Comp 1

For the past 6 days, a 7-month-old infant has been receiving amoxicillin trihydrate to treat an ear infection. Now the parents report redness in the diaper area and small, red patches on the infant's inner thighs and buttocks. After diagnosing Candida albicans, the physician orders topical nystatin to be applied to the perineum four times daily. The nurse should focus her assessment on: the infant's heart and respiratory rate. the infant's fontanels. the inside of the infant's mouth. the infant's height and weight.

the inside of the infant's mouth. Explanation: The nurse should pay close attention to the inside of the infant's mouth for white patches. Signs of thrush, these patches are common in children with C. albicans infections and should be reported to the physician. Although the other assessments should be performed as a part of an infant evaluation, they aren't the nurse's primary focus in this situation.

The nurse is teaching a client with trigeminal neuralgia how to minimize pain episodes. Which comments by the client indicate an understanding of the instructions? Select all that apply. "I'll eat food that is very hot." "I'll try to chew my food on the unaffected side." "I can wash my face with cold water." "Drinking fluids at room temperature should reduce pain." "If brushing my teeth is too painful, I'll try to rinse my mouth instead."

"I'll try to chew my food on the unaffected side." "Drinking fluids at room temperature should reduce pain." "If brushing my teeth is too painful, I'll try to rinse my mouth instead." Explanation: Mechanical or thermal stimuli trigger the facial pain of trigeminal neuralgia. Chewing food on the unaffected side and rinsing the mouth rather than brushing teeth reduce mechanical stimulation. Drinking fluids at room temperature reduces thermal stimulation. Eating hot food and washing the face with cold water are likely to trigger pain.

A client on vacation experiences severe allergy symptoms, headache, and sinusitis (without respiratory distress). This client adamantly declines any supportive medications when offered. The nurse questions the client and learns the client receives weekly acupuncture treatments for these symptoms. The nurse's best response is: "Acupuncture is still very experimental." "Let us try this until you can have acupuncture." "There are very good medications available." "I can give you injections if that's what you like.

"Let us try this until you can have acupuncture." Explanation: The nurse should respect the client's choice of alternative treatments. It is respectful to offer choices until the client can again access acupuncture treatment. Acupuncture is not experimental. The nurse is being disrespectful to offer medications when the client has declined them, and it is silly to compare acupuncture to injectable medications.

treatment of cellulitis

Penicillin G

A nurse is preparing a neonate for circumcision. Which behavior is the best example of nursing advocacy? Recommending the use of analgesia for circumcision Ensuring that the neonate has had nothing by mouth (NPO) for at least 6 hours before the procedure Promptly returning the neonate to his mother for comfort and bonding after the procedure Monitoring the neonate for the excessive bleeding after the procedure

Recommending the use of analgesia for circumcision Explanation: Recommending the use of analgesia is an example of advocacy for the neonate. Ensuring that the neonate has been NPO for at least 6 hours before the procedure, monitoring for excessive bleeding after the procedure, and returning the neonate to his mother for comfort and bonding are examples of providing safe care, not of advocacy.

A client has been prescribed diuretic therapy for hypertension. It has been causing frequent urination at night and now the client is refusing to take the morning dose of furosemide. What would be the best response by the nurse?

Reinforce the reason for the medication. Respect the decision if the client still refuses the medication, and chart the refusal.

A client is transferred from the coronary care unit to the step-down unit. Which information should be included in the transfer report? Select all that apply. The client needs oxygen at 2 L/minute. The client has a "do not resuscitate" prescription. The client uses the bedpan. The client has four grandchildren. The client has been in normal sinus rhythm for 6 hours.

The client needs oxygen at 2 L/minute. The client has a "do not resuscitate" prescription. The client uses the bedpan. The client has been in normal sinus rhythm for 6 hours. Explanation: The nurse should report that the client is using oxygen, has a "do not resuscitate" prescription, can use the bedpan, and is in normal sinus rhythm. Information about having four grandchildren is not needed to help with the client's continuity of care.

A nurse should question an order for a heating pad for a client who has: active bleeding. a reddened abscess. an edematous lower leg. purulent wound drainage.

active bleeding. Explanation: Heat application increases blood flow and therefore is contraindicated in active bleeding. For the same reason, however, applying heat to a reddened abscess, an edematous lower leg, or a wound with purulent drainage promotes healing.

aplastic anemia

failure of blood cell production in the bone marrow

Aminoglycosides adverse effects

ototoxicity and nephrotoxicity

After staying several hours with her 9-year-old daughter who is admitted to the hospital with an asthma attack, the mother leaves to attend to her other children. The child exhibits continued signs and symptoms of respiratory distress. Which finding should lead the nurse to believe the child is experiencing anxiety? not able to get comfortable frequent requests for someone to stay in the room inability to remember her exact address verbalization of a feeling of tightness in her chest

frequent requests for someone to stay in the room Explanation: A 9-year-old child should be able to tolerate being alone. Frequently asking for someone to be in the room indicates a degree of psychological distress that, at this age, suggests anxiety. The inability to get comfortable is more characteristic of a child in pain. Inability to answer questions correctly may reflect a state of anoxia or a lack of knowledge. Tightness in the chest occurs as a result of bronchial spasms.

A primigravid client at 8 weeks' gestation tells the nurse that since having had sexual relations with a new partner 2 weeks ago, she has noticed flu-like symptoms, enlarged lymph nodes, and clusters of vesicles on her vagina. The nurse refers the client to a primary health care provider because the nurse suspects which sexually transmitted infection? gonorrhea Chlamydia trachomatis infection syphilis herpes genitalis

herpes genitalis Explanation: The client is reporting symptoms typically associated with herpes genitalis. Some women have no symptoms of gonorrhea. Others may experience vaginal itching and a thick, purulent vaginal discharge. C. trachomatis infection in women is commonly asymptomatic, but symptoms may include a yellowish discharge and painful urination. The first symptom of syphilis is a painless chancre.

Using the nursing process to make ethical decisions involves following several steps. Which step is the nurse implementing when he or she reflects on the decision-making process and the role it will play in making future decisions?

Evaluating

A nurse explains the guidelines for the unit's seclusion room to a client with an impulse control disorder. Which client statement indicates that the nurse has adequately communicated the client's rights? "Although I don't think I will, I can ask to go into seclusion, but I know you can make me go into the seclusion room." "If I lose my temper in the community room, I'll be locked up in the seclusion room." "When I go into seclusion, I won't be able to see my physician until I calm myself down." "Every time I decide that I won't attend a group meeting, I'll be put in seclusion."

"Although I don't think I will, I can ask to go into seclusion, but I know you can make me go into the seclusion room." Explanation: As a proactive part of the treatment plan, clients may request to go into seclusion to prevent disruptive or destructive actions. In addition, the staff may use seclusion for a client whose behavior is out of control. A client who loses his temper can be guided by staff to modify his behavior. It's possible that this staff intervention can make the seclusion option unnecessary. When a client is placed in seclusion, a physician must perform a clinical assessment within 24 hours. Consequences of a client's decision not to attend a unit group meeting are related to what's written in the treatment plan. The client shouldn't be placed in seclusion unless he's a danger to himself or to others.

The nurse must administer a unit of packed red blood cells to a 4-year-old child. The child's blood type is Type B. When the unit of blood arrives, it is labeled as Type O. What is the appropriate action for the nurse to take?

Begin the administration of the blood as ordered. Explanation: Type O blood is the universal donor and therefore can be administered to a child who is Type B.

A nurse is required to irrigate a client's nasogastric tube, a procedure the nurse has not performed before. What is the most appropriate action by the nurse?

Contact the nurse educator for an in-service and support in performing the skill.

Aplastic Anemia Treatment

bone marrow transplant

The nurse evaluates the client's understanding of nutritional modifications to manage his hypertension. The nurse knows the teaching was successful when the client makes what statement? "A glass of red wine each day will lower my blood pressure." "I should eliminate caffeine from my diet to lower my blood pressure." "If I include less fat in my diet, I'll lower my blood pressure." "Limiting my salt intake to 2 grams per day will improve my blood pressure."

"Limiting my salt intake to 2 grams per day will improve my blood pressure." Explanation: To lower blood pressure, a client should limit daily salt intake to 2 g or less. Alcohol intake is associated with a higher incidence of hypertension, poor compliance with treatment, and refractory hypertension. Chronic, moderate caffeine intake and fat intake do not affect blood pressure.

A parent asks the nurse about the nutritional needs of her toddler. Which response by the nurse would be most appropriate? "Toddlers usually do not have a good appetite." "Toddlers have definite food preferences." "Toddlers usually consume large quantities of milk." "Toddlers are inquisitive, willing to try new foods."

"Toddlers have definite food preferences." Explanation: Toddlers have definite food preferences, typically wanting the same food item for several days in a row. Because toddlers experience a slow and steady growth rate, they usually have a good appetite. Toddlers should consume 2 to 3 servings of milk per day. The majority of their nutrients should come from table foods. Toddlers typically are not interested in trying new foods.

A parent brings a 5-year-old child to a weekend vaccination clinic to prepare for school entry. The nurse notes that the child has not had any vaccinations since 4 months of age. What is the best way for the nurse to determine how to catch-up the child's vaccinations?

Review nationally published immunization guidelines.

Pheochromocytoma

a benign tumor of the adrenal medulla that causes the gland to produce excess epinephrine

An infant is brought to the clinic with a possible diagnosis of Wilms' tumor. When obtaining the health history, which question should the nurse consider a priority to ask the parent? "Does your baby have projectile vomiting after feeding?" "Did the healthcare provider find a mass in the abdominal area?" "Did your baby have a reddish jelly-like bowel movement?" "Does your baby have a pulsating anterior fontanel?"

"Did the healthcare provider find a mass in the abdominal area?" Explanation: The most common sign of Wilms' tumor is a painless, palpable abdominal mass, sometimes accompanied by an increase in abdominal girth. Projectile vomiting after a feeding is found with pyloric stenosis. A reddish, jelly-like bowel movement referred to as "currant jelly" is seen in intussusception. A pulsating anterior fontanel is a normal finding.

The nurse is developing an educational program about prostate cancer. The nurse should provide information about which topic? The Prostate-Specific Antigen (PSA) test is reliable for detecting the presence of prostate cancer. For all men, age 50 and older, the American and Canadian Cancer Societies recommend an annual rectal examination. Men over 50 should have a colonoscopy. Regular sexual activity promotes health of the prostate gland to prevent cancer.

For all men, age 50 and older, the American and Canadian Cancer Societies recommend an annual rectal examination. Explanation: Most cases of prostate cancer are adenocarcinomas. An adenocarcinoma is palpable on rectal examination because it arises from the posterior portion of the gland. Although the PSA is not a perfect screening test, the American Cancer Society and the Canadian Cancer Society recommend an annual rectal examination and blood PSA level for all men age 50 years and older, or starting at age 40 years if the client is of African descent, or if there is family history of prostate cancer. A colonoscopy is performed to diagnose colon cancer, not prostate cancer. Regular sexual activity does not prevent cancer of the prostate.

The nurse determines that a multigravid client in active labor is about to give birth. The nurse has no health care provider immediately available. After calling for assistance, what should the nurse do first? Have the client push with a contraction. Ask the client to take a deep breath and hold it. Prepare a clean area on which to receive the neonate. Lower the head of the bed to a flat position.

Prepare a clean area on which to receive the neonate. Explanation: Because the birth is imminent and no additional help is available, the nurse should immediately prepare a clean area for childbirth. Most agency labor units have emergency birth packs with sterile towels, a bulb syringe, and a cord clamp. Having the client push with a contraction may push the head out quickly, resulting in tearing of the perineum. The nurse should instruct the client to pant or pant/blow to decrease the urge to push. Trying to delay the birth is contraindicated. The head of the bed should be elevated to about 45 degrees, not lowered. The client should assume a position of comfort.

