ATI Practice B 201

A nurse is providing discharge teaching to the parents of a newborn about crib use. Which of the following statements should the nurse make? A. "Arranging small stuffed animals in the crib is recommended to provide a feeling of security for your baby." B. "Moving the crib near a window in the nursery will provide your baby with necessary fresh air and natural light." C. "Dressing your baby in a one-piece sleeper for bedtime will replace the need to use a blanket or a sheet." D. "Placing your baby on her tummy in the crib will hasten drowsiness and provide a more restful night's sleep."

C. "Dressing your baby in a one-piece sleeper for bedtime will replace the need to use a blanket or a sheet." - "Arranging small stuffed animals in the crib is recommended to provide a feeling of security for your baby."The nurse should instruct the parents that placing any object in the crib is a safety hazard and significantly increases the newborn's risk for suffocation. - "Moving the crib near a window in the nursery will provide your baby with necessary fresh air and natural light."The nurse should instruct the parents to place the crib on an inner wall away from windows. Placing the crib near a window in the nursery can increase the newborn's risk of cold stress. This also is a safety hazard due to glass breakage. Cords on window treatments increase the risk of strangulation as the infant gets old enough to reach them. - "Dressing your baby in a one-piece sleeper for bedtime will replace the need to use a blanket or a sheet."MY ANSWERThe nurse should instruct the parents to dress the newborn in a one-piece sleeper or a "sleep-sack" at bedtime, which keeps the newborn's body covered. Blankets and quilts significantly increase the newborn's risk of suffocation and should be avoided. - "Placing your baby on her tummy in the crib will hasten drowsiness and provide a more restful night's sleep."Placing the newborn on her abdomen in the crib for sleeping significantly increases the risk for suffocation and sudden infant death syndrome (SIDS). Therefore, the nurse should instruct the parents to place the newborn in the supine position at all times for sleeping.

A nurse is providing teaching for a client following cataract surgery. Which of the following statements indicates to the nurse that the client understands the teaching? A. "I will have my best vision 3 weeks after my surgery." B. "I should report a creamy white discharge from my eye to my doctor." C. "I will avoid getting water in my eyes until the second day after surgery." D. "I should avoid using the vacuum cleaner for several weeks."

"I should avoid using the vacuum cleaner for several weeks." - "I will have my best vision 3 weeks after my surgery." The nurse should instruct the client to anticipate an improvement in vision within days of the surgical procedure. However, the best vision will occur around 4 to 6 weeks following the surgery. - "I should report a creamy white discharge from my eye to my doctor." The nurse should instruct the client that a creamy white discharge can become dry and crusted on the eyelids or lashes. This drainage is expected and does not require reporting. However, yellow or green drainage should be reported to the provider. - "I will avoid getting water in my eyes until the second day after surgery." The nurse should instruct the client to avoid getting water in the eye for 3 to 7 days following surgery. - "I should avoid using the vacuum cleaner for several weeks." MY ANSWER The nurse should instruct the client to avoid using the vacuum cleaner for several weeks. The forward flexion and rapid, jerking movements that occur while vacuuming can increase intraocular pressure.

A hospice nurse is visiting with a client following the death of her partner 1 month ago. The client is tearful and states she does not see how she can ever be happy again. Which of the following responses should the nurse make? - "You're sad now, but the grief will pass eventually." - "You should attend a grief support group to see how others cope with loss." - "What are some of the best times with your partner that you remember?" - "How are other members of the family managing?"

- "What are some of the best times with your partner that you remember?" "You're sad now, but the grief will pass eventually."While identifying a client's emotions is therapeutic, offering false reassurances, such as "the grief will pass," is nontherapeutic and inhibits the client from exploring her feelings in a manner that allows for processing of the grief response. "You should attend a grief support group to see how others cope with loss."Attending a grief support group can facilitate the grief response by allowing the client to talk about her feelings, fears, and experiences with other individuals who are also dealing with the loss of a significant other. However, the nurse is giving advice by stating the client should attend the group, which is nontherapeutic. "What are some of the best times with your partner that you remember?"MY ANSWEREncouraging the client to reminisce about her partner allows the client to acknowledge the loss and to progress through the grief process. "How are other members of the family managing?"Inquiring about other members of the family is a nontherapeutic response by the nurse because it takes the focus away from the client by changing the subject. This inhibits the client from exploring her feelings in a manner that allows for processing of the grief response.

