1st Set
The home health nurse visits a client with a diagnosis of type 1 diabetes mellitus. The client relates a history of vomiting and diarrhea and tells the nurse that no food has been consumed for the last 24 hours. Which additional statement by the client indicates a need for further teaching?
*1. "I need to stop my insulin." 2."I need to increase my fluid intake." 3."I need to monitor my blood glucose every 3 to 4 hours." 4."I need to call the primary health care provider (PHCP) because of these symptoms." - When a client with diabetes mellitus is unable to eat normally because of illness, the client still should take the prescribed insulin or oral medication. The client should consume additional fluids and should notify the PHCP. The client should monitor the blood glucose level every 3 to 4 hours. The client should also monitor the urine for ketones during illness.
The nurse teaches the client with hypocalcemia how to take calcium carbonate. Which statement by the client indicates an understanding of the instructions?
*1. "I should take the tablet an hour after lunch." 2."I should swallow the tablet whole with toast at breakfast." 3."I should crush the tablet and take it with applesauce at breakfast." 4."I should cut the tablet in half and take it with ice cream after dinner." - Calcium carbonate is best administered 1 to 1½ hours after meals. The tablets should be given with a full glass of water.
A client has begun taking a stimulant laxative. In monitoring the client for medication side and adverse effects, the nurse is likely to note which finding?
*1. Abdominal cramps 2.Peptic ulcer disease 3.Gastrointestinal bleeding 4.Partial bowel obstruction - A stimulant laxative causes nausea and abdominal cramps as the most frequent side effects. The incorrect options represent health problems that are not caused by this medication.
A unit of platelets was just received from the blood bank for transfusion to an assigned client. The nurse should select tubing with which feature for the transfusion?
*1. An in-line filter 2.At least 3 Y-ports 3.Self-sealing valves 4.Tinted to protect the blood from light - The tubing used for platelet administration has an in-line filter. This helps ensure that any particles larger than the size of the filter are caught in the filter and are not infused into the client. Self-sealing valves and Y-ports are unnecessary. These features may be used to administer medication. No medication is infused through the intravenous (IV) line that the blood is infusing through. If the client needed medications as a result of a complication while receiving blood or for another reason, it would need to be administered via a different IV site and line. Platelets do not need to be protected from light.
A child is seen in the school nurse's office with complaints of pain in his right forearm. In reviewing the child's record the nurse notes that he has a history of being physically abused by the mother. Which should be the initial intervention with this child?
*1. Assess the child's physical status. 2.Ask the child how the injury occurred. 3.Report the case as suspected child abuse. 4.Observe the interactions between the child and his friends. - The initial intervention is to assess the child's physical status. The child should be initially assessed for injury to the right arm and for bruises, burns, scars, and any other signs of abuse. The nurse would next report the case as suspected child abuse to the appropriate authorities. Option 2 may or may not be appropriate, depending on the situation because the child may be fearful of telling the truth about how the injury occurred. Option 4, although appropriate for some situations, is not appropriate as the initial intervention.
The nurse is assessing a client newly diagnosed with mild hypertension. Which assessment finding should the nurse expect?
*1. Asymptomatic 2.Shortness of breath 3.Visual disturbances 4.Frequent nosebleeds - Hypertensive clients often have no symptoms until target organ involvement, which happens with very high blood pressure. This is why it is often noted as the "silent killer." The remaining options are incorrect because those clinical manifestations occur with severely high hypertension.
A child is brought to the emergency department after falling from a high swing and landing on the back. The nurse notes that the client also has hemophilia. Based on the client's history and the nature of the injury, which should the nurse assess for first?
*1. Blood in the urine 2.Oxygen saturation 3.Presence of headache 4.Presence of slurred speech - Because the kidneys are located in the flank region of the body, trauma to the back area can cause hematuria, particularly in the child with hemophilia. The nurse would be most concerned about the child's airway and respiratory rate if the child sustained an injury to the neck region. Headache and slurred speech are associated with head trauma.
The nurse is providing instructions to a client diagnosed with irritable bowel syndrome (IBS) who is experiencing abdominal distention, flatulence, and diarrhea. What interventions should the nurse include in the instructions? Select all that apply.
*1. Eat yogurt. *2.Take loperamide to treat diarrhea. *3.Use stress management techniques. *4.Avoid foods such as cabbage and broccoli. 5.Decrease fiber intake to less than 15 g/day. - IBS is a common, chronic functional disorder, meaning that no organic cause is currently known. Treatment is directed at psychological and dietary factors and medications to regulate stool output. Options 1, 2, 3, and 4 are correct, as clients diagnosed with IBS whose primary symptoms are abdominal distention and flatulence should be advised to avoid common gas-producing foods such as broccoli and cabbage and to consume yogurt, as it may be better tolerated than milk. In addition, the probiotics found in yogurt may be beneficial because alterations in intestinal bacteria are believed to exacerbate IBS. The client should be advised to take loperamide, a synthetic opioid that slows intestinal transit and treats diarrhea when it occurs. Also, psychological stressors are associated with development and exacerbation of IBS, so stress management techniques are important. Option 5, decrease fiber intake, is incorrect, as clients should be encouraged to have a dietary fiber intake of at least 20 g/day.
Which nursing actions are most appropriate for medication administration to a client at risk for aspiration? Select all that apply.
*1. Ensure all medications can be crushed: *2.Assess for the presence of a gag reflex. *3.Assess the client's level of consciousness. *4.Assess the client's ability to swallow and cough on command. 5.Place the client in high-fowler's immediately after medication administration. - If a client is determined to be at risk for aspiration, there are specific actions the nurse should take to ensure client safety when administering oral medications. As with the administration of any medication, the nurse checks the medication prescription and compares it against the medical record clarifying any incomplete prescriptions; checks the rights of medication administration; reviews any pertinent information related to medication administration, such as the international normalized ratio for the client taking warfarin; and assesses for any contraindications for administration of oral medications, such as NPO status. Next, the nurse places the client in a high-Fowler's position (before, not after, medication administration) and assesses for the client's aspiration risk using the agency-approved screening tool to determine if it is safe to administer oral medications, checking for the ability to swallow and cough on command and checking for the presence of a gag reflex. If the client is unable to swallow or does not have a gag reflex, then the nurse would not administer the medications and would collaborate with the primary health care provider. If the client is able to swallow and cough and has a gag reflex, then the nurse checks the rights of medication administration again and prepares the medications and any liquids used in the most appropriate form based on the outcome of the swallow screen. Next, the nurse checks the rights of medication administration immediately before administration for the last time, administers the medications 1 at a time in the prepared form, and ensures that the client has effectively swallowed each medication. The nurse then ensures that the client is comfortable and safe and documents the medications given per agency policy.
The nurse is reviewing the record of a client admitted to the hospital with a diagnosis of Hodgkin's disease. Which assessment findings noted in the client's record are associated with this diagnosis? Select all that apply.
*1. Fever *2.Weight loss *3.Night sweats 4.Visual changes *5.Enlarged, painless lymph nodes - Assessment of a client with Hodgkin's disease most often reveals enlarged, painless lymph nodes along with fever, malaise, and night sweats. Weight loss may be a feature in metastatic disease. Visual changes are not specifically associated with Hodgkin's disease.
A client has been prescribed pindolol for hypertension. The nurse provides anticipatory guidance, knowing that which common side effect of this medication may decrease client compliance?
*1. Impotence 2.Mood swings 3.Increased appetite 4.Difficulty swallowing - A common side effect of beta-adrenergic blocking agents such as pindolol is impotence. Other common side effects include fatigue and weakness. Central nervous system side effects are rarer and include mental status changes, nervousness, depression, and insomnia. Mood swings, increased appetite, and difficulty swallowing are not side effects of this medication.
The nurse is creating a plan of care for a client experiencing dystocia and includes several nursing interventions in the plan. The nurse prioritizes the plan and selects which nursing intervention as the highest priority?
*1. Monitoring fetal status 2.Providing comfort measures 3.Changing the client's position frequently 4.Keeping the significant other informed of the progress of the labor - The priority in the plan of care should include the intervention that addresses the physiological integrity of the fetus. Although providing comfort measures, changing the client's position frequently, and keeping the significant other informed of the progress of the labor are components of the plan of care, fetal status is the priority.