A client has a blockage in the proximal portion of a coronary artery. After learning about treatment options, the client decides to undergo percutaneous transluminal coronary angioplasty (PTCA). During this procedure, the nurse expects to administer an: antibiotic. anticoagulant. antihypertensive. anticonvulsant.

anticoagulant. Explanation: During PTCA, the client receives heparin, an anticoagulant, as well as calcium agonists, nitrates, or both, to reduce coronary artery spasm. Nurses don't routinely give antibiotics during this procedure; however, because the procedure is invasive, the client may receive prophylactic antibiotics to reduce the risk of infection. An antihypertensive may cause hypotension, which should be avoided during the procedure. An anticonvulsant isn't indicated because this procedure doesn't increase the risk of seizures.

A nurse is preparing a client for bronchoscopy. Which of the following instructions is appropriate for the nurse to give to the client? "You will need to stay flat after the procedure." "Don't cough after the procedure." "You will not be able to talk for 4 hours following the procedure." "Don't eat for 6 hours prior to the procedure."

"Don't eat for 6 hours prior to the procedure." Explanation: Bronchoscopy involves visualization of the trachea and bronchial tree. To prevent aspiration of stomach contents into the lungs, the nurse should instruct the client not to eat or drink anything for approximately 6 hours before the procedure. The client will need to be in a semi-Fowler's position after the procedure. It isn't necessary for the client to avoid talking or coughing.

A nurse on the geropsychiatric unit receives a call from the son of a recently discharged client. He reports that his father just got a prescription for memantine to take "on top of his donepezil." The son then asks, "Why does he have to take extra medicines?" What should the nurse should tell the son? "Maybe the donepezil alone is not improving his dementia fast enough or well enough." "Memantine and donepezil are commonly used together to slow the progression of dementia." "Memantine is more effective than donepezil. Your father will be tapered off the donepezil." "Donepezil has a short half-life, and memantine has a long half-life. They work well together."

"Memantine and donepezil are commonly used together to slow the progression of dementia." Explanation: Memantine and donepezil are commonly given together. Neither medicine will improve dementia, but they may slow the progression. Neither medicine is more effective than the other; they act differently in the brain. Both medicines have a half-life of 60 or more hours.

A client with bleeding esophageal varices and cirrhosis of the liver due to alcoholism asks the nurse, "Will I survive and make it out of the hospital? One of my friends died from the same problem." What is the best nursing response to the question? "You'll be okay after the physician gets the bleeding under control." "That's a difficult question to answer, and this must be very frightening for you." "What makes you think you're not going to make it?" "Chronic alcoholism has serious consequences, and you may have the same outcome as your friend."

"That's a difficult question to answer, and this must be very frightening for you." Explanation: This answer is an honest response that acknowledges the client's fears and concerns, yet does not give false reassurance.

The maximum transfusion time for a unit of packed red blood cells (RBCs) is:

4 hours. Explanation: A unit of packed RBCs may be transfused over a period of between 1 and 4 hours. It shouldn't infuse for longer than 4 hours because the risk of contamination and sepsis increases after that time. The nurse should discard any blood not given within this time, or return it to the blood bank, in accordance with facility policy.

A school-age child has just spilled hot liquid on his arm, and a 4-in (10-cm) area on his forearm is severely burned. His mother calls the emergency department. What should the nurse advise the mother to do? Keep the child warm. Cover the burned area with an antibiotic cream. Apply cool water to the burned area. Call 911 to transport the child to the hospital.

Apply cool water to the burned area. Explanation: To prevent further injury to the skin, the mother should apply cool water to the burn site. Doing so causes vasoconstriction, retards further damage to tissues, and decreases fluid loss. Keeping the child warm promotes vasodilation, increases fluid loss, and decreases blood pressure and, thus, circulation to the area. Applying ointment to the burn is contraindicated because it does not allow healing to occur and may need to be removed in the hospital. Only a clean cloth should be used to cover the wound to prevent contamination or decrease pain or chilling. If only the arm is burned, a call to 911 for emergency care is not necessary, but the mother should seek health care services immediately.

Before a routine checkup, an 8-month-old infant sits contentedly on the parent's lap, chewing on a toy. When preparing to examine this infant, what should the nurse plan to do first? Measure the head circumference. Auscultate the heart and lungs. Elicit the pupillary reaction. Weigh the child.

Auscultate the heart and lungs. Explanation: The nurse should first ausculate the heart and lungs because this assessment rarely distresses an infant. Placing a tape measure on the infant's head, shining a light in the eyes, or undressing the infant before weighing may cause distress, making the rest of the examination more difficult.

A client with suspected lymphoma is scheduled for lymphangiography. The nurse should inform the client that this procedure may cause which harmless temporary change? Purplish stools Bluish urine Redness of the upper part of the feet Coldness of the soles

Bluish urine Explanation: Lymphangiography may turn the urine blue temporarily; it doesn't alter stool color. For several months after the procedure, the upper part of the feet may appear blue, not red. Lymphangiography doesn't affect the soles.

A client diagnosed with leukemia is now experiencing neutropenia. Which assessment is a priority for the nurse? Blood glucose Bowel sounds Heart sounds Breath sounds

Breath sounds Explanation: Pneumonia, both viral and fungal, is a common cause of death in clients with neutropenia. Frequent assessment of respiratory rate and breath sounds is required. Although assessing blood pressure, bowel sounds, and heart sounds is important, it will not help detect pneumonia.

A client has soft wrist restraints to prevent the client from pulling out the nasogastric tube. Which nursing intervention should be implemented while the restraints are on the client? Instruct the client not to move while the restraints are in place. Remove the restraints every 4 hours to provide skin care. Secure the restraints to side rails of the bed. Check on the client every 30 minutes while the restraints are on.

Check on the client every 30 minutes while the restraints are on. Explanation: The application of restraints places the client in a vulnerable, confined position. The nurse should check on the client every 30 minutes while restrained to make sure that the client is safe. The client should be able to move while the restraints are in place. The restraints should be removed every 2 hours to provide skin care and exercise the extremities. Restraints should not be secured to the side rails; they should be secured to the movable bed frame so that when the bed is adjusted the restraints will not be pulled too tightly.

During a home visit, the nurse assesses a client who is taking hydrochlorothiazide and lisinopril for the treatment of hypertension. Which finding would indicate the nurse should inform the health care provider of a possible need to change medication therapy? Blood pressure is 132/80 mm Hg. Client has a persistent cough. Potassium level is 4.1 mEq/L. Client is experiencing nocturia.

Client has a persistent cough. Explanation: A persistent cough is a side effect of the ACE inhibitor that may warrant a change to another antihypertensive medication. BP and potassium are within normal limits. The nurse assesses when the drug is taken and changes to an earlier time of administration.

A client is admitted to the acute psychiatric care unit after 2 weeks of increasingly erratic behavior. He has been sleeping poorly, has lost 8 lb (3.6 kg), is poorly groomed, exhibits hyperactivity, and loudly denies the need for hospitalization. Which nursing intervention takes priority for this client? Providing adequate hygiene Administering a sedative as ordered Decreasing environmental stimulation Involving the client in unit activities

Decreasing environmental stimulation Explanation: This client is at increased risk for injuring himself or others. Decreasing environmental stimulation, a measure the nurse may take independently, may reduce the client's hyperactivity. If this nursing intervention is ineffective, the nurse may administer a sedative, as ordered. Providing adequate hygiene is an appropriate nursing intervention but isn't the highest priority. Because the overall goal is to reduce the client's hyperactivity, involving him in unit activities is contraindicated.

A nurse-manager appropriately behaves as an autocrat in which situation? Planning vacation time for staff Directing staff activities if a client experiences a cardiac arrest Evaluating a new medication-administration process Identifying the strengths and weaknesses of a client-education video

Directing staff activities if a client experiences a cardiac arrest Explanation: In a crisis situation, the nurse-manager should take command for the benefit of the client. Planning vacation time and evaluating procedures and client resources require staff input and are actions characteristic of a democratic or participative manager.

A client admitted with bacterial pneumonia develops a fever. Which health care provider order should the nurse implement first? Draw blood cultures from two sites Obtain portable chest X-ray Administer ciprofloxacin 400 mg intravenous piggyback (IVPB) Administer acetaminophen 500 mg by mouth

Draw blood cultures from two sites Explanation: Blood cultures should be obtained before antibiotic administration in order to avoid altering the culture results—this is the priority. Both acetaminophen administration and portable chest x-ray can wait until the blood cultures are obtained and the antibiotics are started.

A nurse is assessing a client who comes to the clinic for care. Which findings in this client suggest bacterial pneumonia? Nonproductive cough and normal temperature Sore throat and abdominal pain Hemoptysis and dysuria Dyspnea and wheezing

Dyspnea and wheezing Explanation: In a client with bacterial pneumonia, retained secretions cause dyspnea, and respiratory tract inflammation causes wheezing. Bacterial pneumonia also produces a productive cough and fever, rather than a nonproductive cough and normal temperature. Sore throat occurs in pharyngitis, not bacterial pneumonia. Abdominal pain is characteristic of a GI disorder, unlike chest pain, which can reflect a respiratory infection such as pneumonia. Hemoptysis and dysuria aren't associated with pneumonia.

While planning the care for a client with paranoid delusions, which of the following will be the nurse's initial goal for the client? Be free of delusions. Participate in unit activities. Meet self-care needs. Establish trust with staff.

Establish trust with staff. Explanation: Establishing a trusting relationship is the priority goal when working with clients with delusions. Only after trust is established can other assessment and goal setting or interventions take place. Being free of delusions, participating in unit activities, and performing tasks independently are important but are not initial priorities.

A client with schizophrenia displays a lack of interest in activities, reduced affect, and poor ability to perform activities of daily living. What term would be used to describe this clustering of symptoms? Positive symptoms Negative symptoms Physiologic symptoms Extrapyramidal symptoms

Explanation: Schizophrenic clients commonly display positive and negative symptoms. Negative symptoms are characterized by the absence of typically displayed emotional responses. Clients with these symptoms tend to respond poorly to medication. Positive symptoms, such as auditory or visual hallucinations, are characterized by enhancement of a sensory modality. These aren't physiologic symptoms of schizophrenia. Extrapyramidal symptoms may be result from long-term antipsychotic drug use in schizophrenics.

A health care provider (HCP) has prescribed valproic acid for a client with bipolar disorder who has achieved limited success with lithium carbonate. Which information should the nurse teach the client about taking valproic acid? Follow-up blood tests are necessary while on this medication. The extended-release tablet can be crushed if necessary for ease of swallowing. Tachycardia and upset stomach are common side effects. Consumption of a moderate amount of alcohol is safe if the medication is taken in the morning.

Follow-up blood tests are necessary while on this medication. Explanation: Valproic acid can cause hepatotoxicity, so regular liver function tests are needed. Other side effects include nausea and drowsiness. Extended-release tablets should not be split or crushed; doing so changes their absorption. Alcohol should never be mixed with this medication. There will be medication in the client's body at all times. Nausea and tachycardia are not common side effects of valproic acid.

An order has been written to discontinue an infusion of total parenteral nutrition (TPN) for a child. What is the priority nursing action? Gradually reduce the rate of the TPN per health care provider order Prepare to infuse a glucose solution after discontinuing the TPN Notify pharmacy to prevent additional preparation of the expensive fluid Prepare to administer insulin for prevention of hyperglycemia

Gradually reduce the rate of the TPN per health care provider order Explanation: Gradually reducing the rate will avoid a sudden loss of the highly concentrated solution of amino acids, glucose and other nutrients, and allow the child's body to adapt. Infusing a glucose solution after discontinuing TPN is not necessary when if infusion rate has been tapered. A glucose solution may need to be infused if discontinuation was sudden to avoid an abrupt drop in blood glucose. Administering insulin after discontinuing TPN would result in hypoglycemia. The pharmacy should be notified so that additional TPN is not prepared, but that is not a priority nursing action.