A nurse is assessing a client who has musculoskeletal trauma following a motor- vehicle crash 2 days ago. Which of the following findings should the nurse report to the provider?

- Laboratory resultsA hematocrit of 42% and a hemoglobin of 14 g/dL are within the expected reference range. However, the nurse should continue to monitor these laboratory results because a decrease could indicate that the client is bleeding from the musculoskeletal trauma, which would require notification of the provider. - Blood pressureA blood pressure of 144/90 mm Hg is above the expected reference range. However, for a client who has musculoskeletal trauma, pain is an expected finding, and an elevation of blood pressure is an indication of pain. The nurse should also monitor the client for hypertension, which could be an indication that the client is bleeding from the musculoskeletal trauma. - Pain reportMY ANSWERThe nurse should report the client's pain level of 8 on a scale of 0 to 10 to the provider. Excessive pain in a casted arm that is unrelieved by analgesics can be an indication of compartment syndrome, which is a medical emergency. - ECG resultsSinus tachycardia indicates that the client has a heart rate above the expected reference range. However, for a client who has musculoskeletal trauma, pain is an expected finding, and an elevation of heart rate is an indication of pain.

A nurse is teaching a client who has hypokalemia about nutrition management. Which of the following fruits should the nurse recommend as the best source of potassium? - One small apple - One-half cup of sweet cherries - One-half cup of fresh pineapple - One small orange

- One small orange - One small appleClients who have hypokalemia should eat apples. One small apple that is 7.1 cm (2.8 in) in diameter has 159 mg of potassium. However, there is another fruit that is a better source of potassium. - One-half cup of sweet cherriesClients who have hypokalemia should eat cherries. One-half cup of sweet cherries has 171 mg of potassium. However, there is another fruit that is a better source of potassium. - One-half cup of fresh pineappleClients who have hypokalemia should eat pineapple. One-half cup of fresh pineapple has 90 mg of potassium. However, there is another fruit that is a better source of potassium. - One small orangeMY ANSWERThe nurse should recommend that a client who has hypokalemia eat oranges due to the high potassium content. One orange that is 7.1 cm (2.8 in) in diameter contains 232 mg of potassium.

A nurse is providing teaching about home care to the parent of an adolescent who has infectious mononucleosis. Which of the following manifestations should the nurse intruct the parent to report to the provider?

- Swollen cervical lymph nodes The nurse should not instruct the parent to report swollen cervical lymph nodes because this is an expected manifestation of infectious mononucleosis. Other manifestations include fever and sore throat. - Exudate on tonsils The nurse should not instruct the parent to report exudate on tonsils because this is an expected manifestation of infectious mononucleosis. Other manifestations include fever and sore throat. - Lack of energy The nurse should not instruct the parent to report lack of energy because this is an expected manifestation of infectious mononucleosis. Other manifestations include fever and sore throat. - Onset of abdominal pain MY ANSWER: The nurse should instruct the parent to report the onset of abdominal pain to the provider because this is an indication of splenomegaly. Splenic hemorrhage or rupture can occur and is usually caused by trauma.

A nurse is assessing a client Urinary burning who has acute pyelonephritis.Which of the following findings should the nurse expect? - Pain with palpation to the substernal notch - Urinary burning - Ecchymosis over the flank - Radiating pain to the right shoulder

- Urinary burning - Pain with palpation to the substernal notchA client who has acute pyelonephritis can have discomfort in the back and flank areas. Tenderness can also be elicited by palpating the costovertebral angle, not the substernal notch, which is located at the top of the rib cage. - Urinary burningMY ANSWERA client who has acute pyelonephritis can experience burning, frequency, and urgency with urination. - Ecchymosis over the flankA client who has urolithiasis and was treated with lithotripsy can have ecchymosis over the flank area of the kidney following the procedure. - Radiating pain to the right shoulderA client who has cholecystitis can develop radiating pain to the right shoulder.