A client with Graves' disease has exophthalmos and is experiencing photophobia. Which nursing action would best assist the client with these manifestations?
*1. Obtain dark glasses for the client. 2.Lubricate the eyes with tap water every 2 to 4 hours. 3.Administer methimazole every 8 hours around the clock. 4.Instruct the client to avoid straining or heavy lifting because this effort can increase eye pressure. - Because photophobia (light intolerance) accompanies this disorder, wearing dark glasses is helpful in alleviating the problem. Tap water, which is hypotonic, could actually cause more swelling to the eye because it could pull fluid into the interstitial space. In addition, the client would be at risk for developing an eye infection because the solution is not sterile. Methimazole is a thyroid inhibitor, but medication therapy for Graves' disease does not help to alleviate the clinical manifestation of exophthalmos. There is no need to avoid straining or heavy lifting with exophthalmos.
The nurse is assessing the patency of a client's left arm arteriovenous fistula prior to initiating hemodialysis. Which finding indicates that the fistula is patent?
*1. Palpation of a thrill over the fistula. 2.Presence of a radial pulse in the left wrist. 3.Visualization of enlarged blood vessels at the fistula site. 4.Capillary refill less than 3 seconds in the nailbeds of the fingers on the left hand. - The nurse assesses the patency of the fistula by palpating for the presence of a thrill or auscultating for a bruit. The presence of a thrill and bruit indicate patency of the fistula. Enlarged visible blood vessels at the fistula site are a normal observation but are not indicative of fistula patency. Although the presence of a radial pulse in the left wrist and capillary refill less than 3 seconds in the nailbeds of the fingers on the left hand indicate adequate circulation to the hand, they do not assess fistula patency.
The nurse is preparing for the admission of an infant with a diagnosis of bronchiolitis caused by respiratory syncytial virus (RSV). Which interventions should the nurse include in the plan of care? Select all that apply.
*1. Place the infant in a private room. *2.Ensure that the infant's head is in a flexed position. 3.Wear a mask at all times when in contact with the infant. 4.Place the infant in a tent that delivers warm humidified air. *5.Position the infant on the side, with the head lower than the chest. 6.Ensure that nurses caring for the infant with RSV do not care for other high-risk children. - RSV is a highly communicable disorder and is not transmitted via the airborne route. The virus usually is transferred by the hands. Use of contact and standard precautions during care (wearing gloves and a gown) reduces nosocomial transmission of RSV. A mask is unnecessary. In addition, it is important to ensure that nurses caring for a child with RSV do not care for other high-risk children to prevent the transmission of the infection. An infant with RSV should be isolated in a private room or in a room with another infant with RSV infection. The infant should be positioned with the head and chest at a 30- to 40-degree angle and the neck slightly extended to maintain an open airway and decrease pressure on the diaphragm. Cool humidified oxygen is delivered to relieve dyspnea, hypoxemia, and insensible water loss from tachypnea.
A client receiving thrombolytic therapy with a continuous infusion of alteplase suddenly becomes extremely anxious and reports itching. The nurse hears stridor and notes generalized urticaria and hypotension. Which interventions are a priority? Select all that apply.
*1. Stop the infusion. *2.Raise the head of the bed. 3.Administer protamine sulfate. *4.Administer diphenhydramine. *5..Call for the Rapid Response Team (RRT). - The client is experiencing an anaphylactic reaction. Therefore, the priority action is to stop the infusion and notify the RRT. The client may be treated with antihistamines.. Raising the head of the bed would not be helpful, as that may exacerbate the hypotension. Protamine sulfate is the antidote for heparin, so it is not useful for a client receiving alteplase.
A client has been given a prescription for sulfasalazine. Which allergy should the nurse assess for in the client prior to administration?
*1. Sulfonamides or salicylates 2.Salicylates or acetaminophen 3.Shellfish or calcium channel blockers 4.Histamine receptor antagonists or beta blockers - Sulfasalazine is a sulfonamide. The client who has been prescribed sulfasalazine should be checked for history of allergy to either sulfonamides or salicylates because the chemical composition of sulfasalazine and that of these medications are similar. The other options are not associated with an allergy to sulfasalazine.
A child is suspected of suffering from intussusception. The nurse should be alert to which clinical manifestation of this condition?
*1. Tender, distended abdomen 2.Presence of fecal incontinence 3.Incomplete development of the anus 4.Infrequent and difficult passage of dry stools - Intussusception is an invagination of a section of the intestine into the distal bowel. It is the most common cause of bowel obstruction in children ages 3 months to 6 years. A tender, distended abdomen is a clinical manifestation of intussusception. The presence of fecal incontinence describes encopresis. Encopresis generally affects preschool and school-aged children. Incomplete development of the anus describes imperforate anus, and this disorder is diagnosed in the neonatal period. The infrequent and difficult passage of dry stools describes constipation. Constipation can affect any child at any time, although the incidence peaks at age 2 to 3 years.
An 8-year-old boy is being treated with desmopressin. Understanding the purpose of this medication, the nurse should set which client goal?
*1. The boy will have 5 nights in sequence without enuresis. 2.The boy will have increased urine output to 2400 mL per day. 3.The boy will have an increase in white blood cell count to 4000 mm3 (4 × 109/L). 4.The boy will have decreased use of the metered dose inhaler to 3 times per week. - Desmopressin may be used to treat nocturnal enuresis; therefore, the client goal will be several nights in sequence without enuresis. The medication does not increase urine output and does not have an effect on white blood cells. The medication is not indicated as an intervention in the client with asthma.
Salicylic acid is prescribed for a client with a diagnosis of psoriasis. The nurse monitors the client, knowing that which finding indicates the presence of systemic toxicity from this medication?
*1. Tinnitus 2.Diarrhea 3.Constipation 4.Decreased respirations - Salicylic acid is absorbed readily through the skin, and systemic toxicity (salicylism) can result. Symptoms include tinnitus, dizziness, hyperpnea, and psychological disturbances. Constipation and diarrhea are not associated with salicylism.
The nurse is monitoring a client who was diagnosed with type 1 diabetes mellitus and is being treated with NPH and regular insulin. Which manifestations would alert the nurse to the presence of a possible hypoglycemic reaction?
*1. Tremors 2.Anorexia *3.Irritability *4.Nervousness 5.Hot, dry skin 6.Muscle cramps - Decreased blood glucose levels produce autonomic nervous system symptoms, which are manifested classically as nervousness, irritability, and tremors. Option 5 is more likely to occur with hyperglycemia. Options 2 and 6 are unrelated to the manifestations of hypoglycemia. In hypoglycemia, usually the client feels hunger
The nurse is providing instructions to a client who will be taking phenytoin. Which statement, if made by the client, would indicate an understanding of the information about this medication?
*1."I need to perform good oral hygiene, including flossing and brushing my teeth." 2."I should try to avoid alcohol, but if I'm not able to, I can drink alcohol in moderation." 3."I should take my medication before coming to the laboratory to have a blood level drawn." 4."I should monitor for side effects and adjust my medication dose depending on how severe the side effects are." - Phenytoin is an anticonvulsant used to treat seizure disorders. The client should see a dentist at regularly scheduled times because gingival hyperplasia is a side effect of this medication. The client should perform good oral hygiene, including flossing and brushing the teeth. The client should avoid alcohol while taking this medication. The client should also be instructed that follow-up serum blood levels are important and that, on the day of the scheduled laboratory test, the client should avoid taking the medication before the specimen is drawn. The client should not adjust medication dosages.
The nurse is preparing a teaching plan for a client who had a cataract extraction with intraocular implantation. Which home care measures should the nurse include in the plan? Select all that apply.
*1.Avoid activities that require bending over. 2.Contact the surgeon if eye scratchiness occurs. *3.Take acetaminophen for minor eye discomfort. 4.Expect episodes of sudden severe pain in the eye. *5.Place an eye shield on the surgical eye at bedtime. *6.Contact the surgeon if a decrease in visual acuity occurs. - Following eye surgery, some scratchiness and mild eye discomfort may occur in the operative eye and usually is relieved by mild analgesics. If the eye pain becomes severe, the client should notify the surgeon, because this may indicate hemorrhage, infection, or increased intraocular pressure (IOP). The nurse also would instruct the client to notify the surgeon of increased purulent drainage, increased redness, or any decrease in visual acuity. The client is instructed to place an eye shield over the operative eye at bedtime to protect the eye from injury during sleep and to avoid activities that increase IOP, such as bending over.