A client with a history of Addison's disease is experiencing weakness and headache. The vital signs are blood pressure of 100/60 and heart rate of 80. Laboratory values are Na 130, potassium 4.8, and blood glucose 70. Which of the following would the nurse expect to administer? IV total parenteral nutrition and insulin coverage IV normal saline and glucocorticoids IV lactated Ringer's solution and packed cells IV 5% dextrose and dopamine

IV normal saline and glucocorticoids Explanation: The client with Addison's is expected to have hypotension and inadequate corticosteroids. There is no evidence that the client would be anemic. Although the blood pressure may be a little below normal, there is no indication for an inotropic drug such as dopamine to increase perfusion. There is no indication that the client would be weak and hypoglycemic.

Which of the following actions most clearly demonstrates a nurse's commitment to social justice? Lobbying for an expansion of Medicare eligibility and benefits. Ensuring that a hospital client's diet is culturally acceptable. Answering a client's questions about her care clearly and accurately. Documenting nursing care in a timely, honest, and through manner.

Lobbying for an expansion of Medicare eligibility and benefits. Explanation: Social justice is a professional value that encompasses efforts to promote universal access to healthcare, such as the expansion of publicly funded programs like Medicare. Culturally competent care is a reflection of human dignity while answering clients' questions and documenting accurately are expressions of the value of integrity.

For a client with Graves' disease, which nursing intervention promotes comfort? Restricting intake of oral fluids Placing extra blankets on the client's bed Limiting intake of high-carbohydrate foods Maintaining room temperature in the low-normal range

Maintaining room temperature in the low-normal range Explanation: Graves' disease causes signs and symptoms of hypermetabolism, such as heat intolerance, diaphoresis, excessive thirst and appetite, and weight loss. To reduce heat intolerance and diaphoresis, the nurse should keep the client's room temperature in the low-normal range. To replace fluids lost via diaphoresis, the nurse should encourage, not restrict, intake of oral fluids. Placing extra blankets on the bed of a client with heat intolerance would cause discomfort. To provide needed energy and calories, the nurse should encourage the client to eat high-carbohydrate foods.

A mother of a 5-year-old child who was admitted to the hospital has a Protection from Abuse order for the child against his father. A copy of the order is kept on the pediatric medical surgical unit where the child is being treated. The order prohibits the father from having any contact with the child. One night, the father approaches the nurse at the nurses' station, politely but insistently demanding to see his child, and refusing to leave until he does so. What should the nurse do first?

Notify hospital security or the local authorities. Explanation: The Protection from Abuse order legally prohibits the father from seeing the child. In this situation, the nurse should notify hospital security or the local authorities of this attempt to breach the order, and allow them to escort the father out of the building. The father could be jailed or fined if he violates the order. The nurse shouldn't argue or continue explaining to the father that he must leave because it could place the nurse and the child at risk if the father becomes angry or agitated. The nursing coordinator and nurse-manager should be notified of the incident; the nurse's first priority, however, should be contacting security or the authorities.

A school nurse assesses that an 8-year-old child is preoccupied with sexual comments and activities. The nurse is concerned that the child may have been sexually abused at home. What is the nurse's best response to this situation? Notify the local Child Protective Services. Continue to observe the behavior of the child. Discuss the child's behavior with the parents. Advise the child that the inappropriate behavior must stop.

Notify the local Child Protective Services. Explanation: If a nurse suspects abuse of any nature, it must be reported to the appropriate authorities, such as Child Protective Services. The other options are incorrect because they do not demonstrate the required action of the nurse in this situation.

Which of the following is the recommended nursing assessment to confirm placement of the nasogastric (NG) tube into the stomach of a client?

Obtain a chest X-ray and measure the pH of stomach contents. Explanation: A chest X-ray and pH that shows acidity are the only definitive diagnostic tools to confirm placement. The other choices are not best practice. Measuring the tube or using makings do not confirm placement, only approximate distance for insertion.

A client with acute diarrhea is requesting an as-needed medication for loose, watery stools. After reviewing the physician's orders, which medication should the nurse administer? Paregoric 5 ml P.O. Morphine sulfate 1 mg I.V. Chlorpheniramine polistirex and hydrocodone polistirex 25 ml P.O. Alprazolam 0.25 mg P.O.

Paregoric 5 ml P.O. Explanation: Paregoric helps decrease peristalsis and diarrhea caused by muscle spasms of the GI tract. Morphine sulfate, chlorpheniramine polistirex and hydrocodone polistirex, and alprazolam aren't indicated for diarrhea.

When developing the plan of care for a client with aplastic anemia, the nurse should include which goal? Perform activities of daily living without excessive fatigue or dyspnea. Learn how to administer weekly vitamin B12 injections. Correctly demonstrate how to take prescribed anticoagulant drug therapy. Describe self-care behaviors to prevent the transmission to family members.

Perform activities of daily living without excessive fatigue or dyspnea. Explanation: With aplastic anemia, measures to conserve energy and reduce oxygen requirements are essential. Therefore, an appropriate goal would be to strive to perform activities of daily living without excessive fatigue or dyspnea. The client needs adequate vitamin B12 in the diet. However, vitamin B12 injections usually are not required. Anticoagulants are contraindicated in clients with low platelet counts, which often occur in aplastic anemia. Aplastic anemia is not contagious. Thus, measures to prevent transmission are inappropriate.

A 34-year-old client birthed a healthy baby boy 5 days ago. The client is experiencing insomnia and weepiness, lasting for short periods of time each day. What factor/condition does the nurse believe is causing this experience? Postpartum baby blues Postpartum anxiety Postpartum reaction Postpartum depression

Postpartum baby blues Explanation: Postpartum baby blues occurs in up to 70% of women after the birth of a child. It is a mild depression and functioning of the woman is usually not impaired. Postpartum baby blues usually begins on days 3 to 10 postpartum. Postpartum anxiety and postpartum depression do not usually start until at least 3 to 4 weeks postpartum and up to 1 year following the birth of the baby. Postpartum reaction is usually a larger term to include postpartum depression, anxiety, and psychosis.

A nurse is caring for a client with pheochromocytoma. What is the most important intervention by the nurse? Promoting an environment free from emotional distress Avoiding analgesia administration Advising a low-calorie, high-nutrient diet Avoiding parents rooming in because they make the client less dependent on staff

Promoting an environment free from emotional distress Explanation: The child experiencing hyperfunctioning of the adrenal gland, or pheochromocytoma has excessive epinephrine resulting in an accelerated metabolism. Symptoms include hypertension, headaches, hyperglycemia with weight loss, diaphoresis, and hyperventilation. Through provision of a low-stress environment, analgesia as needed, a high-calorie diet, and supportive parents, the child will be able to prepare for surgery to eliminate the tumor causing the hypersecretion of epinephrine.

A client with type 1 diabetes mellitus is conscious but confused, weak, diaphoretic, and is having heart palpitations. What is the nurse's priority action? Administer glucagon intramuscularly (IM) or subcutaneously (subQ) Give an intravenous (IV) bolus of dextrose 50% Provide 15 to 20 grams of a fast-acting oral carbohydrate Inject 10 units of fast-acting insulin subcutaneously (subQ)

Provide 15 to 20 grams of a fast-acting oral carbohydrate Explanation: The client is exhibiting signs of hypoglycemia. Since the client is conscious, the first intervention is to give a fast-acting oral carbohydrate, such as orange juice, hard candy, or honey. If the client becomes unconscious, the nurse would administer IM or subQ glucagon or dextrose 50% IV if access is available. Administering insulin wouldn't be appropriate because the client is experiencing hypoglycemia.

A client continually reports of pain after the administration of an oral analgesic. The physician writes an order for the nurse to administer a placebo to the client the next time the client reports of pain. The doctor states, "Tell the client it is a stronger analgesic." What would be the appropriate action by the nurse? Give the placebo as ordered by the physician. Give the placebo but do not tell the client it is a stronger medication. Refuse to administer the placebo to the client. Consult with the pharmacist to discuss the dosage of the placebo.

Refuse to administer the placebo to the client. Explanation: The nurse should refuse to give the placebo and should also refuse to misinform the client. The nurse has a responsibility to explain the client's medications to the client. The client can then make an informed decision about accepting or refusing the medication. The other options are incorrect because the nurse would be misinforming the client about the medication that is being administered. The client would not be able to provide informed consent.

A nurse in a psychiatric care unit finds that a client with psychosis has become violent and has struck another client in the unit. What action should the nurse take in this case? Do not restrain the client, as it is equivalent to false imprisonment. Restrain the client, as he is harmful to the other clients. Do not restrain the client, as it is equivalent to battery. Inform the physician and complete a comprehensive assessment.

Restrain the client, as he is harmful to the other clients. Explanation: The nurse should restrain the client because he is potentially harmful to other clients in the psychiatric care unit. Restraints should be used as a last resort and their use should be justified. Unnecessary restraining can lead to allegations of false imprisonment and battery; both are not applicable in this case, however. The nurse should inform the physician about the client, but sometimes it may not be logical to wait for orders to restrain a violent client.

A client with a diagnosis of respiratory acidosis is experiencing renal compensation. What function does the kidney perform to assist in restoring acid-base balance? Sequestering free hydrogen ions in the nephrons Returning bicarbonate to the body's circulation Returning acid to the body's circulation Excreting bicarbonate in the urine

Returning bicarbonate to the body's circulation Explanation: The kidney performs two major functions to assist in acid-base balance. The first is to reabsorb and return to the body's circulation any bicarbonate from the urinary filtrate; the second is to excrete acid in the urine. Retaining bicarbonate will counteract an acidotic state. The nephrons do not sequester free hydrogen ions.

A client's pulmonary function tests note an increased residual volume and a decreased vital capacity. Which is the best nursing diagnosis? Risk for activity intolerance Altered health maintenance Impaired physical mobility Risk for fluid volume deficit

Risk for activity intolerance Explanation: These findings indicate respiratory disease; this client will have shortness of breath with exertion because of the trapped air. The client may have impaired physical mobility because of the inability to tolerate activities. Altered health maintenance or risk for fluid volume deficit are not supported by the test results.

The nurse is assisting a client diagnosed with dementia during meal time. Which nursing would best prevent complications? Provide a plate with a variety of foods to give a more complete choice of foods. Serve one course at a time with the appropriate utensil. Keep mealtimes short to prevent loss of attention. Encourage the client to open containers to allow for independence.

Serve one course at a time with the appropriate utensil. Explanation: The client with dementia may be at risk for less than required nutrition. Therefore, food and fluid intake is a priority. One course at a time will prevent the client from becoming overwhelmed. A plate with too many choices, rushing a client with a short meal time, and expecting them to prepare a meal by opening containers may frustrate a client with cognitive deficits.

An emergency room nurse concerned about the emotional health of a child who has been in a motor vehicle accident should collaborate with which disciplines? pharmacy nutritionist social services chaplain

Social services

Which child should the nurse assess as demonstrating behaviors that need further evaluation? Joey, age 2, who refuses to be toilet-trained and talks to himself Adrienne, age 6, who sucks her thumb when tired and has never spent the night with a friend Curt, age 10, who frequently tells his mother that he is going to run away whenever they argue Stephen, age 2, who is indifferent to other children and adults and is mute

Stephen, age 2, who is indifferent to other children and adults and is mute Explanation: Indifference to other people and mutism may be indicators of autism and would require further investigation. A 2-year-old who talks to himself and refuses to cooperate with toilet training is displaying behaviors typical for this age. Occasional thumb sucking and not having spent the night with a friend would be normal at age 6. Threatening to run away when angry is considered within the range of normal behaviors for a 10-year-old child.

