisis. The initial nursing intervention should be to

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

When teaching a caregiver of a school-age client about signs and symptoms accompanying fever that require immediate notification of the physician, which description should the nurse include?

reports of a stiff neck The nurse should discuss reports of a stiff neck because fever and a stiff neck indicate possible meningitis. Burning or pain with urination, a cough that progresses to productive sputum, and a history of febrile seizures should be addressed by the physician but can wait until office hours.

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

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

The nurse notes bulging and separation of an abdominal incision while assessing a client. What is the purpose of applying a binder?

to reduce stress on the abdominal incision Applying an abdominal binder will reduce further stress on the incision and prevent another dehiscence, thus allowing the skin and tissue to heal. The other choices are not accurate reasons to use a binder.

A nurse is assessing a client admitted with deep partial-thickness and full-thickness burns on the face, arms, and chest. Which finding indicates a potential problem?

urine output of 20 ml/hour A urine output of less than 30 ml/hour in a client with burns indicates a deficient fluid volume. This client's PaO2 value falls within the normal range (80 to 100 mm Hg). White pulmonary secretions are normal. The client's rectal temperature isn't significantly elevated, and the slight increase in temperature probably results from the deficient fluid volume.

A nurse is providing care for a client who underwent mitral valve replacement. The best example of a measurable client outcome goal is for the client to

walk from their room to the end of the hall and back before discharge. Walking from the client's room to the end of the hall and back before discharge is a specific, measurable, attainable, and timed goal. It's also a client-oriented outcome goal. Having the client change their own dressing is incomplete and not as significant. Just walking in the hall isn't measurable. The need for a special diet isn't evident in this case.

A 4-year-old child is receiving dextrose 5% in water and half-normal saline solution at 100 ml/hour. The nurse should suspect that the child's I.V. fluid intake is excessive if assessment reveals

worsening dyspnea. Dyspnea and other signs of respiratory distress signify fluid volume overload, which can occur quickly in a child as fluid shifts rapidly between the intracellular and extracellular compartments. Gastric distention suggests excessive oral (not I.V.) fluid intake or infection. Nausea and vomiting or an elevated temperature may indicate a fluid volume deficit, not an excess.