Propylthiouracil is prescribed for a client with hyperthyroidism. The nurse provides instructions to the client regarding the medication and informs the client to notify the primary health care provider (PHCP) if which sign or symptom occurs?
*1.Fever 2.Dry mouth 3.Drowsiness 4.Increased urination - An adverse effect of propylthiouracil is agranulocytosis. The client needs to be informed of the early signs of this side and adverse effect, which include fever and sore throat. Drowsiness is an occasional side effect of the medication. Dry mouth and increased urination are unrelated to this medication.
The nurse is caring for a client who begins to experience seizure activity while in bed. Which actions should the nurse take? Select all that apply.
*1.Loosening restrictive clothing 2.Restraining the client's limbs *3.Removing the pillow and raising padded side rails *4.Positioning the client to the side, if possible, with the head flexed forward 5.Keeping the curtain around the client and the room door open so when help arrives they can quickly enter to assist - Nursing actions during a seizure include providing for privacy, loosening restrictive clothing, removing the pillow and raising padded side rails in the bed, and placing the client on 1 side with the head flexed forward, if possible, to allow the tongue to fall forward and facilitate drainage. The limbs are never restrained because the strong muscle contractions could cause the client harm. If the client is not in bed when seizure activity begins, the nurse lowers the client to the floor, if possible; protects the head from injury; and moves furniture that may injure the client.
The nurse is creating a plan of care for a client with cirrhosis and ascites. Which nursing actions should be included in the care plan for this client? Select all that apply.
*1.Monitor daily weight. *2.Measure abdominal girth. *3.Monitor respiratory status. 4.Place the client in a supine position. *5.Assist the client with care as needed. - Ascites is a problem because as more fluid is retained, it pushes up on the diaphragm, thereby impairing the client's breathing patterns. The client should be placed in a semi-Fowler's position with the arms supported on a pillow to allow for free diaphragm movement. The correct options identify appropriate nursing interventions to be included in the plan of care for the client with ascites.
The nurse is preparing to perform an otoscopic examination on an adult client. Which action should the nurse take to perform this examination?
*1.Pull the pinna up and back before inserting the speculum. 2.Pull the earlobe down and back before inserting the speculum. 3.Tilt the client's head forward and down before inserting the speculum. 4.Use the smallest speculum available to decrease the discomfort of the exam. - The nurse tilts the client's head slightly away and holds the otoscope upside down as if it were a large pen. The pinna is pulled up and back, and the nurse visualizes the external canal while slowly inserting the speculum. The remaining options are incorrect procedures.
The community health nurse has instructed a group of parents of preschoolers about home safety measures for children. Which statement by 1 of the parents should the nurse identify as something that requires the need for reinforcement of the instructions?
*1.Refers to medication as "candy for when you are sick" 2.Says he or she will store medications in child-proof containers 3.Keeps the poison control center telephone number readily available 4.States the intention to label all toxic substances and place them in a locked area - Medicine should not be referred to as candy. Home safety measures are simple but important. Medications should be stored in child-proof containers. The number of tablets in a container should be limited. The poison control center telephone number should be visible near all telephones. Toxic substances should be labeled with poison stickers and placed in a locked area out of reach of children.
The nurse is caring for a client who has had spinal fusion, with insertion of hardware. The nurse would be most concerned with which assessment finding?
*1.Temperature of 101.6º F (38.7º C) orally 2.Complaints of discomfort during repositioning 3.Old bloody drainage outlined on the surgical dressing 4.Discomfort during coughing and deep-breathing exercises - The nursing assessment conducted after spinal surgery is similar to that done after other surgical procedures. For this specific type of surgery, the nurse assesses the neurovascular status of the lower extremities, watches for signs and symptoms of infection, and inspects the surgical site for evidence of cerebrospinal fluid leakage (drainage is clear and tests positive for glucose). A mild temperature is expected after insertion of hardware, but a temperature of 101.6º F (38.7º C) should be reported.
After performing an initial abdominal assessment on a client with nausea and vomiting, the nurse should expect to note which finding?
*1.Waves of loud gurgles auscultated in all 4 quadrants 2.Low-pitched swishing auscultated in 1 or 2 quadrants 3.Relatively high-pitched clicks or gurgles auscultated in all 4 quadrants 4.Very high-pitched, loud rushes auscultated especially in 1 or 2 quadrants - Although frequency and intensity of bowel sounds vary depending on the phase of digestion, normal bowel sounds are relatively high-pitched clicks or gurgles. Loud gurgles (borborygmi) indicate hyperperistalsis and are commonly associated with nausea and vomiting. A swishing or buzzing sound represents turbulent blood flow associated with a bruit. Bruits are not normal sounds. Bowel sounds are very high-pitched and loud (hyperresonance) when the intestines are under tension, such as in intestinal obstruction. Therefore, options 2, 3, and 4 are incorrect.
The nurse caring for a client who has been receiving intravenous (IV) diuretics suspects that the client is experiencing a fluid volume deficit. Which assessment finding would the nurse note in a client with this condition?
*1.Weight loss and poor skin turgor 2.Lung congestion and increased heart rate 3.Decreased hematocrit and increased urine output 4.Increased respirations and increased blood pressure - A fluid volume deficit occurs when the fluid intake is not sufficient to meet the fluid needs of the body. Assessment findings in a client with a fluid volume deficit include increased respirations and heart rate, decreased central venous pressure (CVP) (normal CVP is between 4 and 11 cm H2O), weight loss, poor skin turgor, dry mucous membranes, decreased urine volume, increased specific gravity of the urine, increased hematocrit, and altered level of consciousness. Lung congestion, increased urinary output, and increased blood pressure are all associated with fluid volume excess.
The client says to the nurse, "I wish you would just be my friend." Which is the appropriate response by the nurse?
1. "I am your friend." *2."Our relationship is a therapeutic and helping one." 3."I can't be your friend. I'm the nurse, and you're the client." 4."You have plenty of friends. You don't need me to be your friend, too." - Nurses may struggle with requests by clients to "be my friend." When this occurs, the nurse should make it clear that the relationship is a therapeutic and helping one. This does not mean that the nurse is not friendly toward the client at times. It does mean, however, that the nurse follows the stated guidelines regarding a therapeutic relationship. The remaining options are inappropriate, particularly in their failure to define the relationship.
The nurse has just administered the first dose of omalizumab to a client. Which statement by the client alerts the nurse of a life-threatening effect?
1. "I have a severe headache." 2."My feet are quite swollen." 3."I am nauseated and may vomit." 4."My lips and tongue are swollen." - Omalizumab is an antiinflammatory and monoclonal antibody used for long-term control of asthma. Anaphylactic reactions can occur with the administration of omalizumab. The nurse administering the medication should monitor for adverse reactions of the medication. Swelling of the lips and tongue are an indication of an anaphylaxis. The client statements in options 1, 2, and 3 are not indicative of an adverse reaction.
A client with Crohn's disease is experiencing acute pain, and the nurse provides information about measures to alleviate the pain. Which statement by the client indicates the need for further teaching?
1. "I know I can massage my abdomen." 2."I will continue using antispasmodic medication." 3."One of the best things I can do is use relaxation techniques." *4."The best position for me is to lie supine with my legs straight. - Pain associated with Crohn's disease is alleviated by the use of analgesics and antispasmodics and also by practicing relaxation techniques, applying local cold or heat to the abdomen, massaging the abdomen, and lying with the legs flexed. Lying with the legs extended is not useful because it increases the muscle tension in the abdomen, which could aggravate inflamed intestinal tissues as the abdominal muscles are stretched.
As part of chemotherapy education, the nurse teaches a female client about the risk for bleeding and self-care during the period of greatest bone marrow suppression (the nadir). The nurse understands that further teaching is needed if the client makes which statement?
1. "I should avoid blowing my nose." 2."I may need a platelet transfusion if my platelet count is too low." *3."I'm going to take aspirin for my headache as soon as I get home." 4."I will count the number of pads and tampons I use when menstruating. - during the period of greatest bone marrow suppression (the nadir), the platelet count may be low, less than 20,000 cells mm3 (20.0 × 109/L). The correct option describes an incorrect statement by the client. Aspirin and nonsteroidal antiinflammatory drugs and products that contain aspirin should be avoided because of their antiplatelet activity. Options 1, 2, and 4 are correct statements by the client to prevent and monitor bleeding.