A nurse is teaching about ezetimibe with a client who has hyperlipidemia. Which of the following client statements indicates an understanding of the teaching? -I should avoid this medication with milk -I will return to have my cholesterol levels checked in 2 weeks -I can expect to lose weight while taking this medication -I understand that muscle tenderness is an expected result of this medication

-I will return to have my cholesterol levels checked in 2 weeks - "I should avoid taking this medication with milk."The nurse should instruct the client to take this medication without regard to foods, but that it should be taken at the same time each day. - "I will return to have my cholesterol levels checked in 2 weeks."MY ANSWER The nurse should instruct the client that their cholesterol level will be reevaluated within 2 to 4 weeks after initiating therapy, and periodically thereafter. - "I can expect to lose weight while taking this medication."The nurse should instruct the client that this medication does not assist with weight loss; however, the client should follow dietary restrictions of fat and cholesterol, which can help with weight loss. - "I understand that muscle tenderness is an expected result of this medication."The nurse should instruct the client to notify the provider if experiencing muscle pain, tenderness, or weakness because these manifestations can indicate myopathy or rhabdomyolysis.

A nurse is assessing a client who has an external fixator to the right lower arm following musculoskeletal trauma. Which of the following findings should indicate to the nurse that the client has developed compartment syndrome? -Serous drainage is present on the pin site dressings -Flushing of the skin on the right arm -Bounding pulse palpated in the radial artery -Numbness to the fingers on the right arm

-Numbness to the fingers on the right arm - Serous drainage is present on the pin site dressings The nurse should identify serous drainage as an expected finding in a client following placement of an external fixator of the right lower arm. However, it does not indicate the development of compartment syndrome. - Flushing of the skin on the right arm The nurse should identify pallor or duskiness of the skin as an indication of compartment syndrome of the right lower arm. - Bounding pulse palpated in the radial artery The nurse should identify a weakened pulse or an inability to palpate a pulse as an indication of compartment syndrome of the right lower arm. - Numbness to the fingers on the right arm MY ANSWER The nurse should identify a decrease in sensation, such as numbness and tingling of the fingers, as one of the first indications that the client might be developing compartment syndrome of the right lower arm. Compartment syndrome is the result of edema and ischemia, a complication following musculoskeletal injury. Other manifestations include increased pain, paralysis, pallor, and decreased or absent pulses.

A nurse is caring for a group of clients. Which of the following clients should the nurse identify as being at risk for developing respiratory acidosis? -fever -abdominal ascites -anxious -nasogastric suctioning

-abdominal ascites A client who has a feverThe nurse should identify that fever is a risk factor for developing metabolic acidosis. Acute illnesses, often accompanied by fever, cause an accumulation of lactic acid, which can lead to a state of metabolic acidosis. A client who has abdominal ascitesMY ANSWERThe nurse should identify that a client who has abdominal ascites can experience a restriction of chest expansion, which impairs gas exchange and places the client at an increased risk for developing respiratory acidosis. A client who is anxiousThe nurse should identify that anxiety is a risk factor for developing respiratory alkalosis. As anxiety increases a client's respiratory rate, excessive CO2 is lost, creating an alkalotic state. A client who is receiving nasogastric suctioningThe nurse should identify that nasogastric suctioning is a risk factor for developing metabolic alkalosis because excess acids are lost through suctioned secretions.

A nurse is assessing a client who is receiving intravenous medications. Which of the following findings should the nurse identify as a manifestation of respiratory acidosis? A. Confusion B. Flushed, moist skin C. Hyperreflexia D. Bounding peripheral pulses

A. Confusion - ConfusionMY ANSWERThe client who has respiratory acidosis can display mental cloudiness or confusion due to elevated carbon dioxide (CO2) retention as a result of hypoventilation. - Flushed, moist skinThe client who has respiratory acidosis can have pale, cyanotic, and dry skin due to hypoventilation, causing CO2 retention. - HyperreflexiaThe client who has respiratory acidosis can have hyporeflexia due to hypoventilation, causing CO2 retention. - Bounding peripheral pulsesThe client who has respiratory acidosis from hypoventilation will have hypotension that can cause weak peripheral pulses. Hypotension is due to vasodilation from CO2 retention.