A client arrives at a public health clinic worried that she has breast cancer after finding a lump in her breast. When assessing the breast, which assessment finding provides an indication that the lump is more typical of fibrocystic breast disease? One breast is larger than the other. The lump is firm and nonmovable. The lump is round and movable. Nipple retractions are noted.

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

A nurse hears a client state, "I have had it with this marriage. It would be so much easier to just hire someone to kill my husband!" What action should the nurse take? Since the client is still admitted to the hospital, the nurse must hold the statement in confidence. The nurse must start the process to warn the client's husband. An assessment of the client's response to treatment must be performed. The comment must be held in confidence because the client did not report the statement directly to the nurse.

The nurse must start the process to warn the client's husband. Explanation: Confidentiality must be broken if there are credible threats made against another person's safety. Confidentiality does not override the safety of other persons.

A nurse inadvertently gives a client a double dose of an ordered medication. After discovering the error, whom should the nurse notify first? The client The prescriber The pharmacist The risk manager

The prescriber Explanation: After discovering a medication error, the safety of the patient is top priority. The nurse should immediately check the client and observe for any adverse effects which may develop. The first person the nurse needs to notify is the prescriber, followed by the nursing manager (or the nursing supervisor). Then pharmacist and risk manager should also be notified.

When teaching the client to care for an ileal conduit, the nurse instructs the client to empty the appliance frequently. Which outcome indicates that the client is following instructions? The skin around the stoma is red. The urine is a deep yellow. There is no odor present. The seal around the stoma is intact.

The seal around the stoma is intact. Explanation: If the appliance becomes too full, it is likely to pull away from the skin completely or to leak urine onto the skin; thus if the seal is intact, the client is emptying the appliance regularly. The skin around the seal should not be red or irritated, which could indicate a leak. There will likely be an odor from the urine. Deep yellow urine indicates that the client should be increasing fluid intake.

The nurse working with a group of nursing students. What breaches in client care require the nurse to intervene to protect client privacy? Select all that apply. Asking a client's name and date of birth prior to medication administration Attaching client's hospital labels to a laboratory specimen Transporting a client to radiology on the public elevator Keeping the client's door closed during bathing Discussing clients in the cafeteria with other hospital staff

Transporting a client to radiology on the public elevator Discussing clients in the cafeteria with other hospital staff Explanation: Transporting a client to radiology on the public elevator and discussing clients in the cafeteria are examples of breaches in client privacy. Asking a client's name and date of birth prior to medication administration, attaching client's hospital labels to a laboratory specimen, and keeping the client's door closed during bathing will allow the nurse to provide client privacy.

During a routine prenatal examination, a client who is at 32 weeks' gestation becomes dizzy, lightheaded, and pale. After placing the client in a supine position, what is the priority nursing action? Listen to fetal heart tones Take the client's blood pressure Ask the client to breathe deeply Turn the client on her left side

Turn the client on her left side Explanation: As the uterus gets larger, it increases pressure on the inferior vena cava. This inhibits venous return causing dizziness, lightheadedness, and pallor when the client is supine. Turning the client on her left side relieves the pressure on the vena cava and restores venous return. Although they're valuable assessments, listening to fetal heart tone and measuring maternal blood pressure don't alleviate the symptoms. Deep breathing has no effect on venous return, and will not relieve this client's symptoms.

The nurse should utilize SBAR communication (Situation, Background, Assessment, Recommendation) during which of the following clinical situations?

When communicating a change in a client's condition to his or her physician.

A client has just begun treatment with busulfan, 4 mg by mouth daily, for chronic myelogenous leukemia. The client receives busulfan until his white blood cell (WBC) count falls to between 10,000/mm3 and 25,000/mm3. Then the drug is stopped. When should treatment resume? When the WBC falls to 5,000/mm3 When lost hair begins to grow back When the WBC count rises to 50,000/mm3 When the client displays anemia

When the WBC count rises to 50,000/mm3 Explanation: Busulfan treatment should resume when the WBC count rises to 50,000/mm3. Hair growth and anemia aren't appropriate markers for resuming busulfan treatment.

During a bedside shift report, the nurse finds that the client is receiving the wrong IV solution. Which action by the nurse is indicated? Notify the nurse manager Change the solution after shift report is complete Write up an incident report describing the error Report the off-going nurse to the board of nursing

Write up an incident report describing the error Explanation: After starting the correct solution, the nurse should complete an incident report describing the specific error. The healthcare provider should be notified as well as the nurse manager; however, if the manager is not present and the error corrected, notification may take place after the report is complete. The solution should be changed to the correct fluids immediately upon discovery so that the error is not continued. The staff nurse does not report a routine error to the board of nursing; if there is concern for substance abuse or other issue, the nurse or manager may choose to involve the board.

There has been a car accident involving four vehicles on a remote highway. The nearest emergency department is 15 minutes away. Which victim should be transported by helicopter rather than an ambulance to the nearest hospital? a 10-year-old with a simple fracture of the femur, who is crying and cannot find his parents a middle-aged female with cold, clammy skin; heart rate of 120 bpm; and is unconscious middle-aged male with severe asthma, heart rate of 120 bpm, and is having difficulty breathing an older adult with severe headache, but conscious

a middle-aged female with cold, clammy skin; heart rate of 120 bpm; and is unconscious Explanation: The middle-aged female is likely in shock; she is classified as a triage level I, requiring immediate care. The child with moderate trauma is classified as triage level III, urgent, and can be treated within 30 min. The man with asthma and the man with the severe headache are classified as emergent, triage level II, and can be transported by ambulance and reach the hospital within 15 min.

A client with diabetes has been diagnosed with hypertension, and the health care provider (HCP) has prescribed atenolol, a beta-blocker. When performing discharge teaching, it is important for the nurse to emphasize that the addition of atenolol can cause: a decrease in the hypoglycemic effects of insulin. an increase in the hypoglycemic effects of insulin. an increase in the incidence of ketoacidosis. a decrease in the incidence of ketoacidosis.

an increase in the hypoglycemic effects of insulin. Explanation: There is a direct interaction between the effects of insulin and those of beta blockers. The nurse must be aware that there is a potential for increased hypoglycemic effects of insulin when a beta blocker is added to the client's medication regimen. The client's blood sugar should be monitored. Ketoacidosis occurs in hyperglycemia. Although a decrease in the incidence of ketoacidosis could occur when a beta blocker is added, the direct result is an increase in the hypoglycemic effect of insulin.

When assessing a toddler's growth and development, the nurse understands that a child in this age group displays behavior that fosters which developmental task? initiative autonomy trust industry

autonomy Explanation: The toddler's developmental task is to achieve autonomy while overcoming shame and doubt. Developing initiative is the preschooler's task whereas developing trust is the infant's task. Developing industry is the task of the school-age child.

A client with autoimmune thrombocytopenia and a platelet count of 8,000/μl develops epistaxis and melena. Treatment with corticosteroids and immunoglobulins has been unsuccessful, and the physician recommends a splenectomy. The client states, "I don't need surgery — this will go away on its own." In considering her response to the client, the nurse must depend on the ethical principle of:

autonomy. Explanation: Autonomy is the right of the individual to make his own decisions. In this case, the client is capable of making his own decision and the nurse should support his autonomy. Beneficence, promoting and doing good, and justice (being fair) aren't the principles that directly relate to the situation. Advocacy is the nurse's role in supporting the principle of autonomy.

WBC: 6,500 Platelet count: 40,000 HCT: 41.2% The nurse reviews the laboratory report of a child with leukemia (see exhibit). What does the nurse determine is the priority problem for this client? activity intolerance bleeding impaired tissue perfusion risk for infection

bleeding Explanation: A normal platelet count is 150,000/μL to 400,000/μL (150 to 400 X 109/L). A platelet count of 40,000/μL (40 X 109/L) is low and puts the child at risk for injury, bruising, and bleeding. A hematocrit count of 41.2% (0.412) is normal; therefore, the child will have adequate oxygenation and tissue perfusion. The white count of 6,500 mm3 (6.5 X 109/L) is normal; therefore, the child has no increase in risk for infection.

Benztropine is used to treat the extrapyramidal effects induced by antipsychotics. This drug exerts its effect by: decreasing the anxiety causing muscle rigidity. blocking cholinergic activity in the central nervous system (CNS). increasing the level of acetylcholine in the CNS. increasing norepinephrine in the CNS.

blocking cholinergic activity in the central nervous system (CNS). Explanation: Benztropine blocks cholinergic activity in the CNS. Anxiety doesn't cause extrapyramidal effects. Overactivity of acetylcholine and lower levels of dopamine are the causes of extrapyramidal effects. Benztropine doesn't increase norepinephrine in the CNS.

When performing cardiopulmonary resuscitation on a 7-month-old infant, which location would the nurse use to evaluate the presence of a pulse? carotid artery femoral artery brachial artery radial artery

brachial artery Explanation: The brachial artery is the best location for evaluating the pulse of an infant younger than age 1. A child of this age has a very short and often fat neck, so the carotid artery is inaccessible. The femoral artery is usually inaccessible because of clothing and diapers. The radial artery may not be palpable if cardiac output is low, even if there is a heartbeat.

The nurse should instruct the client to avoid taking which drug while taking metoclopramide hydrochloride? antacids antihypertensives anticoagulants central nervous system depressants

central nervous system depressants Explanation: Metoclopramide hydrochloride can cause sedation. Alcohol and other central nervous system depressants add to this sedation. A client who is taking this drug should be cautioned to avoid driving or performing other hazardous activities for a few hours after taking the drug. Clients may take antacids, antihypertensives, and anticoagulants while on metoclopramide.

A caregiver brings a 19-month-old client to the clinic for a regular checkup. When palpating the client's fontanels, what should the nurse expect to find? closed anterior fontanel and open posterior fontanel open anterior fontanel and closed posterior fontanel closed anterior and posterior fontanels open anterior and posterior fontanels

closed anterior and posterior fontanels Explanation: By age 18 months, the anterior and posterior fontanels should be closed. The diamond-shaped anterior fontanel normally closes between ages 9 and 18 months. The triangular posterior fontanel normally closes between ages 2 and 3 months.

The nurse is performing a respiratory assessment on a client who has a pleural effusion. The nurse would expect that the client has: decreased breath sounds on the affected side. normal bronchial breath sounds. hyperresonance on percussion. wheezing on auscultation.

decreased breath sounds on the affected side. Explanation: A pleural effusion is a collection of fluid between the pleural layers of the lung. The effusion decreases chest wall movement on the affected side. The nurse should expect the breath sounds to be decreased or diminished over the affected area. Because of the presence of fluid, percussion would elicit dullness, not hyperresonance. The nurse should not expect to hear wheezing on auscultation.

What therapeutic outcome does the nurse expect for a client who has received a premedication of glycopyrrolate? increased heart rate increased respiratory rate decreased secretions decreased amnesia

decreased secretions Explanation: Glycopyrrolate is an anticholinergic given for its ability to reduce oral and respiratory secretions before general anesthesia. Increased heart rate and respiratory rate would be adverse effects of the drug. Amnesia should not be an effect of the drug.

When assessing an elderly client, the nurse expects to find various aging-related physiologic changes. These changes include: increased coronary artery blood flow. decreased posterior thoracic curve. decreased peripheral resistance. delayed gastric emptying.

delayed gastric emptying. Explanation: Aging-related physiologic changes include delayed gastric emptying, decreased coronary artery blood flow, an increased posterior thoracic curve, and increased peripheral resistance.