Cortisone acetate is prescribed for a client with adrenal insufficiency. The nurse provides instructions to the client regarding the medication. Which statement, if made by the client, indicates a need for further instruction?
1. "I will limit my sodium intake." 2."I will avoid people with colds." 3."I will eat a good breakfast every day." *4."I will stop the medication when I feel better." - To prevent acute adrenal insufficiency, glucocorticoids should not be abruptly discontinued. These medications can cause sodium and water retention and the loss of potassium, so clients should be instructed to limit sodium intake and consume potassium-rich foods. These medications can increase the risk of infection, and the client should avoid contact with clients who are ill. Additionally, adequate dietary intake is important.
The nurse teaches a preoperative client about the use of a nasogastric (NG) tube for the planned surgery. Which statement indicates to the nurse that the client understands when the tube can be removed in the postoperative period?
1. "When I can tolerate food without vomiting." 2."When my gastrointestinal system is healed enough." *3."When my bowels begin to function again, and I begin to pass gas." 4."When my primary health care provider says the tube can come out." - NG tubes are discontinued when normal function returns to the gastrointestinal (GI) tract. Food would not be administered unless bowel function returns. The tube will be removed before GI healing. Although the primary health care provider (PHCP) determines when the NG tube will be removed, it does not determine effectiveness of teaching and the need for the NG tube.
The nurse is caring for a client diagnosed with schizophrenia who states, "I decided not to take my medication because I realize that it really can't help me. Only I can help me." Which question asked by the nurse has the best therapeutic value?
1. "Why do you think this is a wise decision?" 2."I don't understand. Only you can help you?" 3."You've decided not to take your medication. Is that right?" *4."Do you recall what it was like before you started your medication?" - Noncompliance with antipsychotic medication is 1 of the chief reasons that clients with schizophrenia have relapses. The most therapeutic response is to initiate a conversation with the client directed toward discussing the disadvantages of being noncompliant. While it is therapeutic to use communication techniques like restating and clarification, it is not useful to this client since the intent of the behavior is already understood. Asking a "why" question is usually viewed as argumentative by the client and so is not therapeutic.
A pediatrician's prescription reads "ampicillin sodium 125 mg." The medication label reads that there are 1000 mg in 7.4 mL after reconstitution. The nurse prepares to draw up how many milliliters to administer 1 dose?
1. 1 mL 2. 0.54 mL 3 7.425 mL *4. 0.925 mL - desired / available x volume = ml/dose
The nurse is explaining an upper gastrointestinal series to a client and provides the client with the preprocedure and postprocedure instructions. The nurse informs the client that after this procedure, the stools can be expected to remain white for what time period?
1. 1 week 2. 6 hours 3. 8 hours *4. 1 to 2 days - It takes at least 12 to 24 hours for a substance to pass through the colon. One week is too long a period, and 6 to 8 hours is too short a period because of residual barium and decreased peristalsis.
The nurse is urging a client to cough and deep breathe after nephrectomy. The client tells the nurse, "That's easy for you to say! You don't have to do this." The nurse interprets that the client's statement is most likely to be a result of which factor?
1. A stress response to the ordeal of surgery 2.A latent fear of needing dialysis if the surgery is unsuccessful *3.Pain that is intensified because of the location of the incision near the diaphragm 4.Effects of circulating metabolites that have not been excreted by the remaining kidney - After nephrectomy, the client may be in considerable pain. This is because of the size of the incision and its location near the diaphragm, which make coughing and deep breathing very uncomfortable. For this reason, opioids are used liberally and may be most effective when provided as patient-controlled analgesia or through epidural analgesia. The items in the other options are not likely factors for the client's statement.
The nurse is caring for a client on a mechanical ventilator. The low-pressure alarm sounds. The nurse suspects that the most likely cause of the alarm is which finding?
1. A tubing obstruction or kink 2.The accumulation of secretions *3.Disconnection of the ventilator tubing 4.Condensation of water in the ventilator tubing - The low-pressure alarm sounds when little or no pressure is generated during the delivery of the machine breaths. Alarm triggers include disconnection of the ventilator tubing at any point in the circuit, a cuff leak, and exaggerated client respiratory effort generating extreme negative pressure. The remaining options identify causes for triggering the high-pressure alarm.
The nurse reviewing a client's diagnostic results recognizes that which is a possible positive indication for a diagnosis of schizophrenia?
1. Abnormally high blood flow to the frontal lobes 2.Atrophy of both the limbic structures and cerebellum 3.Abnormally small fissures on the surface of the brain *4.Atrophy of the lateral and/or third ventricles of the brain - Imaging studies of the brains of individuals with confirmed diagnoses of schizophrenia have shown the consistent atrophy of the lateral and/or third ventricles. The remaining options are not consistent with the brain structure of individuals with schizophrenia.
The nurse is performing an assessment on a client after a closed reduction of a fractured right humerus and application of a plaster cast. To assess for signs of compartment syndrome, the nurse should perform which action?
1. Assess the client's cognitive level. 2.Assess the temperature of the cast. 3.Monitor for the presence of drainage or odors on or beneath the cast. *4.Assess capillary refill, temperature, color, and amount of pain in the right hand. - he major signs and symptoms of compartment syndrome include pallor or cyanosis; pain, even following the administration of opioid analgesics; vascular compromise demonstrated by weakened or absent pulses and poor capillary refill; and edema of the extremity distal to the area of the fracture. Cognitive level, temperature of the cast, and the presence of drainage or odors on or beneath the cast are not assessments related to compartment syndrome.
Betaxolol hydrochloride eye drops have been prescribed for a client with glaucoma. Which nursing action is most appropriate related to monitoring for side and adverse effects of this medication?
1. Assessing for edema 2.Monitoring temperature *3.Monitoring blood pressure 4.Assessing blood glucose level - Hypotension, dizziness, nausea, diaphoresis, headache, fatigue, constipation, and diarrhea are side and adverse effects of the medication. Nursing interventions include monitoring the blood pressure for hypotension and assessing the pulse for strength, weakness, irregular rate, and bradycardia.
A client in the postpartum care unit who is recovering from disseminated intravascular coagulopathy is to be discharged on low dosages of an anticoagulant medication. In developing home care instructions for this client, the nurse should include which priority safety instruction regarding this medication?
1. Avoid brushing the teeth. *2.Avoid taking acetylsalicylic acid (aspirin). 3.Avoid walking long distances and climbing stairs. 4.Avoid all activities because bruising injuries can occur. - Aspirin can interact with the anticoagulant medication to increase clotting time beyond therapeutic ranges. Avoiding aspirin is a priority. The client does not need to avoid brushing the teeth; however, the client should be instructed to use a soft toothbrush. Walking and climbing stairs are acceptable activities. Not all activities need to be avoided.
The nurse is caring for a client the day after a left total knee arthroplasty surgery. In reviewing the client's past medical history, the nurse notes that the client has a history of urinary incontinence and heart failure, which is managed with a potassium-retaining diuretic and a beta-adrenergic blocker. Which prescription, if not already prescribed, should the nurse contact the primary health care provider to obtain?
1. Daily electrolytes 2.A 12-lead electrocardiogram *3.Resume the client's dose of metoprolol 4.Insertion of an indwelling urinary catheter - surgery clients on beta-blocker therapy prior to surgery should receive a beta blocker within 24 hours of surgery. Thus, option 3 is the correct option. Beta blockers have been found to decrease the risk for mortality associated with noncardiac surgery in high-risk clients. However, for treatment to be both safe and effective, dosing should begin before surgery and continue for at least 1 month after surgery. In this case, the client was already on the beta-blocker therapy prior to surgery, but it needs to be resumed postoperatively. Option 1 is incorrect, as the client is on a potassium-retaining diuretic, so hypokalemia is unlikely to occur. Option 2 is incorrect, as a 12-lead electrocardiogram would have been done prior to surgery, and there is no indication that another one is needed. Option 4 is incorrect, as there is nothing that indicates an indwelling urinary catheter is necessary (history of incontinence and diuretic therapy do not necessitate an indwelling urinary catheter), and it should be avoided to prevent developing a catheter-associated urinary tract infection.