A nurse is assessing a client who is experiencing diarrhea and vomiting and has a sodium level of 124 mEq/L. Which of the following manifestations should the nurse expect? A. Orthostatic hypotension B. Hoarse voice C. Neck vein distention D. Muscle twitching

A. Orthostatic hypotension - Orthostatic hypotension MY ANSWERThe nurse should monitor the client who has a sodium level of 124 mEq/L for orthostatic hypotension. The expected reference range for sodium is 136 to 145 mEq/L. Other manifestations of hyponatremia include decreased deep tendon reflexes, headache, confusion, and lethargy. - Hoarse voice Hoarse voice is not a manifestation of hyponatremia. - Neck vein distention Neck vein distention is a manifestation of hypernatremia. - Muscle twitching Muscle twitching is a manifestation of hypernatremia.

A nurse is reviewing the laboratory records of a client who has AIDS. Which of the following laboratory results should the nurse review to determine if the client is at risk for malnutrition?

Albumin level - WBC count The nurse should review the WBC count to determine if the client is experiencing an infection. - Albumin level MY ANSWER The nurse should review albumin levels to determine a client's risk for malnutrition. A client who is malnourished will have an albumin level below the expected reference range of 3.5 to 5 g/dL. - CD4 T cell count The nurse should review CD4 T lymphocyte cell counts to monitor for a decrease, which indicates a worsening of the client's illness. - C-reactive protein level The nurse should review C-reactive protein levels to monitor for inflammation. This laboratory test can assist in diagnosing coronary illness.

A nurse is planning care for a client following collection of admission data. Which of the following findings should the nurse identify as the priority client need? A. The client requests to see a priest for spiritual guidance. B. The client reports coughing and a change of voice whenever he eats. C. The client reports pain immediately following physical therapy. D. The client is worried about financially supporting his family because of his illness.

B. The client reports coughing and a change of voice whenever he eats. - The client requests to see a priest for spiritual guidance.The nurse should acknowledge the client's spiritual needs, such as a request to see a priest, as important because it is the nurse's responsibility to promote the client's spiritual health. However, there is another finding that the nurse should identify as the client's priority need. - The client reports coughing and a change of voice whenever he eats.MY ANSWERWhen using Maslow's hierarchy of needs, the nurse should determine that the priority finding is the client's physiological needs, such as coughing and a change of voice whenever he eats. This finding indicates a risk for aspiration, which can impair the client's breathing and oxygenation status. Difficulty eating also creates an impairment of nutrition. Breathing, oxygenation, and nutrition are all physiological needs. Therefore, the nurse should identify this finding as the priority client need. - The client reports pain immediately following physical therapy.The nurse should identify the client's safety and security needs, such as pain following physical therapy, as important because it is the nurse's responsibility to promote the client's comfort and assist the client in receiving the optimal benefit from physical therapy. However, there is another finding that the nurse should identify as the client's priority need. - The client is worried about financially supporting his family because of his illness.The nurse should identify the client's self-esteem needs, such as financial concerns, as important because it is the nurse's responsibility to coordinate with social services or other interprofessional team members to meet client needs. However, there is another finding that the nurse should identify as the client's priority need.

A nurse is assessing a 6-month- nasal flaring old infant who has bacterial pneumonia. Which of the following manifestations should the nurse expect? A. Protruding tongue B. Facial flushing C. Nasal flaring D. Tympany with chest percussion

C. Nasal flaring - Protruding tongueA protruding tongue is an expected manifestation of epiglottitis, not bacterial pneumonia. - Facial flushingInfants who have bacterial pneumonia can have manifestations of pallor or cyanosis due to decreasing oxygen saturation levels. - Nasal flaringMY ANSWERInfants who have bacterial pneumonia can exhibit manifestations such as nasal flaring and retractions of the intercostal and substernal spaces due to attempts to breathe in more oxygen to compensate for hypoxia. - Tympany with chest percussionInfants who have bacterial pneumonia will have dullness with chest percussion due to the consolidation of secretions in the lungs along with vascular congestion and inflammation of the alveolar walls.