Cellulitis

diffuse, acute infection of the skin marked by local heat, redness, pain, and swelling

A nurse is caring for a client who underwent a subtotal gastrectomy. To manage dumping syndrome, the nurse should advise the client to: restrict fluid intake to 1 qt (1,000 ml)/day. drink liquids only with meals. don't drink liquids 2 hours before meals. drink liquids only between meals.

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

The emergency department nurse is assessing a client with reports of right-sided dull, abdominal and flank pain, nausea, and vomiting. The client's temperature is 101.2° F (38.4° C), pain is 10 out of 10, and rebound tenderness is exhibited. The healthcare provider orders: VS q 30 min, CBC, morphine 2 mg IM q 4 hours, regular diet, and enemas until clear. Which orders should the nurse question? Select all that apply. vital signs enemas until clear CBC morphine regular diet

enemas until clear regular diet Explanation: The nurse should question the enema order, as enema could cause the appendix to burst. If the condition is an appendicitis, the client should be NPO for possible surgery so a regular diet should not be given to the client. It is important that the client does not take laxatives or enemas to relieve constipation as these medications could cause the appendix to burst.

Because of an outbreak of influenza among the nursing staff, the hospital is very short staffed. The nurse manager prioritizes client needs on the surgical unit by which strategy? rescheduling surgeries ensuring that clients receive medications but omitting full bathing when possible allowing all medications to be given 2 hours late asking unlicensed assistive personnel (UAPs) to assist in administering analgesics

ensuring that clients receive medications but omitting full bathing when possible Explanation: Daily bathing is not required to meet standards of care. Rescheduling surgeries is not a strategy for meeting nursing care needs of clients. Medications are required to be given as prescribed to maintain standards of care and efficacy of the medication. UAPs are not licensed to administer analgesics.

A client with chronic sinusitis comes to the outpatient department complaining of headache, malaise, and a nonproductive cough. When examining the client's paranasal sinuses, the nurse detects tenderness. To evaluate this finding further, the nurse should transilluminate the: frontal sinuses only. sphenoidal sinuses only. frontal and maxillary sinuses. sphenoidal and ethmoidal sinuses.

frontal and maxillary sinuses. Explanation: After detecting tenderness of the paranasal sinuses, the nurse should transilluminate both the frontal and maxillary sinuses; lack of illumination may indicate sinus congestion and pus accumulation. The sphenoidal and ethmoidal sinuses can't be transilluminated because of their location.

The administration of medications during infancy is often necessary. The nurse needs to be concerned about the metabolism of these drugs. What concern regarding metabolism should the nurse consider when administering medications to an infant? decreased glomerular filtration reduced protein-binding ability increased tubular secretion inefficient liver function

inefficient liver function Explanation: Inefficient liver function will most likely decrease drug metabolism during infancy. As the liver matures during the first year of life, drug metabolism improves. Decreased glomerular filtration and increased tubular secretion may affect drug excretion rather than metabolism; reduced protein-binding ability may affect drug distribution but not metabolism.

A client has urge incontinence. When obtaining the health history, the nurse should ask the client about which factors that could precipitate incontinence? inability to empty the bladder loss of urine when coughing involuntary urination frequent dribbling of urine

involuntary urination Explanation: A characteristic of urge incontinence is involuntary urination with little or no warning. The inability to empty the bladder is urine retention. Loss of urine when coughing occurs with stress incontinence. Frequent dribbling of urine is common in male clients after some types of prostate surgery or may occur in women after the development of a vesicovaginal or urethrovaginal fistula.

Pheochromocytoma treatment

irreversible alpha-agonists (e.g. phenoxybenzamine) followed by beta-blockers prior to tumor resection (must be alpha then beta to avoid hypertensive crisis)

To assess the development of a 1-month-old, the nurse asks the parent if the infant is able to demonstrate which skill? smile and laugh out loud roll from back to side hold a rattle briefly lift head from prone position

lift head from prone position Explanation: A 1-month-old infant is usually able to lift the head from a prone position. The full-term infant with no complications has probably been able to do this since birth. Smiling and laughing is expected behavior at 2 to 3 months. Rolling from back to side and holding a rattle are characteristics of a 4-month-old.

The nurse is observing an unlicensed assistive personnel (UAP) give care to a client after gynecologic surgery. The nurse should intervene if the UAP: ambulates the client. massages the client's legs. has client wear elasticized stockings. assists the client perform range-of-motion exercises in bed.

massages the client's legs. Explanation: Massaging the legs postoperatively is contraindicated because it may dislodge small clots of blood, if present, and cause even more serious problems. Ambulation, elasticized stockings, and moving the legs in bed all help reduce the risk of thrombophlebitis.

A nurse is assessing a client with nephrotic syndrome. The nurse should assess the client for which condition? hematuria massive proteinuria increased serum albumin level weight loss

massive proteinuria Explanation: Nephrotic syndrome is characterized by massive proteinuria caused by increased glomerular membrane permeability. Other symptoms include peripheral edema, hyperlipidemia, and hypoalbuminemia. Because of the edema, clients retain fluid and may gain weight. Hematuria is not a symptom related to nephrotic syndrome.

A child with cystic fibrosis is receiving gentamicin. Which nursing action is most important? monitoring intake and output obtaining daily weights monitoring the client for indications of constipation obtaining stool samples for hemoccult testing

monitoring intake and output Explanation: Monitoring intake and output is the most important nursing action when administering an aminoglycoside, such as gentamicin, because a decrease in output is an early sign of renal damage. Daily weight monitoring is not indicated when the client is receiving an aminoglycoside. Constipation and bleeding are not adverse effects of aminoglycosides.

A nurse is providing postprocedure care for a client who underwent percutaneous lithotripsy. In this procedure, an ultrasonic probe inserted through a nephrostomy tube into the renal pelvis generates ultra-high-frequency sound waves to shatter renal calculi. The nurse should instruct the client to: limit oral fluid intake for 1 to 2 weeks. report the presence of fine, sandlike particles through the nephrostomy tube. notify the physician about cloudy or foul-smelling urine. report bright pink urine within 24 hours after the procedure.

notify the physician about cloudy or foul-smelling urine. Explanation: The nurse should instruct the client to report the presence of foul-smelling or cloudy urine to the physician. Unless contraindicated, the client should be instructed to drink large quantities of fluid each day to flush the kidneys. Sandlike debris is normal because of residual stone products. Hematuria is common after lithotripsy.

After gastric resection surgery, which signs alert the nurse to the development of a leaking anastomosis? pain, fever, and abdominal rigidity diarrhea with fat in the stool palpitations, pallor, and diaphoresis after eating feelings of fullness and nausea after eating

pain, fever, and abdominal rigidity Explanation: Pain, fever, and abdominal rigidity are signs and symptoms of inflammation or peritonitis caused by the leaking anastomosis. Diarrhea with fat in the stool is steatorrhea and is not present in peritonitis. Palpitations, pallor, and diaphoresis after eating are vasomotor symptoms of gastric retention. Feelings of fullness and nausea after eating are not present in peritonitis.

A school-age client is admitted to the facility with a diagnosis of acute lymphocytic leukemia (ALL). The nurse formulates a nursing diagnosis of Risk for infection. What is the most effective way for the nurse to reduce the client's risk of infection? implementing reverse isolation maintaining standard precautions requiring staff and visitors to wear masks practicing thorough hand washing

practicing thorough hand washing Explanation: Both ALL and its treatment cause immunosuppression. Therefore, thorough hand washing is the single most effective way to prevent infection in an immunosuppressed client. Reverse isolation doesn't significantly reduce the incidence of infection in immunosuppressed clients; furthermore, isolation may cause psychological stress. Standard precautions are intended mainly to protect caregivers from contact with infectious matter, not to reduce the client's risk of infection. Staff and others needn't wear masks when visiting because most infections are transmitted by direct contact. Instead of relying on masks and other barrier methods, the nurse should keep persons with known infections out of the client's room.

A 32-year-old multigravida returns to the clinic for a routine prenatal visit at 36 weeks' gestation. The assessments during this visit include: blood pressure 140/90 mm Hg; pulse 80 beats/min; respiratory rate 16 breaths/min. What further information should the nurse obtain to determine if this client is becoming preeclamptic? headaches blood glucose level proteinuria peripheral edema

proteinuria Explanation: The two major defining characteristics of preeclampsia are blood pressure elevation of 140/90 mm Hg or greater and proteinuria. Because the client's blood pressure meets the gestational hypertension criteria, the next nursing responsibility is to determine if she has protein in her urine. If she does not, then she may be having transient hypertension. The peripheral edema is within normal limits for someone at this gestational age, particularly because it is in the lower extremities. While, the preeclamptic client may significant edema in the face and hands, edema can be caused by other factors and is not part of the diagnostic criteria. Headaches are significant in pregnancy-induced hypertension but may have other etiologies. The client's blood glucose level has no bearing on a preeclampsia diagnosis.

A health care provider prescribes gentamicin for a client with peritonitis. The client has preexisting impaired vision and hearing. The nurse should: give the drug as prescribed. question whether the drug is appropriate for treatment of peritonitis. question the prescription because gentamicin could cause further hearing impairment. question the prescription because gentamicin could cause further visual impairment.

question the prescription because gentamicin could cause further hearing impairment. Explanation: Aminoglycoside antibiotics can cause damage to the eighth cranial nerve and result in ototoxicity. If the client is already hearing impaired, the nurse should question the prescription with the health care provider, who may determine that prescribing another antibiotic would be safer. Gentamicin is an appropriate antibiotic for gram-negative infections such as peritonitis. Gentamicin does not cause visual impairment.

A client with acute pulmonary edema has been taking an angiotensin-converting enzyme (ACE) inhibitor. The nurse explains that this medication has been ordered to: promote diuresis. increase cardiac output. decrease contractility. reduce blood pressure.

reduce blood pressure. Explanation: ACE inhibitors are given to reduce blood pressure by inhibiting aldosterone production, which in turn decreases sodium and water reabsorption. ACE inhibitors also reduce production of angiotensin II, a potent vasoconstrictor. Diuretics are given to increase urine production. Vasodilators increase cardiac output. Negative inotropic agents decrease contractility.

A charge nurse is preparing client care assignments for the next shift. A client who underwent femoral-popliteal bypass surgery is scheduled to return from the postanesthesia care unit. Which staff member would best receive this client? registered nurse (RN) with 2 years of experience registered practical nurse/licensed practical or vocational nurse with 5 years of experience registered nurse who just completed orientation charge nurse with 10 years of experience

registered nurse (RN) with 2 years of experience Explanation: Because this client requires frequent neurovascular assessments, an RN with experience would best receive the client. A registered practical nurse/licensed practical or vocational nurse, although experienced and capable of collecting data, would not be receiving the client and report from the operating room as skilled assessments are necessary. The registered nurse who just finished orientation would best assist the registered nurse and be assigned a more stable client at this time. The charge nurse needs to be available to direct the care of other clients and management of unit.

When caring for the client who is receiving an aminoglycoside antibiotic, the nurse should monitor which laboratory value? serum sodium serum potassium serum creatinine serum calcium

serum creatinine Explanation: It is essential to monitor serum creatinine in the client receiving an aminoglycoside antibiotic because of the potential of this type of drug to cause acute tubular necrosis. Aminoglycoside antibiotics do not affect serum sodium, potassium, or calcium levels.

A client believes she is experiencing premenstrual syndrome (PMS). The nurse should next ask the client about what symptom? menstrual cycle irregularity with increased menstrual flow mood swings immediately after menses tension and fatigue before menses and through the second day of the menstrual cycle midcycle spotting and abdominal pain at the time of ovulation

tension and fatigue before menses and through the second day of the menstrual cycle Explanation: The timing of symptoms is important to the diagnosis of PMS. The client should keep a 3-month log of symptoms and menses. With PMS, the symptoms begin 3 to 7 days before menses and resolve 1 to 2 days after the menstrual cycle has started. Menstrual cycle irregularity and mood swings after menses are not related to PMS, and other causes should be investigated. Midcycle spotting and pain are related to ovulation.