The nurse is reviewing the laboratory test results for a client seen in the health care clinic and notes that the red blood cell (RBC) count is decreased. The nurse determines that this finding occurs in which condition?
1. Dehydration *2.Iron deficiency 3.Severe diarrhea 4.Polycythemia vera - Decreased RBC counts occur in clients with vitamin B6 and B12 deficiencies, iron deficiency, chronic infection, bone marrow depression, multiple myeloma, leukemia, hemolytic anemia, and pernicious anemia. A decrease in the RBC count also may be noted in the older client. Increased RBC counts are noted in clients with the disorders in the remaining options.
A client recovering from cardiac surgery has a left pleural effusion and is about to undergo a thoracentesis. What position should the nurse place the client in for the procedure?
1. Dorsal recumbent 2.Left lateral, with the right arm supported by a pillow 3.Right side-lying, with the legs curled up into a fetal position *4.Upright and leaning forward with the arms on an over-the-bed table - The client undergoing thoracentesis usually sits in an upright position with the anterior thorax supported by pillows or leaning over an over-the-bed table. The client must be placed in a position that will enlist the aid of gravity in accessing and draining the effusion. The dorsal recumbent position is an inaccessible position. Any side-lying position will cause fluid to accumulate under that side, which is inaccessible to the primary health care provider. However, if the client cannot sit upright, the client will be placed in a side-lying position on the unaffected side, with the side to be tapped uppermost.
A client being admitted to the nursing unit has been taking bethanechol chloride at home. During the admission assessment, the nurse gives special attention to assessing the client for which side and adverse effect of this medication?
1. Dry mouth *2.Bradycardia 3.Constipation 4.Hypertension - Bethanechol chloride is a direct-acting muscarinic agonist (cholinergic medication). It can cause hypotension secondary to vasodilation and bradycardia. It also can cause excessive salivation, increased secretion of gastric acid, abdominal cramps, and diarrhea. Higher doses can cause involuntary defecation.
The nurse is reviewing the history of a client with bladder cancer. The nurse expects to note documentation of which most common sign or symptom of this type of cancer?
1. Dysuria *2.Hematuria 3.Urgency on urination 4.Frequency of urination - The most common sign in clients with cancer of the bladder is hematuria. The client also may experience irritative voiding symptoms such as frequency, urgency, and dysuria, and these symptoms often are associated with carcinoma in situ. Dysuria, urgency, and frequency of urination are also symptoms of a bladder infection.
The nurse is assigned to care for a client in traction. The nurse creates a plan of care for the client and should include which action in the plan?
1. Ensure that the knots are at the pulleys. *2.Check the weights to ensure that they are off of the floor. 3.Ensure that the head of the bed is kept at a 45- to 90-degree angle. 4.Monitor the weights to ensure that they are resting on a firm surface. - To achieve proper traction, weights need to be free-hanging, with knots kept away from the pulleys. Weights should not be kept resting on a firm surface. The head of the bed is usually kept low to provide countertraction.
The nurse assists in the vaginal delivery of a newborn. Following the delivery, the nurse observes a spurt of blood from the vagina. The nurse should document this observation as signs of which condition?
1. Hematoma 2.Uterine atony 3.Placenta previa *4.Placental separation - As the placenta separates, it settles downward into the lower uterine segment. The umbilical cord lengthens, and a sudden trickle or spurt of blood appears. The other options are not characterized by these findings.
The nurse collects a urine specimen preoperatively from a child with epispadias who is scheduled for surgical repair. When analyzing the results of the urinalysis, which should the nurse most likely expect to note?
1. Hematuria 2.Glucosuria *3.Bacteriuria 4.Proteinuria - Epispadias is a congenital defect involving abnormal placement of the urethral orifice of the penis. The urethral opening is located anywhere on the dorsum of the penis. This anatomical characteristic facilitates entry of bacteria into the urine. Hematuria, proteinuria, and glucosuria are not characteristically noted in this condition.
A client being seen in an ambulatory clinic for an unrelated complaint has a butterfly rash noted across the nose. The nurse interprets that this finding is consistent with early manifestations of which disorder?
1. Hyperthyroidism 2.Pernicious anemia 3.Cardiopulmonary disorders *4.Systemic lupus erythematosus (SLE) - An early sign of SLE is the appearance of a butterfly rash across the nose. Hyperthyroidism often leads to moist skin and increased perspiration. Pernicious anemia is exhibited by pale skin. Severe cardiopulmonary disorders may lead to clubbing of the fingers.
When performing a surgical dressing change on a client's abdominal dressing, the nurse notes an increased amount of drainage and separation of the incision line. The underlying tissue is visible to the nurse. The nurse should take which action in the initial care of this wound?
1. Leave the incision open to the air to dry the area. 2.Irrigate the wound and apply a sterile dry dressing. *3.Apply a sterile dressing soaked with normal saline. 4.Apply a sterile dressing soaked in povidone-iodine - Wound dehiscence is the separation of wound edges at the suture line. Signs and symptoms include increased drainage and the visible appearance of underlying tissues. Dehiscence usually occurs 6 to 8 days after surgery. The client should be instructed to remain quiet and to avoid coughing or straining. The client should be positioned to prevent further stress on the wound (semi-Fowler's position). Sterile dressings soaked with sterile normal saline should be used to cover the wound. The nurse must notify the primary health care provider after applying this initial dressing to the wound.
The nurse is caring for a client admitted to the hospital with a suspected diagnosis of acute appendicitis. Which laboratory result should the nurse expect to note if the client does have appendicitis?
1. Leukopenia with a shift to the left *2.Leukocytosis with a shift to the left 3.Leukopenia with a shift to the right 4.Leukocytosis with a shift to the right - Laboratory findings do not establish the diagnosis of appendicitis, but there is often an elevation of the white blood cell count (leukocytosis) with a shift to the left (an increased number of immature white blood cells).
The nurse is initiating nasogastric tube feedings in a child. What is the nurse's best action?
1. Microwave the formula. 2.Place the child in a prone position. 3.Encourage the child to point the head downward. *4.Position the child with the head slightly hyperflexed. - When initiating nasogastric tube feedings in a child, the child should be positioned so that the head is slightly hyperflexed or in a sniffing position with the nose pointed toward the ceiling. The formula should be warmed to room temperature, and a microwave should not be used.
The nurse is reviewing the primary health care provider's (PHCP's) prescriptions for a client admitted for premature rupture of the membranes. Gestational age of the fetus is determined to be 37 weeks. Which prescription should the nurse question?
1. Monitor fetal heart rate continuously. 2.Monitor maternal vital signs frequently. *3.Perform a vaginal examination every shift. 4.Administer an antibiotic per prescription and per agency protocol. - Vaginal examinations should not be done routinely on a client with premature rupture of the membranes because of the risk of infection. The nurse would expect to monitor fetal heart rate, monitor maternal vital signs, and administer an antibiotic.
The nurse is caring for a client with heart failure who is receiving high doses of a diuretic. On assessment, the nurse notes that the client has flat neck veins, generalized muscle weakness, and diminished deep tendon reflexes. The nurse suspects hyponatremia. What additional signs would the nurse expect to note in a client with hyponatremia?
1. Muscle twitches 2.Decreased urinary output *3.Hyperactive bowel sounds 4.Increased specific gravity of the urine - The normal serum sodium level is 135 to 145 mEq/L (135 to 145 mmol/L). Hyponatremia is evidenced by a serum sodium level lower than 135 mEq/L (135 mmol/L). Hyperactive bowel sounds indicate hyponatremia. The remaining options are signs of hypernatremia. In hyponatremia, muscle weakness, increased urinary output, and decreased specific gravity of the urine would be noted.
A nurse provides instructions to a client taking fludrocortisone acetate. The nurse instructs the client to notify the primary health care provider (PHCP) if which manifestation occurs?
1. Nausea 2.Fatigue 3.Weight loss *4.Swelling of the feet - Excessive levels of fludrocortisone acetate cause retention of sodium and water and excessive excretion of potassium, resulting in expansion of blood volume, hypertension, cardiac enlargement, edema, and hypokalemia. The client needs to be informed about the signs of sodium and water retention, such as unusual weight gain or swelling of the feet or lower legs. If these signs occur, the PHCP needs to be notified.