A nurse is assessing a client for Oliguria manifestations of heat stroke.Which of the following findings should the nurse expect? A. Hypertension B. Somnolence C. Oliguria D. Bradycardia

C. Oliguria - Hypertension The nurse should expect a client who has heat stroke to manifest hypotension. - Somnolence The nurse should expect a client who has heat stroke to manifest agitation, anxiety, and bizarre behavior. - Oliguria MY ANSWER A client who has heat stroke will manifest a body temperature of 40° C (104° F) or greater, which can lead to dehydration and oliguria. Complications include multiple organ dysfunction syndrome, which includes renal impairment. The nurse should closely monitor the client's urine output and specific gravity to assist with determining fluid needs. - Bradycardia The nurse should expect a client who has heat stroke to manifest tachycardia.

A nurse is providing teaching to a client who has osteoporosis. Which of the following information should the nurse include in the teaching? A. Increase daily intake of foods containing vitamin A. B. Limit alcohol consumption to 10 oz daily. C. Perform exercises to strengthen the abdominal core. D. Start a daily jogging regimen.

C. Perform exercises to strengthen the abdominal core. - Increase daily intake of foods containing vitamin A.The nurse should instruct the client to increase daily intake of calcium and vitamin D to decrease the rate of bone loss. - Limit alcohol consumption to 10 oz daily.The nurse should instruct the client to limit alcohol consumption to 5 oz daily to decrease the rate of bone loss. - Perform exercises to strengthen the abdominal core.MY ANSWERThe nurse should instruct the client to perform exercises to strengthen the abdominal and back muscles to maintain stability of the spinal column and prevent vertebral fractures. - Start a daily jogging regimen.The nurse should instruct the client to avoid jarring exercises, such a jogging or horseback riding, to prevent potential vertebral compression fractures.

A nurse is reviewing the laboratory results of an adult client who has metabolic alkalosis. Which of the following findings should the nurse expect? A. Calcium 9.5 mg/dL B. Bicarbonate 23 mEq/L C. Potassium 3 mEq/L D. pH 7.4

C. Potassium 3 mEq/L - Calcium 9.5 mg/dL The nurse should expect to find hypocalcemia in a client who has metabolic alkalosis. This value is within the expected reference range of 9 to 10.5 mg/dL. - Bicarbonate 23 mEq/L The nurse should expect to find an increased bicarbonate level in a client who has metabolic alkalosis. This value is within the expected reference range of 21 to 28 mEq/L. - Potassium 3 mEq/LMY ANSWER The nurse should expect to find hypokalemia in a client who has metabolic alkalosis due to the response to decreased blood cation levels. This decrease in potassium can lead to an increased stimulation of the nervous, neuromuscular, and cardiac systems. The client's potassium level of 3 mEq/L is below the expected reference range of - 3.5 to 5 mEq/L. pH 7.4 The nurse should expect to find an elevated pH in a client who has metabolic alkalosis. This pH value is within the expected reference range of 7.35 to 7.45.

A nurse is reviewing a client's medical record prior to a laparoscopic appendectomy. Which of the following findings should the nurse report to the provider? A. Prothrombin time 12 seconds B. History of sinusitis several times each year C. BMI of 24 D. Report of urinating small amounts twice daily

D. Report of urinating small amounts twice daily - Prothrombin time 12 secondsThe nurse should recognize that an increased prothrombin time can increase the client's risk for hemorrhage postoperatively. However, this finding is within the expected reference range of 11 to 12.5 seconds. - History of sinusitis several times each yearThe nurse should notify the provider if the client has cardiac issues, such as hypertension, or other chronic illnesses that could affect recovery postoperatively. However, a history of sinusitis should not affect the client's perioperative care plan. - BMI of 24The nurse should recognize that clients who are obese can have conditions that can lead to medical complications following anesthesia, which can require increased medication dosages. However, a BMI of 24 is within the expected reference range of 18.5 to 25. - Report of urinating small amounts twice dailyMY ANSWERThe nurse should recognize that a report of oliguria, or urinating only small amounts daily, indicates possible impaired kidney function. Therefore, the nurse should report this finding to the provider for further evaluation. Kidney function affects medication metabolism and impaired function increases the client's risk for postoperative complications.