A client is admitted for an overdose of amphetamines. When assessing this client, the nurse should expect to see: tension and irritability. slow pulse. hypotension. constipation.

tension and irritability. Explanation: Amphetamines are a nervous system stimulant that are subject to abuse because of their ability to produce wakefulness and euphoria. An overdose increases tension and irritability. Amphetamines stimulate norepinephrine, which increases the heart rate and blood flow. Diarrhea, not constipation, is a common adverse effect.

A client is having elective surgery under general anesthesia. Who is responsible for obtaining the informed consent?

the surgeon Explanation: It is the role of the surgeon or the person performing the procedure to obtain the informed consent. This consists of informing the client about the procedure, the risks of treatment, the side effects, other types of treatments available, and the effects without the procedure. Nurses, anesthesiologists, and social workers do not obtain informed consent.

A client is hospitalized with fractures of the right femur and right humerus sustained in a motorcycle accident. Police suspect the client was intoxicated at the time of the accident. Laboratory tests reveal a blood alcohol level of 0.2% (200 mg/dl)(43.2 mmol/dL). The client later admits to drinking heavily for years. During hospitalization, the client periodically complains of tingling and numbness in his hands and feet. The nurse realizes that these symptoms probably result from: acetate accumulation. thiamine deficiency. triglyceride buildup. a below-normal serum potassium level.

thiamine deficiency. Explanation: Numbness and tingling in the hands and feet are symptoms of peripheral polyneuritis, which results from inadequate intake of vitamin B1 (thiamine) secondary to prolonged and excessive alcohol intake. Treatment includes reducing alcohol intake, correcting nutritional deficiencies through diet and vitamin supplements, and preventing such residual disabilities as foot and wrist drop. Acetate accumulation, triglyceride buildup, and a below-normal serum potassium level are unrelated to the client's symptoms.

A daughter is concerned that her mother is in denial because when they discuss the diagnosis of breast cancer, the mother says that breast cancer is not that serious and then changes the subject. The nurse can tell the daughter that denial can be a healthy defense mechanism if it is used when? to permit her mother to seek unconventional treatments when making decisions about her care alone and not in combination with other defense mechanisms to allow her mother to continue in her role as a mother

to allow her mother to continue in her role as a mother Explanation: Denial is a defense mechanism used to shut out a situation that is too frightening or threatening to tolerate. In this case, denial allows the client to vacillate between acceptance of the illness and its treatment and denial of the actual or potential seriousness of the disease. This may allow the client more psychological freedom to maintain her current roles in the family and elsewhere. Denial can be harmful if the client ignores standard medical therapies in favor of unconventional treatments. Denial is not helpful when it interferes with a client's willingness to seek treatment or make decisions about care. Using any one defense mechanism exclusively usually reflects maladaptive coping. Other defense mechanisms that may be used include regression, humor, and sublimation.

The charge nurse on a hematology/oncology unit is reviewing the policy for using abbreviations with the staff. The charge nurse should emphasize which information about why dangerous abbreviations need to be eliminated? Select all that apply. to ensure efficient and accurate communication to prevent medication errors to ensure client safety to make it easier for clients to understand the medication prescription to make data entry into a computerized health record easier

to ensure efficient and accurate communication to prevent medication errors to ensure client safety Explanation: Abbreviations can be misinterpreted and all health care professionals should avoid the use of easily misunderstood abbreviations. The purpose of avoiding abbreviations is not to make it easier for clients to understand the medication prescriptions or to make data entry easier.

The nurse explains to the mother of a child receiving digoxin that the primary reason for giving this drug is: to relax the walls of the heart's arteries. to improve the strength of the heartbeat. to prevent irregularities in ventricular contractions. to decrease inflammation of the heart wall.

to improve the strength of the heartbeat. Explanation: Digitalis preparations such as digoxin act to improve and strengthen the heartbeat. They increase cardiac output by increasing the strength of the heart's contraction and decreasing the heart rate. Digoxin does not relax the heart's arterial walls, prevent irregularities in ventricular contractions, or decrease inflammation of the heart wall.

A client with Raynaud's phenomenon is considering having a sympathectomy. What information should the nurse give the client about this surgery? A sympathectomy is performed: in the early stages of the disease to prevent further circulatory disturbances. when the disease is controlled by medication. when the client is unable to control stress-related vasospasm. when other treatment alternatives have not been effective.

when other treatment alternatives have not been effective. Explanation: Sympathectomy is scheduled only after other treatment alternatives have been explored and have failed. Medication and stress management are beneficial strategies to prevent advancement of the disease process. If the disease is controlled by medication, there is no reason for surgery.

A group has asked the nurse to discuss how lifestyle factors affect heart health. Which of the following statements by members of the group would indicate that the teaching was effective? Select all that apply. "Chewing tobacco rather than smoking it lessens the negative effect on the heart." "Gradually increasing my exercise levels will help enhance circulation through the heart." "If I change my diet and lessen my intake of saturated fats and trans fatty acids, this may decrease my cholesterol levels." "As a borderline diabetic, if I lose weight and lessen my intake of simple carbohydrates, this should benefit my heart." "Walking is excellent exercise to strengthen my heart."

"Gradually increasing my exercise levels will help enhance circulation through the heart." "If I change my diet and lessen my intake of saturated fats and trans fatty acids, this may decrease my cholesterol levels." "As a borderline diabetic, if I lose weight and lessen my intake of simple carbohydrates, this should benefit my heart." "Walking is excellent exercise to strengthen my heart." Explanation: Increasing exercise levels, diet changes, losing weight, and walking are all important elements of heart health. Chewing tobacco is still harmful to the body.

The nurse teaches the parents of a 2-year-old child how to instill antibiotic eardrops. Which statement about the direction to pull on the earlobe indicates that the child's father has understood the teaching? "I should pull the earlobe up and forward." "I should pull the earlobe up and backward." "I should pull the earlobe down and outward." "I should pull the earlobe down and backward."

"I should pull the earlobe down and backward." Explanation: For children aged 3 years and younger, the external auditory canal is straightened by gently pulling the earlobe down and backward. For an older child or an adult, the earlobe is gently pulled up and backward.

A client with constipation takes psyllium granules as one rounded teaspoon mixed in fruit juice three times daily. Which of the following statements by the client indicates that further teaching is required? "I will mix this medication with at least 8 oz (240 mL) of water or juice immediately before taking it." "I will check for soft to semi-liquid stools being passed within 1 to 3 days of taking this medication." "I will drink at least 6 to 10 glasses of water or juice when taking this laxative." "I will need to take the medication for 4 weeks."

"I will need to take the medication for 4 weeks." Explanation: Psyllium is a bulk-forming laxative used to treat constipation. It absorbs liquid in the intestines, swells, and forms a bulky, easy-to-pass stool. Psyllium comes in the following forms: powder, granules, capsule, liquid, and wafer to take by mouth. It is usually taken 1 to 3 times daily. It should not be taken for more than 1 week unless advised. Clients cannot continue this drug for 4 weeks. Regular use may prevent normal bowel function, cause adverse drug reactions, and delay treatment for conditions that cause constipation. The powder or granules must be mixed with 8 oz (240 mL) of pleasant tasting liquid such as fruit juice right before use. Therapeutic effects (soft to semi-liquid stools) occur in approximately 1 to 3 days with bulk-forming laxatives like psyllium and stool softeners, while effects (liquid to semi-liquid stools) occur in 1 to 3 hours with saline cathartics and castor oil. These granules absorb water rapidly in the intestines and solidify into a gelatinous mass, so the client should drink 6 to 10 glasses of water or juice daily.

The health care provider (HCP) has prescribed a sterile urine specimen for a 3-year-old boy with a history of recurrent urinary tract infections. The family is upset because the last time the child was catheterized, the procedure was very painful and traumatic. What is the nurse's best response? "I'll request a prescription for a sedative to help him relax." "I can't do anything to reduce the pain, but you can hold him during the procedure." "I'll get a prescription for a numbing lubricant to make the procedure more comfortable." "I can apply a topical anesthetic 20 minutes before placing the catheter."

"I'll get a prescription for a numbing lubricant to make the procedure more comfortable." Explanation: Two percent lidocaine lubricants have been found to significantly reduce the pain of urinary catheter insertion in children. If the unit does not have a standing protocol to use the lubricant, the nurse should request a prescription. A sedative would carry with it additional risks that could be avoided with the use of other methods to reduce pain. The parents should be encouraged to hold the child in addition to other pain relief methods. Frequent urination would make the use of topical anesthetics that must be left in place for a period of time impractical.

The client who experiences residual arm pain after a fall has been referred to an acupuncture treatment center. What is the nurse's best response to the client's question, "How is acupuncture supposed to help me?"

"Pain is relieved by releasing endorphins, which balance the flow of energy." Explanation: The main goal of acupuncture is self-healing and the treatment relieves pain by releasing endorphins, the body's natural pain-killing chemicals. Furthermore, it can also affect serotonin release in the brain, which can enhance a person's mood. The statements about acupuncture being better than pain medication, or acupuncture is used when other treatment does not help, or focusing solely on a person's chronic pain are negative and do not provide the client with hope or faith in future or prior treatment received.

A client in early labor is connected to an external fetal monitor. The physician hasn't noted any restrictions on her chart. The client tells the nurse that she needs to go to the bathroom frequently and that her partner can help her. How should the nurse respond? "Because you're connected to the monitor, you can't get out of bed. You'll need to use the bedpan." "I'll show your partner how to disconnect the transducer so you can walk to the bathroom." "Please press the call button. I'll disconnect you from the monitor so you can get out of bed." "I'll insert a urinary catheter; then you won't need to get out of bed."

"Please press the call button. I'll disconnect you from the monitor so you can get out of bed." Explanation: The nurse should instruct the client to use the call button when she needs to use the bathroom. The nurse will need to disconnect the fetal monitor and mark the strip to indicate the activity. If the client's partner disconnects and reconnects the monitor, the nurse can't determine if the readings are accurate. Inserting a catheter without a physician's order or not allowing the client to get out of bed isn't acceptable nursing practice.

A client with chronic pancreatitis is discharged with a prescription for pancrelipase. Which instruction must the nurse include when providing discharge instructions regarding this medication? "Store this medication in the refrigerator." "Take this medication before going to bed." "Dissolve the medication in a full glass of water." "Swallow this medication whole. Do not chew it."

"Swallow this medication whole. Do not chew it." Explanation: Digestion begins in the mouth. Pancrelipase needs to be swallowed whole in order to reach the stomach before digestion begins and cannot be crushed, chewed, or held in the mouth. In order for the medication to be effective, it must be taken before meals or snacks. The medication needs to be stored in a dry place but does not require refrigeration.

A client in a long-term care facility signed a form requesting not to be resuscitated. The client develops pneumonia, and the client's health rapidly deteriorates. The client is no longer competent, but the family wants everything possible done for the client. When the family asks the nurse what will be done, what is the best response by the nurse? "We will resuscitate the client only if there is a respiratory arrest." "We will continue to use antibiotics to treat the pneumonia." "We will honor the family's wishes because the client cannot make decisions." "We will not provide any pharmacologic intervention at this time."

"We will continue to use antibiotics to treat the pneumonia." Explanation: The client has signed a document indicating a wish not to be resuscitated. Treating the client's pneumonia with antibiotics would not be considered a resuscitation measure. The other options do not respect the client's right to choice.