A client with myasthenia gravis becomes increasingly weaker. The primary health care provider injects a dose of edrophonium to determine whether the client is experiencing a myasthenic crisis or a cholinergic crisis. The nurse expects that the client will have which reaction if in cholinergic crisis?
1. No change in the condition 2.Complaints of muscle spasms 3.An improvement of the weakness *4.A temporary worsening of the condition - An edrophonium injection makes the client in cholinergic crisis temporarily worse. An improvement of the condition indicates myasthenic crisis. The other options are unrelated to the test.
A client with a severe allergic reaction is prescribed intravenous corticosteroids. The nurse should expect that which desired effect will be achieved?
1. Pain relief 2.Enhanced immunity 3.Increased serum glucose *4.Decreased inflammation - A corticosteroid acts as an anti-inflammatory. Although reduction of inflammation may relieve pain, this is not the indication of the use of corticosteroids in the allergic response. Corticosteroids increase serum glucose, but this is not a therapeutic response. These medications decrease immunity.
An older client is admitted to the hospital with a diagnosis of malnutrition. Other than cognitive status, what other factors can increase the risk of malnutrition and dehydration? Select all that apply.
1. Past profession *2.Physical fatigue *3.Limited mobility *4.Sensory decreases *5.Inadequate dental care 6.Family history of malnutrition - Other factors besides cognitive status that can increase the risk of malnutrition and dehydration include physical fatigue, limited mobility, sensory decreases, and inadequate dental care. Past profession and family history of malnutrition do not increase one's risk for malnutrition.
The nurse obtains a prescription from a primary health care provider to restrain a client and instructs an assistive personnel (AP) to apply the safety device to the client. Which observation of unsafe application of the safety device would indicate that further instruction is required by the AP?
1. Placing a safety knot in the safety device straps *2.Safely securing the safety device straps to the side rails 3.Applying safety device straps that do not tighten when force is applied against them 4.Securing so that 2 fingers can slide easily between the safety device and the client's skin - The safety device straps are secured to the bed frame and never to the side rails to avoid accidental injury in the event that the side rails are released. A half-bow or safety knot or device with a quick release buckle should be used to apply a safety device because it does not tighten when force is applied against it and it allows quick and easy removal of the safety device in case of an emergency. The safety device should be secure, and 1 or 2 fingers should slide easily between the safety device and the client's skin.
A child with developmental dysplasia of the hip is placed in a Pavlik harness. The nurse should demonstrate to the parents how to place the child in this harness by placing the child's legs in which position?
1. Prone 2.Abduction 3.Extension 4.Adduction - The Pavlik harness consists of chest and shoulder straps and foot stirrups. The device, which is used to correct hip dislocations in infants with developmental dysplasia of the hip, consists of a set of straps that hold the hips in flexion and abduction. Therefore, the remaining options are incorrect positions.
A postpartum client is diagnosed with cystitis. The nurse should plan for which priority action in the care of the client?
1. Providing sitz baths *2.Encouraging fluid intake 3.Placing ice on the perineum 4.Monitoring hemoglobin and hematocrit levels - Cystitis is an infection of the bladder. The client should consume 3000 mL of fluids per day if not contraindicated. Sitz baths and ice would be appropriate interventions for perineal discomfort. Hemoglobin and hematocrit levels would be monitored with hemorrhage.
A postpartum woman with mastitis in the right breast complains that the breast is too sore for her to breast-feed her infant. The nurse should tell the client to implement which measure?
1. Pump both breasts and discard the milk. 2.Bottle-feed the infant on a temporary basis. *3.Breast-feed from the left breast and gently pump the right breast. 4.Stop breast-feeding from both breasts until this condition resolves. - In most cases, the mother can continue to breast-feed with both breasts. If the affected breast is too sore, the mother can pump the breast gently. Regular emptying of the breast is important to prevent abscess formation. If an abscess forms and ruptures into the ducts of the breast, breast-feeding will need to be discontinued and a pump should be used to empty the breast (but the milk should be discarded). The remaining options are incorrect instructions.
A maternity unit nurse is creating a plan of care for a client with severe preeclampsia who will be admitted to the nursing unit. The nurse should include which nursing intervention in the plan?
1. Restrict food and fluids. *2.Reduce external stimuli. 3.Monitor blood glucose levels. 4.Maintain the client in a supine position. - The client with severe preeclampsia is kept on bed rest in a quiet environment. External stimuli such as lights, noise, and visitors that may precipitate a seizure should be kept to a minimum. Food and fluid are not restricted unless specifically prescribed by the primary health care provider. The client is instructed to rest in a left lateral position to decrease pressure on the vena cava, thereby increasing cardiac perfusion of vital organs.
The nurse is assessing a woman in the second trimester of pregnancy who was admitted to the maternity unit with a suspected diagnosis of abruptio placentae. Which findings should the nurse expect to note if abruptio placentae is present? Select all that apply.
1. Soft uterus *2.Abdominal pain 3.Nontender uterus *4.Firm uterus by palpation 5.Painless vaginal bleeding - Classic signs and symptoms of abruptio placentae include vaginal bleeding, abdominal pain, and uterine tenderness and contractions. Mild to severe uterine hypertonicity is present. Pain is mild to severe and either localized or diffuse over 1 region of the uterus, with a board-like abdomen. Painless vaginal bleeding and a soft, nontender uterus in the second or third trimester of pregnancy are signs of placenta previa.
A client with cancer is receiving a continuous intravenous infusion of morphine sulfate. The nurse monitoring the client for adverse effects would become most concerned about which vital sign?
1. Temperature of 99.1º F (37.3º C) 2.Blood pressure of 110/70 mm Hg *3.Respirations of 10 breaths/minute 4.Apical heart rate of 90 beats/minute - Before an opioid is administered, respiratory rate, blood pressure, and pulse rate should be assessed. Morphine sulfate should be withheld and the primary health care provider notified if the respiratory rate is at or below 12 breaths per minute, if the blood pressure is significantly below the pretreatment value, or if the pulse rate is significantly above or below pretreatment value. A temperature of 99.1º F (37.3º C) is not associated with the use of morphine sulfate.
A child with croup is being discharged from the hospital. The nurse provides instructions to the mother and advises the mother to bring the child to the emergency department if which occurs?
1. The child is irritable. 2.The child appears tired. *3.The child develops stridor. 4.The child takes fluids poorly. - The mother should be instructed to bring the child to the emergency department if the child develops stridor at rest, cyanosis, severe agitation or fatigue, or moderate to severe retractions or is unable to take oral fluids.
A client has a difficulty with the ability to flex the hips. The nurse determines that the client is adapting successfully to this problem if the client demonstrates proper use of which item?
1. Walker 2.Slider board *3.Raised toilet seat 4.Adaptive eating utensils - A raised toilet seat is useful if the client does not have the mobility or ability to flex the hips. The cerebellum is responsible for balance and coordination. A walker would provide stability for the client during ambulation. A slider board is used in transferring a client from a bed to a stretcher or wheelchair. Adaptive eating utensils may be beneficial if the client has partial paralysis of the hand
The nurse in a newborn nursery is performing an assessment of an infant. What procedure should the nurse use to measure the infant's head circumference?
1. Wrap the tape measure around the infant's head, and measure just below the eyebrows. *2.Place the tape measure under the infant's head, wrap around the occiput, and measure just above the eyebrows. 3.Place the tape measure under the infant's head at the base of the skull and wrap around to the front just below the eyes. 4.Place the tape measure at the back of the infant's head, wrap around across the ears, and measure across the infant's mouth. - To measure head circumference, the nurse should place the tape measure under the infant's head, wrap the tape around the occiput, and measure just above the eyebrows so that the largest area of the occiput is included. The techniques in the remaining options are incorrect methods to measure the head circumference.
The nurse is assessing a client with epididymitis. The nurse anticipates which findings on physical examination?
1. fever, diarrhea, groin pain, and ecchymosis 2.Nausea, painful scrotal edema, and ecchymosis *3.Fever, nausea, vomiting, and painful scrotal edema 4.Diarrhea, groin pain, testicular torsion, and scrotal edema - Typical signs and symptoms of epididymitis include scrotal pain and edema, which often are accompanied by fever, nausea and vomiting, and chills. Epididymitis most often is caused by infection, although sometimes it can be caused by trauma
The nurse is providing care for a client who sustained burns over 30% of the body from a fire. On assessment, the nurse notes that the client is edematous in both burned and unburned body areas. The client's wife asks why her husband "looks so swollen." What is the nurse's best response?