A nurse is counseling a client who recently lost her partner in a motor-vehicle crash. Which of the following reactions should the nurse identify as part of the second stage of the grieving process? A. Persistent feelings of hopelessness B. Loss of self-esteem C. Chronic physical manifestations D. Feeling anger toward family members

Feeling anger toward family members - Persistent feelings of hopelessnessThe nurse should identify that the ability to maintain a sense of hope is expected during the grieving process. Persistent feelings of hopelessness can be an indication that the client has developed a depressive disorder. - Loss of self-esteemThe nurse should identify that the ability to maintain self-esteem is expected during the grieving process. A loss of self-esteem can be an indication that the client has developed a depressive disorder. - Chronic physical manifestationsThe nurse should identify that temporary physical manifestations are an expected reaction during the grieving process. Chronic physical manifestations can be an indication that the client has developed a depressive disorder. - Feeling anger toward family membersMY ANSWERThe nurse should identify that feelings of anger towards herself, her partner, and others is an expected grief reaction and is identified as the second stage of the grieving process.

A nurse is assessing a client Fever, Dyspepsia, Eructation who has acute cholecystitis.Which of the following findingsshould the nurse expect? Select all that apply: A. Fever B. Dyspepsia C. Pain radiating to the left shoulder D. Blood-tinged stools E.Eructation

Fever is correct. The nurse should expect to find a fever in the client who has acute cholecystitis due to the inflammatory process.Dyspepsia is correct. The nurse should expect to find dyspepsia or indigestion in the client who has acute cholecystitis due to the biliary stasis from conditions affecting the filling or emptying of the gallbladder. Pain radiating to the left shoulder is incorrect. The nurse should expect to find pain that often radiates to the right shoulder or scapula in the client who has acute cholecystitis.Blood-tinged stools is incorrect. The nurse should expect to find pale or clay-colored stools due to the lack of bile in the client who has acute cholecystitis.Eructation is correct. The nurse should expect the client who has acute cholecystitis to exhibit eructation, or belching, due to the biliary stasis from conditions affecting the filling or emptying of the gallbladder.

A nurse is providing teaching to the parent of a school-age child who has a severe bee allergy and a new prescription for an epinephrine auto- injector. Which of the following instructions should the nurse include? A. "Administer the medication into your child's abdomen." B. "Expect your child to sleep for several hours after receiving the medication." C. "Place your child's unused extra syringes in the refrigerator for storage." D. "Give a second injection if the first fails to reverse your child's symptoms."

Give a second injection if the first fails to reverse your child's symptoms - "Administer the medication into your child's abdomen."The medication should be administered intramuscularly into the child's outer thigh. The nurse should instruct the parent to firmly press the device into the child's outer thigh about halfway between the hip and the knee at a perpendicular angle, holding it in place until the auto-injector function engages. - "Expect your child to sleep for several hours after receiving the medication."The nurse should instruct the parent to monitor the child for the adverse effects of epinephrine. The most common adverse effect is a feeling of nervousness, rather than apathy or somnolence. Other adverse effects include palpitations, restlessness, increased pulse rate, sweating, dizziness, insomnia, and headache. - "Place your child's unused extra syringes in the refrigerator for storage."The parent should avoid refrigeration of the epinephrine syringes because this can cause the injection mechanism to become compromised, and therefore fail to engage during the next use. The extra syringes should be stored in a dark place at room temperature. - "Give a second injection if the first fails to reverse your child's symptoms."MY ANSWERThe nurse should instruct the parent to administer a second dose, using a second auto-injector, if the first dose doesn't completely reverse the child's allergic reaction. The effects of the medication will begin to fade in 20 min. However, the child should be transported to the nearest hospital immediately because hospitalization for a few hours following administration of the injection is recommended. The nurse should instruct the parent to bring the auto-injector with the child to the hospital.