A young client is diagnosed with enuresis. Tests revealed there is no medical cause attributed to the client's bed wetting. The client's mother is upset and is blaming the client's father, from whom she has recently separated, for the problem. "It is all his father's fault!" the client's mother declares to the nurse. What would be the nurse's best response? "These things are generally no one's fault." "You seem really upset by this situation." "Why do you say that, exactly?" "Why are you blaming your child's father?"

"You seem really upset by this situation." Explanation: Hearing her child's diagnosis has led the client's mother to express her emotions and to project blame. Acknowledging her feelings would build further trust and encourage her to discuss her thoughts and feelings. Asking her to pinpoint blame or denying her feelings will not build the helping relationship during this time of perceived distress.

The nurse is administering penicillian V potasium to a child with cellulitis. The child weighs 27.5 lb (12.5 kg). The order reads penicillian V potasium 40 mg/kg/day po divided every six hours. How many milligrams of antibiotics should this child receive with each dose? Record your answer using a whole number.

125

A health care provider prescribes intravenous normal saline solution to be infused at a rate of 150 ml/hour for a client. How many liter(s) of solution will the client receive during an 8-hour shift? Record your answer using one decimal place (For example: 6.2).

1.2

During morning assessment, a nurse assesses four clients. Which client is the priority for follow up? An 84-year-old client with heart failure who's on telemetry and 2 L/minute of oxygen. A 42-year-old client who has left lower lobe pneumonia and an I.V. line. A 48-year-old client with chronic obstructive pulmonary disease with occasional atrial fibrillation. A 73-year-old client who has pneumonia with coarse crackles, is receiving 2 L/minute of oxygen, and has an I.V. line.

A 73-year-old client who has pneumonia with coarse crackles, is receiving 2 L/minute of oxygen, and has an I.V. line. Explanation: The 73-year-old client with pneumonia should be the nurse's priority because of the oxygenation complications and the audible crackles that may result from fluid overload from the I.V. line. The 42-year-old client is younger and more mobile than the others. The 84-year-old client doesn't have pressing needs at this time. The nurse should evaluate the 48-year-old client if he goes into atrial fibrillation, but he isn't a priority at this time.

chorionic carcinoma

A malignant, fast-growing tumor that develops from trophoblastic cells (cells that help an embryo attach to the uterus and help form the placenta). Almost all chorionic carcinomas form in the uterus after fertilization of an egg by a sperm, but a small number form in a testis or an ovary.

A client receiving 5-fluorouracil is experiencing nausea and vomiting. Which is the nurse's best course of action? Hold the medication, as this is a dose-limiting side effect Assess for dry mucous membranes and poor skin turgor Administer odansetron prior to administering the 5-fluorouracil Assess for elevated temperature

Administer odansetron prior to administering the 5-fluorouracil Explanation: Fluorouracil, an antimetabolite antineoplastic medication, may cause nausea, vomiting, diarrhea, bone marrow suppression, and stomatitis. Premedication with an antiemetic medication such as odansetron will prevent nausea and vomiting during treatment.

During a routine follow up clinic visit, the client with stable human immunodeficiency virus/acquired immunodeficiency disorder (HIV/AIDS) stated, "I just don't eat much anymore." What significant information is most important for the nurse to obtain during the assessment? Obtain information about the time of day the client eats and about meal preparation. Identify if the client eats alone or has someone to eat with on a regular basis. Address personal and environmental factors that interfere with the client's food intake. Determine the specific meal plans the client was instructed to eat when first diagnosed.

Address personal and environmental factors that interfere with the client's food intake. Explanation: By assessing the personal and environmental factors that interfere with the client's eating, the nurse can develop interventions to address specific problems. The other information such as eating times, preparing meals, following specific meal plans, sharing a meal with others or eating alone can reflect the client's personal preferences, the most significant issues to assess are the client's personal problems and environmental barriers.

The nurse is working as charge on a medical-surgical unit. The nurse is providing orientation for a newly hired RN. Which action by the new RN requires immediate attention? Teaching a newly admitted burn client about the use of pressure garments Discussing the use of herpes zoster vaccine with a young adult Administering oral tetracycline with milk to a client with cellulitis Obtaining an anaerobic culture specimen from a superficial burn wound

Administering oral tetracycline with milk to a client with cellulitis Explanation: Dairy products inhibit the absorption of tetracycline, decreasing the effectiveness of the antibiotic. All the other activities are not appropriate, but would not cause as much potential harm as the administration of tetracycline with milk. Anaerobic bacteria would not likely grow in a superficial wound. Herpes zoster vaccine is recommended for clients who are older adults (60 years or older). Pressure garments are used after graft wounds heal and during the rehabilitation phase after a burn injury, and should be discussed when the client is ready for rehabilitation, not when the client is admitted.

A client with severe shortness of breath comes to the emergency department. He tells the emergency department staff that he recently traveled to China for business. Based on his travel history and presentation, the staff suspects severe acute respiratory syndrome (SARS). Which isolation precautions should the staff institute? Droplet precautions Airborne and contact precautions Contact and droplet precautions Contact precautions

Airborne and contact precautions Explanation: SARS, a highly contagious viral respiratory illness, is spread by close person-to-person contact. The client should be placed on airborne and contact precautions to prevent the spread of infection. Droplet precautions don't require a negative air pressure room and wouldn't protect the nurse who touches contaminated items in the client's room. Contact precautions alone don't provide adequate protection from airborne particles.

While listening to a taped-report at shift change, one of the other team members remarks that "My mother lives near this client, and his yard is always full of junk." What should the nurse assigned to provide care to this client do in this situation? Ask the team member to be quiet. Include the information in report for the next shift. Ask the team member what the purpose was in sharing the information. Ignore the comment.

Ask the team member what the purpose was in sharing the information. Explanation: The assigned nurse should determine if the comment has any relevance to the care of this client. Ignoring the comment or asking the team member to be quiet does not help determine if the comment was appropriate. Only information that has therapeutic value should be shared with other team members.

A nurse medicates a client with another client's morning medicines. What is the best action by the nurse upon realizing the error? Assess the patient for the medications' effects. Notify the charge nurse of the error. Call the practitioner of the patient who received the wrong medications. Have the nursing assistant complete a set of vital signs.

Assess the patient for the medications' effects. Explanation: The nurse should immediately assess the client who received the wrong medications. This assessment should include potential allergies to the medications and the side effects of the medications. The nurse should then notify the practitioner and the charge nurse. An incident report should be completed and submitted as directed by the facility's policy. The nurse should complete a set of vital signs with the assessment of the client.

A mother asks the nurse if her child's iron-deficiency anemia is related to the child's frequent infections. The nurse responds based on the understanding of which of the following? Little is known about iron-deficiency anemia and its relationship to infection in children. Children with iron-deficiency anemia are more susceptible to infection than are other children. Children with iron-deficiency anemia are less susceptible to infection than are other children. Children with iron-deficiency anemia are equally as susceptible to infection as are other children.

Children with iron-deficiency anemia are more susceptible to infection than are other children. Explanation: Children with iron-deficiency anemia are more susceptible to infection because of marked decreases in bone marrow functioning with microcytosis.

A nurse is providing teaching to a client who's being discharged after delivering a hydatidiform mole. Which expected outcome takes highest priority for this client? Client will state that she may attempt another pregnancy after 3 months of follow-up care. Client will schedule her first follow-up Papanicolaou (Pap) test and gynecologic examination for 6 months after discharge. Client will state that she won't attempt another pregnancy until her human chorionic gonadotropin (hCG) level rises. Client will use a reliable contraceptive method until her follow-up care is complete in 1 year and her hCG level is negative.

Client will use a reliable contraceptive method until her follow-up care is complete in 1 year and her hCG level is negative. Explanation: After a molar pregnancy, the client should receive follow-up care, including regular hCG testing, for 1 year because of the risk of developing chorionic carcinoma. After removal of a hydatidiform mole, the hCG level gradually falls to a negative reading unless chorionic carcinoma is developing, in which case the hCG level rises. A Pap test isn't an effective indicator of a hydatidiform mole. A follow-up examination would be scheduled within weeks of the client's discharge. The client must not become pregnant during follow-up care because pregnancy causes the hCG level to rise, making it indistinguishable from this early sign of chorionic carcinoma.

A client with rheumatoid arthritis states, "I cannot do my household chores without becoming tired. My knees hurt whenever I walk." Which goal for this client should take priority? Conserve energy. Adapt self-care skills. Develop coping skills. Employ a housekeeping service.

Conserve energy. Explanation: Based on the information from the client, the nurse should develop a plan with the client that will conserve energy and decrease episodes of fatigue. Although the client may develop a self-care deficit related to the increasing joint pain, the client is voicing concerns about household chores and difficulty around the house and yard, not self-care issues. Over time, the client may have difficulty coping, but that is not the current concern. Employing cleaning services may not be within the client's budget, and the client should first try a plan that balances rest and activity.

A nurse assesses a client in the physician's office. Which assessment findings support a suspicion of systemic lupus erythematosus (SLE)? Facial erythema, pericarditis, pleuritis, fever, and weight loss Photosensitivity, polyarthralgia, and painful mucous membrane ulcers Weight gain, hypervigilance, hypothermia, and edema of the legs Hypothermia, weight gain, lethargy, and edema of the arms

Facial erythema, pericarditis, pleuritis, fever, and weight loss Explanation: An autoimmune disorder characterized by chronic inflammation of the connective tissues, SLE causes fever, weight loss, malaise, fatigue, skin rashes, and polyarthralgia. Nearly half of clients with SLE have facial erythema, (the classic butterfly rash). SLE also may cause profuse proteinuria (excretion of more than 0.5 g/day of protein), pleuritis, pericarditis, photosensitivity, and painless mucous membrane ulcers. Weight gain, hypervigilance, hypothermia, and edema of the legs and arms don't suggest SLE.

A client is admitted with numbness and tingling of the feet and toes after having an upper respiratory infection and flu for the past 5 days. Within 1 hour of admission, the client's legs are numb all the way up to the hips. What should the nurse do next? Select all that apply. Call the family to come in to visit. Notify the health care provider (HCP) of the change. Place respiratory resuscitation equipment in the client's room. Check for advancing levels of paresthesia. Have the client perform ankle pumps.

Notify the health care provider (HCP) of the change. Place respiratory resuscitation equipment in the client's room. Check for advancing levels of paresthesia. Explanation: A client who has been admitted for numbness and tingling in the lower extremities that advances upward, especially after having a viral infection, has clinical manifestations characteristic of Guillain-Barré syndrome. The HCP must be notified of the change immediately because this disease is progressively paralytic and should be treated before paralysis of the respiratory muscles occurs. The nurse must assess the client continuously to determine how fast the paralysis is advancing. The family does not need to be called in to visit until the client is stabilized and emergency equipment is placed at the bedside. Performing ankle pumps will not relieve the numbness or change the course of the disease.

What is the most important nursing intervention when caring for a child with a newly applied wet hip-spica cast? Use the abductor bar to help move the child Cover the cast in plastic to keep it clean Reposition the child every 1 to 2 hours Use the fingertips when handling the cast

Reposition the child every 1 to 2 hours Explanation: The child in a wet hip-spica cast should be turned every 1 to 2 hours to help dry all sides of the cast and prevent skin breakdown. The abductor bar shouldn't be used for turning the child, even after the cast is dry. A wet cast shouldn't be covered with plastic because this will impede drying, reduce air circulation and allow heat to build up in the cast. A wet cast should be handled using the palms, because fingertips may cause indentations and pressure points.

A community health nurse is caring for a Vietnamese client with a diabetic foot ulcer. The client's children, spouse, and best friend are the only people available that speak English. What should the nurse do to provide optimal client care? Select all that apply. Use the oldest child as the interpreter during the home visits. Request that a health related interpreter to come to the home. Ask the client's spouse to be the interpreter during each visit. Appeal to the client's best friend to stay and act as the interpreter. Utilize a trained telephone interpreter while providing care.