1."Constricted blood vessels have caused a loss of protein in the blood." 2."Leaking blood vessels have led to increased protein amounts in the blood." *3."Leaking blood vessels have led to decreased protein amounts in the blood." 4."Constricted blood vessels have led to increased protein amounts in the blood." - In extensive burn injuries (greater than 25% of total body surface area), the edema occurs in both burned and unburned areas as a result of the increase in capillary permeability and hypoproteinemia. Edema also may be caused by the volume and oncotic pressure effects of the large fluid resuscitation volumes required
The parents of a child recently diagnosed with cerebral palsy ask the nurse about the limitations of the disorder. The nurse responds by explaining that the limitations occur as a result of which pathophysiological process?
1.An infectious disease of the central nervous system 2.An inflammation of the brain as a result of a viral illness *3.A chronic disability characterized by impaired muscle movement and posture 4.A congenital condition that results in moderate to severe intellectual disabilities - Cerebral palsy is a chronic disability characterized by impaired movement and posture resulting from an abnormality in the extrapyramidal or pyramidal motor system. Meningitis is an infectious process of the central nervous system. Encephalitis is an inflammation of the brain that occurs as a result of viral illness or central nervous system infection. Down's syndrome is an example of a congenital condition that results in moderate to severe intellectual disabilities.
The nurse is monitoring a diabetic client with a blood glucose level of 400 mg/dL (22.2 mmol/L). Which clinical manifestation would indicate diabetic ketoacidosis (DKA)?
1.Bradycardia 2.Cool, clammy skin 3.Lower extremity edema *4.Rapid, deep respirations - DKA is caused by a profound deficiency of insulin and is characterized by hyperglycemia (blood glucose level greater than or equal to 250 mg/dL [13.9 mmol/L]), ketosis (ketones in urine or serum), metabolic acidosis, and dehydration. The correct option is 4. This is because the body's compensatory response to the metabolic acidosis is to increase carbon dioxide (CO2) excretion by the lungs through deep, rapid breathing (Kussmaul respirations). Options 1, 2, and 3 are incorrect, as clients with DKA are dehydrated and thus have an increased heart rate and dry, scaly skin and do not have lower extremity edema.
A 6-year-old child with diabetes mellitus and the child's mother come to the health care clinic for a routine examination. The nurse evaluates the data collected during this visit to determine if the child has been euglycemic since the last visit. Which information is the most significant indicator of euglycemia?
1.Daily glucose monitor log 2.Dietary history for the previous week *3.Glycosylated hemoglobin (hemoglobin A1c) 4.Fasting blood glucose performed on the day of the clinic visit - The glycosylated hemoglobin assay measures the glucose molecules that attach to the hemoglobin A molecules and remain there for the life of the red blood cell, approximately 120 days. This is not reversible and cannot be altered by human intervention. Daily glucose logs are useful if they are kept regularly and accurately. However, they reflect only the blood glucose at the time the test was done. A fasting blood glucose test performed on the day of the clinic visit is time limited in its scope, as is the dietary history.
A client is suspected of having stage I Lyme disease. The nurse anticipates that which will be part of the treatment plan for the client?
1.Daily oatmeal baths for 2 weeks 2.No treatment unless symptoms develop *3.A 14- to 21-day course of oral antibiotic therapy 4.Treatment with intravenously administered antibiotics Lyme disease is a reportable systemic infectious disease caused by the spirochete Borellia burgdorferi and results from the bite of an infected deer tick, also known as the black-legged tick. Prevention, public education, and early diagnosis are vital to the control and treatment of Lyme disease. A 14- to 21-day course of oral antibiotic therapy is recommended during stage I. Later stages of Lyme disease may require therapy with intravenously administered antibiotics, such as penicillin G. The remaining options are incorrect.
The nurse is planning care for a newborn of a mother with diabetes mellitus. What is the priority nursing consideration for this newborn?
1.Developmental delays because of excessive size *2.Maintaining safety because of low blood glucose levels 3.Choking because of impaired suck and swallow reflexes 4.Elevated body temperature because of excess fat and glycogen - The newborn of a diabetic mother is at risk for hypoglycemia, so maintaining safety because of low blood glucose levels would be a priority. The newborn would also be at risk for hyperbilirubinemia, respiratory distress, hypocalcemia, and congenital anomalies. Developmental delays, choking, and an elevated body temperature are not expected problems.
The nurse notes that the client's intravenous (IV) site is cool, pale, and swollen and that the solution is not infusing. What is the nurse's priority action?
1.Elevate the extremity. *2.Remove the IV catheter. 3.Assess for signs of infection. 4.Decrease the rate of infusion. - The client's IV has infiltrated. An infiltrated IV is one that has dislodged from the vein and is lying in subcutaneous tissue. Pallor, coolness, and swelling are the results of IV fluid being deposited in the subcutaneous tissue. When the pressure in the tissues exceeds the pressure in the tubing, the flow of the IV solution will stop. The corrective action is to remove the catheter and start a new IV line at another site. Infection, phlebitis, and thrombosis are likely to be accompanied by warmth at the site, not coolness. Elevating the extremity should be implemented after removing the IV to reduce swelling.
The nurse is evaluating a function of the limbic system as a part of the neurological status of a client. What should the nurse assess?
1.Experience of pain *2.Affect or emotions 3.Response to verbal stimuli 4.Insight, judgment, and planning - Affect and emotions are part of the role of the limbic system and involve both hemispheres of the brain. Pain is a complex experience involving several areas of the central nervous system. The response to verbal stimuli is part of the level of consciousness, which is under the control of the reticular activating system and both cerebral hemispheres. Insight, judgment, and planning are part of the functions of the frontal lobes of the brain in conjunction with association fibers connecting to other areas of the cerebrum.
A client is admitted to the hospital with a suspected diagnosis of Hodgkin's disease. Which assessment finding would the nurse expect to note specifically in the client?
1.Fatigue 2.Weakness 3.Weight gain *4.Enlarged lymph nodes - Hodgkin's disease is a chronic progressive neoplastic disorder of lymphoid tissue characterized by the painless enlargement of lymph nodes with progression to extralymphatic sites, such as the spleen and liver. Weight loss is most likely to be noted. Fatigue and weakness may occur but are not related significantly to the disease.
The nurse is preparing to administer an analgesic to a client in labor. Which analgesic is contraindicated for a client who has a history of opioid dependency?
1.Fentanyl 2.Morphine sulfate *3.Butorphanol tartrate 4.Meperidine hydrochloride - Butorphanol tartrate is an opioid analgesic that can precipitate withdrawal symptoms in an opioid-dependent client. Therefore, it is contraindicated if the client has a history of opioid dependency. Fentanyl, morphine sulfate, and meperidine are opioid analgesics but do not tend to precipitate withdrawal symptoms in opioid-dependent clients.
A client is tested for human immunodeficiency virus (HIV) infection with an enzyme-linked immunosorbent assay (ELISA), and the test result is positive. What should the nurse tell the client?
1.HIV infection has been confirmed. 2.The client probably has a gastrointestinal infection. *3.The test will need to be confirmed with a Western blot. 4.A positive test result is normal and does not mean that the client has acquired HIV. - Human immunodeficiency virus (HIV) can cause acquired immunodeficiency syndrome, which is a viral disease that destroys T cells, thereby increasing susceptibility to infection and malignancy. A negative result on an ELISA indicates that infection is absent or that not enough time has passed since exposure for seroconversion. A positive ELISA result must be confirmed with a Western blot. The other options are incorrect.
The nurse is preparing to initiate an intravenous (IV) line containing a high dose of potassium chloride and plans to use an IV infusion pump. The nurse brings the pump to the bedside, prepares to plug the pump cord into the wall, and notes that no receptacle is available in the wall socket. The nurse should take which action?
1.Initiate the IV line without the use of a pump. *2.Contact the electrical maintenance department for assistance. 3.Plug in the pump cord in the available plug above the room sink. 4.Use an extension cord from the nurses' lounge for the pump plug. - Electrical equipment must be maintained in good working order and should be grounded; otherwise, it presents a physical hazard. An IV line that contains a dose of potassium chloride should be administered by an infusion pump. The nurse needs to use hospital resources for assistance. A regular extension cord should not be used because it poses a risk for fire. Use of electrical appliances near a sink also presents a hazard.