A nurse in a community health clinic is reviewing data from the medical records of four clients. Which of the following communicable diseases requires reporting by the nurse? -Gonorrhea -Herpes genitalis -Human papillomavirus -Bacterial vaginosis

Gonorrhea - GonorrheaMY ANSWERGonorrhea is an infectious condition listed on the Nationally Notifiable Infectious Conditions Listing. The nurse should report this communicable disease to the Centers for Disease Control and Prevention. - Herpes genitalisHerpes genitalis does not require reporting by the nurse. - Human papillomavirusHuman papillomavirus does not require reporting by the nurse. - Bacterial vaginosisBacterial vaginosis does not require reporting by the nurse.

A nurse is assessing a client who has gestational diabetes and ketoacidosis. Which of the following manifestations should the nurse expect? -Increased urination -Sweating -Dizziness -Loose stools

Increased urinationMY ANSWERThe nurse should expect the client to exhibit manifestations of hyperglycemia, including increased thirst, nausea, vomiting, increased urination, flushed dry skin, acetone breath odor, and a weak, rapid pulse. SweatingSweating is not an expected manifestation of diabetic ketoacidosis. However, it is a manifestation of hypoglycemia. DizzinessDizziness is not an expected manifestation of diabetic ketoacidosis. However, it is a manifestation of hypoglycemia. Loose stoolsLoose stools are not an expected manifestation of diabetic ketoacidosis. Due to dehydration, constipation might be present.

A nurse is admitting an infant Initiate droplet precautions for the infant who has pertussis. Which of the following actions should the nurse take? - Administer an antiviral medication to the infant. - Initiate droplet precautions for the infant. - Limit the infant's oral intake of fluids to 60 mL/hr. - Monitor the infant for manifestations of increased intracranial pressure.

Initiate droplet precautions for the infant. - Administer an antiviral medication to the infant.Pertussis is an infection caused by the bacterium Bordetella pertussis. The nurse should administer an antibiotic to the infant to eradicate the infection. - Initiate droplet precautions for the infant.MY ANSWERThe nurse should initiate droplet precautions for an infant who has pertussis. Other actions the nurse should take include providing humidified oxygen and suctioning secretions to prevent choking. - Limit the infant's oral intake of fluids to 60 mL/hr.The nurse should encourage oral fluid intake for an infant who has pertussis. Increasing fluid intake can help prevent dehydration and assist in thinning secretions. - Monitor the infant for manifestations of increased intracranial pressure.The nurse should monitor the infant for complications of pertussis, including otitis media, atelectasis, dehydration, and hernias. Pertussis does not increase intracranial pressure.

A nurse is reviewing a client's home medication list during admission to a long-term care facility. The nurse should identify that the client takes which of the following medications to manage osteoarthritis? Select all that apply Lidocaine 5% patches Celecoxib Vancomycin Cyclobenzaprine Glucosamine

Lidocaine 5% patches is correct. The nurse should identify lidocaine 5% patches as a topical medication that can relieve joint pain associated with osteoarthritis.Celecoxib is correct. The nurse should identify celecoxib as a cyclooxygenase-2 (COX-2) inhibitor that treats osteoarthritis pain. Providers usually prescribe celecoxib when over-the-counter medications, such as NSAIDs, are no longer effective in relieving osteoarthritis pain.Vancomycin is incorrect. Vancomycin is an antibiotic that is prescribed to treat certain infections, including osteomyelitis and meningitis.Cyclobenzaprine is correct. The nurse should identify cyclobenzaprine as a muscle relaxant medication that relieves muscle spasms in the back that can occur with osteoarthritis of the vertebral column.Glucosamine is correct. The nurse should identify glucosamine as an over-the-counter dietary supplement that clients can take to relieve osteoarthritis discomfort.