A 10-year-old child with hemophilia A has slipped on the ice and bumped his knee. The nurse should prepare to administer which prescription?
1.Injection of factor X 2.Intravenous infusion of iron *3.Intravenous infusion of factor VIII 4.Intramuscular injection of iron using the Z-track method - Hemophilia refers to a group of bleeding disorders resulting from a deficiency of specific coagulation proteins. The primary treatment is replacement of the missing clotting factor; additional medications, such as agents to relieve pain, may be prescribed depending on the source of bleeding from the disorder. A child with hemophilia A is at risk for joint bleeding after a fall. Factor VIII would be prescribed intravenously to replace the missing clotting factor and minimize the bleeding. Factor X and iron are not used to treat children with hemophilia A.
The pediatric nurse assists the primary health care provider in performing a lumbar puncture on a 3-year-old child with leukemia and suspected central nervous system metastasis. The nurse should place the child in which position for this procedure?
1.Lithotomy position 2.Modified Sims' position *3.Lateral recumbent, knees flexed to the abdomen and the head bent, chin down 4.Prone, with the knees flexed to the abdomen and the head bent, the chin resting on the chest - A lateral recumbent position, with the knees flexed to the abdomen and the head bent with the chin resting on the chest, is assumed for a lumbar puncture. This position separates the spinal processes and facilitates needle insertion into the subarachnoid space. The remaining options are incorrect positions.
A 4-year-old child is admitted to the hospital for abdominal pain. The mother reports that the child has been pale and excessively tired and is bruising easily. On physical examination, lymphadenopathy and hepatosplenomegaly are noted. Diagnostic studies are being performed because acute lymphocytic leukemia is suspected. The nurse determines that which laboratory result confirms the diagnosis?
1.Lumbar puncture showing no blast cells *2.Bone marrow biopsy showing blast cells 3.Platelet count of 350,000 mm3 (350 × 109/L) 4.White blood cell count 4500 mm3 (4.5 × 109/L) - Leukemia is a malignant increase in the number of leukocytes, usually at an immature stage, in the bone marrow. The confirmatory test for leukemia is microscopic examination of bone marrow obtained by bone marrow aspirate and biopsy, which is considered positive if blast cells are present. An altered platelet count occurs as a result of the disease but also may occur as a result of chemotherapy and does not confirm the diagnosis. The white blood cell count may be normal, high, or low in leukemia. A lumbar puncture may be done to look for blast cells in the spinal fluid that indicate central nervous system disease.
The nurse is creating a plan of care for a newly admitted client at high risk for suicide. With the focus of the plan being to promote a safe and therapeutic environment, which intervention should the nurse include?
1.Place the client in a private room. *2.Establish a therapeutic relationship. 3.Assign a leadership task to the client. 4.Maintain a distance of 10 inches at all times. - A therapeutic relationship will increase feelings of acceptance in the suicidal client. Placing the client in a private room would intensify the client's feeling of worthlessness and prevent appropriate observation of the client. Placing the client in a leadership role can overwhelm the client, lead to failure, and reinforce the feelings of worthlessness. Distances of 18 inches or less constitute intimate space, and invasion of this space may increase the client's tension and feelings of helplessness. In addition, the client at risk for suicide is placed on one-to-one suicide precautions.
After the spontaneous rupture of a laboring woman's membranes, the fetal heart rate drops to 85 beats/minute. Which should be the nurse's priority action?
1.Reposition the laboring woman to knee-chest. *2.Assess the vagina and cervix with a gloved hand. 3.Notify the primary health care provider of the need for an amnioinfusion. 4.Document the description of the fetal bradycardia in the nursing notes. - It is most common to see an umbilical cord prolapsed directly after the rupture of membranes, when gravity washes the cord in front of the presenting part. A cord prolapse can be evidenced by fetal bradycardia with variable decelerations occurring with uterine contractions. Because the fetal heart rate became bradycardic immediately following the spontaneous rupture of the client's membranes, the nurse's initial action should be to glove the examining hand and insert 2 fingers into the vagina to assess for the presence of a prolapsed cord and then to relieve compression of the cord by exerting upward pressure on the presenting part. Repositioning the woman to a knee-chest position is a correct intervention for prolapsed cord, but confirmation of the prolapsed cord and relieving compression is the first intervention that should be implemented; therefore, option 1 can be eliminated. An amnioinfusion may be used to minimize the effects of cord compression in utero, not a prolapsed cord, so option 3 can be eliminated. Although documentation of this occurrence is important, it is not the priority in this situation, so option 4 can also be eliminated.
The nurse is providing care to a Hispanic client who is terminally ill. Numerous family members are present most of the time, and many of the family members are very emotional. What is the appropriate action?
1.Restrict the number of family members visiting at 1 time. 2.Inform the family that emotional outbursts are to be avoided. 3.Contact the primary health care provider to speak to the family regarding their behavior. *4.Request permission to move the client to a private room and allow the family members to visit. - In Hispanic cultures, loud crying and other physical manifestations of grief are considered socially acceptable. Of the options provided, the correct choice is the only one that identifies a culturally sensitive approach on the part of the nurse. The remaining options are inappropriate nursing interventions.
The nurse identifies that a client is having occasional premature ventricular contractions (PVCs) on the cardiac monitor. The nurse reviews the client's laboratory results and determines that which result would be consistent with the observation?
1.Serum chloride level of 98 mEq/L (98 mmol/L) 2.Serum sodium level of 145 mEq/L (145 mmol/L) 3.Serum calcium level of 10.5 mg/dL (2.75 mmol/L) *4.Serum potassium level of 2.8 mEq/L (2.8 mmol/L) - The nurse should check the client's serum laboratory study results for hypokalemia. The client may experience PVCs in the presence of hypokalemia because this electrolyte imbalance increases the electrical instability of the heart. The values noted in the remaining options are normal.
A client is due for a dose of bumetanide. The nurse should temporarily withhold the dose and notify the primary health care provider (PHCP) if which laboratory test result is noted?
1.Sodium level of 137 mEq/L (137 mmol/L) 2.Chloride level of 106 mEq/L (106 mmol/L) *3.Potassium level of 2.9 mEq/L (2.9 mmol/L) 4.Magnesium level of 2.1 mEq/L (1.05 mmol/L)
A nurse is providing teaching regarding acarbose. The nurse should tell the client that which expected side or adverse effect(s) may occur with this medication?
1.Tachycardia and dizziness 2.Hypoglycemia and diaphoresis 3.Tinnitus and decreased hearing *4.Abdominal distention and diarrhea - Acarbose delays absorption of dietary carbohydrates and thereby reduces the rise in blood glucose after a meal. Its activity in the bowel promotes flatulence, cramping, and diarrhea. Acarbose does not have an effect on the heart. It may cause hypoglycemia and possibly associated diaphoresis, but this is not an expected side effect. Tinnitus and decreased hearing are side effects of aminoglycosides.
A client with hypertension has been told to maintain a diet low in sodium. The nurse who is teaching this client about foods that are allowed should include which food item in a list provided to the client?
1.Tomato soup 2.Boiled shrimp 3.Instant oatmeal *4.Summer squash - Foods that are lower in sodium include fruits and vegetables (summer squash) because they do not contain physiological saline. Highly processed or refined foods (tomato soup, instant oatmeal) are higher in sodium unless their food labels specifically state "low sodium." Saltwater fish and shellfish are high in sodium.
The nurse is caring for a hospitalized child who is receiving a continuous infusion of intravenous potassium for the treatment of dehydration. Which assessment finding requires the need to notify the primary health care provider?
1.Weight increase of 0.5 kg 2.Temperature of 100.8º F (38.2º C) rectally 3.Blood pressure unchanged from baseline *4.A decrease in urine output to 0.5 mL/kg/hr - The priority assessment is to assess the status of urine output. Potassium should never be administered in the presence of oliguria or anuria. If urine output is less than 1 to 2 mL/kg/hr, potassium should not be administered. A slight elevation in temperature would be expected in a child with dehydration. A weight increase of 0.5 kg is relatively insignificant. A blood pressure that is unchanged is a positive indicator unless the baseline was abnormal. However, there is no information in the question to support such data.