A nurse is caring for a client who has pneumonia. Which of the following actions is the priority for the nurse to take? -Monitor intake and output -Provide teaching about antibiotic therapy -Administer the influenza vaccine -Observe the client perform incentive spirometry

Observe the client perform incentive spirometry - Monitor intake and output. The nurse should monitor intake and output to identify manifestations of dehydration. Fever, tachypnea, and an increased metabolic rate increase the client's need for fluids. However, there is another action that is the nurse's priority. - Provide teaching about antibiotic therapy. The nurse should provide teaching about all medications the client is taking to promote compliance and an awareness of potential adverse effects. However, there is another action that is the nurse's priority. - Administer the influenza vaccine. The nurse should administer the influenza vaccine to decrease the client's risk of influenza in the future. However, there is another action that is the nurse's priority. - Observe the client perform incentive spirometry. MY ANSWER When using the airway, breathing, and circulation framework, the priority action the nurse should take is to observe the client perform incentive spirometry. Incentive spirometry improves gas exchange and oxygenation and stimulates coughing, which assists in clearing secretions.

A nurse is assessing an 18- month-old toddler who has gastroenteritis with dehydration. The toddler is able to consume 3 mL of oral rehydration solution every 5 min but still has emesis and diarrhea. Which of the following medications should the nurse anticipate administering to the toddler? A. Polyethylene glycol B. Bumetanide C. Loperamide D. Ondansetron

Ondansetron - Polyethylene glycolPolyethylene glycol is an osmotic laxative used for bowel cleansing or treatment of acute iron overdose in children. Diarrhea with dehydration is a contraindication to the use of a laxative. - BumetanideBumetanide is a loop diuretic used for the treatment of edema related to heart failure. Diarrhea with dehydration is a contraindication to the use of a diuretic. - LoperamideLoperamide is an antidiarrheal medication that should not be administered to a toddler because it can cause adverse effects, such as an ileus or death. - OndansetronMY ANSWERThe nurse should anticipate administering ondansetron to the toddler. Ondansetron is administered to toddlers who have gastroenteritis and dehydration to decrease the episodes of emesis and to help eliminate the need for intravenous fluids.

A nurse is caring for a client who has right-sided hemiparesis following a stroke. Which of the following images is an indication that the nurse is correctly assisting the client to ambulate?

One hand on gait belt walking behind the patient on affected side (right side) A nurse who is assisting a client who has right-sided hemiparesis with ambulating should support the client using a gait belt, be on the client's affected side, and should avoid holding the client's arm for support. If the client begins to fall, the nurse can have difficulty lowering the client to the floor, which can place the client at risk for injury, such as a shoulder dislocation. MY ANSWER A nurse who is assisting a client who has right-sided hemiparesis with ambulating should stand on the client's affected side and support the client using a gait belt. A nurse who is assisting a client who has right-sided hemiparesis with ambulating should stand on the client's affected side, not in front of the client, and support the client using a gait belt. A nurse who is assisting a client who has right-sided hemiparesis with ambulating should stand on the client's affected side, not the unaffected side, and support the client using a gait belt.

A nurse is assessing a client who has a partial obstruction of the large bowel. Which of the following manifestations should the nurse expect? A. Presence of peristaltic waves B. Epigastric distention C. Large amounts of emesis of fecal material D. Ribbon-like stools

Ribbon-like stools - Presence of peristaltic wavesThe client who has the presence of peristaltic waves has a manifestation of an obstruction of the small bowel. - Epigastric distentionThe client who has epigastric distention has a manifestation of an obstruction of the small bowel. A client who has a large bowel obstruction will have distention in the lower abdomen. - Large amounts of emesis of fecal materialThe client who has emesis of fecal material has a manifestation of an obstruction of the small bowel. A client who has a large bowel obstruction will have minimal or no emesis. - Ribbon-like stoolsMY ANSWERThe client who has a partial obstruction of the large bowel will have ribbon-like stools with an alteration in bowel habits and blood in the stools. A client who has a partial obstruction of the small bowel can have diarrhea.