Request that a health related interpreter to come to the home. Utilize a trained telephone interpreter while providing care. Explanation: When speaking with a client that does not speak the dominant language, the nurse should use a trained interpreter. If an on-site interpreter is unavailable, the nurse should other methods including bilingual staff, webcam, or telephonic interpreting. Family and friends should be avoided as interpreters as they may be protective of the client or not agree with the treatments offered and therefore not the most reliable translators.

A client is diagnosed with syndrome of inappropriate antidiuretic hormone (SIADH). Laboratory results reveal serum sodium level 130 mEq/L and urine specific gravity 1.030. Which nursing intervention helps prevent complications associated with SIADH? Restricting fluids to 800 ml/day Administering vasopressin as ordered Elevating the head of the client's bed to 90 degrees Restricting sodium intake to 1 gm/day

Restricting fluids to 800 ml/day Explanation: Excessive release of antidiuretic hormone (ADH) disturbs fluid and electrolyte balance in SIADH. The excessive ADH causes an inability to excrete dilute urine, retention of free water, expansion of extracellular fluid volume, and hyponatremia. Symptomatic treatment begins with restricting fluids to 800 ml/day. Vasopressin is administered to clients with diabetes insipidus a condition in which circulating ADH is deficient. Elevating the head of the bed decreases vascular return and decreases atrial-filling pressure, which increases ADH secretion, thus worsening the client's condition. The client's sodium is low and, therefore, shouldn't be restricted.

A nurse who is preparing to boost a client up in bed instructs the client to use the overbed trapeze. Which risk factor for pressure ulcer development is the nurse reducing by instructing the client to move in this manner? Friction Impaired circulation Localized pressure Shearing forces

Shearing forces Explanation: Friction, impaired circulation, localized pressure, and shearing forces are all risk factors of pressure ulcer development; trapeze use reduces shearing forces. Shearing forces (opposing forces that cause layers of skin to move over each other, stretching and tearing capillaries and, eventually, resulting in necrosis) can occur as clients slide down in bed or are pulled up in bed. Subcutaneous skin layers adhere to the sheets while deeper layers, muscle, and bone slide in the direction of movement. To reduce shearing forces, the nurse should instruct the client to use an overbed trapeze, place a draw sheet under the client to move him up in bed, and keep the head of the bed no higher than 30 degrees.

A nurse is conducting a detailed skin assessment on an 80-year-old client. Which finding requires further investigation? Yellow, waxy deposits on the lower eyelids Bright red moles on the hands Several areas of dry, scaly skin Small, waxy nodule with pearly borders

Small, waxy nodule with pearly borders Explanation: A small waxy nodule with pearly borders may indicate a basal cell carcinoma. This finding requires further investigation and treatment. Yellow, waxy deposits on the lower eyelids, bright red moles on the hands, and areas of dry, scaly skin are normal age-related changes to skin.

A nurse is completing an admission interview of a client newly diagnosed with multiple myeloma. The client tells the nurse he is concerned that his insurance coverage and limited savings will not pay for all of his family's needs when he is not working. Based on this information, to whom would the nurse initiate a referral? Pastoral care Hospital accounts Social services Case management

Social services Explanation: A social worker can be extremely beneficial in helping clients identify additional personal and community funding resources and support groups. A pastoral care referral would be appropriate if the client had expressed spiritual concerns. The nurse should refer the client to hospital accounts only if there is a need to discuss payment arrangements after identifying existing resources. A referral to case management would be contingent on the client's insurance requirements and would not address the immediate concern.

A nurse overhears a fellow staff member talking about the mother of a child for whom the staff nurse is caring. The nurse is telling others private information that the mother had shared. What is the best response by the nurse overhearing the conversation? Report this incident to the nurse-manager. Report the incident to the organization's privacy officer. Talk to the staff member privately about this. Talk to the staff in general about confidentiality.

Talk to the staff member privately about this. Explanation: The best approach is to talk to the staff member privately about the information that the mother shared. This information is confidential and should not be disclosed. Reporting the incident to the nurse-manager is appropriate once the nurse has spoken to the staff member privately. The decision to contact a privacy officer is dependent on the seriousness of the breech and should be determined after discussion with the nurse manager. Talking to the staff in general about confidentiality may be beneficial. However, the nurse needs to speak with the staff member in private first.

Which health education topic is the priority when teaching parents ways to prevent urinary tract infections (UTIs) in their children? Teach parents to promote adequate fluid intake Teach parents to limit the frequency of tub baths Encourage parents of male infants to avoid circumcision Educate parents about hand washing, and the use of alcohol-based hand sanitizers

Teach parents to promote adequate fluid intake Explanation: Urinary stasis is a major cause of UTIs, and can be partially prevented by increasing fluid intake. Baths and hand hygiene are less significant factors in the development of UTIs. Urinary tract infections are increased in uncircumcised male infants under one year of age, but unaffected thereafter.

Which of the following clients will the nurse prioritize to assess first? The client admitted 24 hours earlier with mild chest pain and negative serial levels of troponin T in the range of 0-0.1 µg/L The client with ESRD (end-stage renal disease) just admitted the night before The client 2 days post-laparoscopic cholecystectomy The client with type 1 diabetes mellitus and a morning blood glucose level of 110 mg/dL

The client with ESRD (end-stage renal disease) just admitted the night before Explanation: The client with ESRD is at risk of significant anemia because the kidneys are responsible for erythropoietin production; the client is also at risk for significant potassium and sodium imbalances. The client with negative troponin levels and mild chest pain is most likely not having a cardiac event. The client with a blood glucose of 110 is in no danger. A client who is 2 days post a laparoscopic cholecystectomy is stable.

A client in the intensive care unit (ICU) is on a dobutamine drip. During an assessment the client states, "I was feeling better but now my chest is tight and I feel like my heart is skipping." Physical assessment reveals a heart rate of 110 beats per minute and blood pressure of 160/98 mm Hg. What is the nurse's immediate concern for this client? The dobutamine may need to be decreased. The client is experiencing an allergic reaction to the dobutamine. The client is experiencing an exacerbation of the heart failure. The dosage of the dobutamine needs to be increased.

The dobutamine may need to be decreased. Explanation: Dobutamine is a vasoactive adrenergic that works by increasing myocardial contractility and stroke volume in order to increase the cardiac output in heart failure clients. A serious side effect of adrenergic drugs is the worsening of a preexisting cardiac disorder. Increasing the dosage of the drug will worsen the problem. The client shows not symptoms of allergic reaction or heart failure.

A client recently gave birth to a boy. Two minutes before breast-feeding the baby, she administers one nasal spray (40 units/ml) of oxytocin into each nostril. Why is the client using this drug? To stimulate lactation To treat eclampsia To reduce postpartum bleeding To treat erythroblastosis

To stimulate lactation Explanation: Oxytocin is administered as a nasal spray before breast-feeding to stimulate lactation. When oxytocin is used to treat eclampsia, reduce postpartum bleeding, or treat erythroblastosis fetalis, the drug is administered parenterally.

A client has been admitted to the emergency department. The client's family tells the nurse that the client has suddenly become lethargic and is "not making sense." The client has not had anything to eat or drink for the last 8 hours. The nurse further assesses the client using the Confusion Assessment Method (CAM). The client's responses to questions are rambling, and the client is not able to focus clearly to answer the nurse's questions. Based on these findings, the nurse should report that the client has which problem? dementia depression delirium dehydration

delirium Explanation: Based on CAM's assessment tool, the client has an acute onset of behaviors, is inattentive, has disorganized thinking, and is lethargic (decreased level of consciousness). This cluster of behaviors constitutes delirium. Dementia has a slow onset, the client's level of consciousness is usually normal, and the client can focus attention. Clients who are depressed are alert and oriented and able to focus attention, although they may be easily distracted. Further assessment is needed to determine if the client also is dehydrated.

A child with asthma has a heart rate of 160 bpm and a respiratory rate of 36 breaths/minute. The child appears restless and anxious and is given albuterol via nebulizer. Which finding would indicate that the nebulizer treatment has been effective? pulse oximeter reading of 91% nonproductive cough expiratory wheezing increase in peak expiratory flow rate

increase in peak expiratory flow rate Explanation: The best indicator of the effectiveness of the albuterol is an increase in peak expiratory flow rate. Albuterol, a bronchodilator, opens and relaxes the airways, allowing a greater exchange of air, which is reflected as a higher peak expiratory flow rate. Pulse oximetry reflects how well the client is oxygenating: the higher the reading, the better the client's oxygenation. Typically, a pulse oximeter reading of 95% or greater is the goal. Furthermore, a pulse oximeter reading of 91% is meaningless in this scenario unless previous readings are available for comparison. As the airways open, the child should begin to have a productive cough. Wheezing may or may not be a reliable indicator for determining the effectiveness of the albuterol treatment. The nebulizer treatment may increase wheezing by opening the airways enough so that air can travel through the excessively mucus-filled bronchioles. Because this child is still experiencing respiratory distress, some wheezing would be expected. However, wheezing in a child with asthma who is in acute distress may indicate an improvement, demonstrating the movement of air through the airways that were previously blocked.

The nurse is teaching an older adult how to prevent falls. The nurse should tell the client to: turn on bright lights in the room so the client can see items in the room. instruct the client to rise slowly from a supine position. encourage the client to not use assistive devices because they reduce independence. instruct the client not to exercise painful joints.

instruct the client to rise slowly from a supine position. Explanation: Normal age-related changes can predispose older adults to falling and include vision, hearing, cardiovascular, musculoskeletal, and neurological changes. One of the most common problems facing older adults is the loss of tissue elasticity that affects the arteries. This loss of elasticity results in a decrease in tissue recoil and leads to changes in blood pressure with position changes. When they rise too quickly from a supine position, they feel light-headed and dizzy and can fall. The nurse should instruct clients to change positions slowly and to dangle the legs a few minutes when arising from a supine position. When aging, the lens of the eye becomes sensitive to very bright light which can causes a glare and visual disturbances that can lead to falls. Rooms should be well lit, but not with bright lights that cause a glare. Neurological changes are seen in impaired reflexes and thus postural instability. This loss of postural stability leads to falls. The need of assistive devices (hand rails, cane, walkers) helps reduce falls and promote independence. If joint pain develops and remains untreated, it can cause older adults to become sedentary or immobile. This disuse of muscles contributes to muscle weakness and falls. Nursing interventions should be directed at encouraging regular ambulation and joint movement (range of motion).

The nurse administers fat emulsion solution during TPN to a malnourished client. What should the nurse tell the client about the purpose of this solution? Fat emulsion solution:

provides essential fatty acids. Explanation: The administration of fat emulsion solution provides additional calories and essential fatty acids to meet the body's energy needs. Fatty acids are lipids, not carbohydrates. Fatty acids do not aid in the metabolism of glucose. Although they are necessary for meeting the complete nutritional needs of the client, fatty acids do not necessarily help a client maintain normal body weight.

An 8-year-old child has been admitted to the oncology unit with a suspected diagnosis of acute lymphoblastic leukemia. The nurse is obtaining a health history from the parents. During the interview, the parents ask the nurse if any of the factors discussed would make their child more at risk for this type of leukemia. What information about potential risk factors is correct for the nurse to share with the parents? the X-rays that the child had at age 6 for a broken leg a weight that is above the limit for the child's age the diagnosis of Down's syndrome at birth a diet that includes a large proportion of dairy products

the diagnosis of Down's syndrome at birth Explanation: Children with Down's syndrome and other genetic conditions have an increased risk of developing acute lymphoblastic leukemia. Prenatal exposure to X-rays is actually a higher concern than postnatal exposure with respect to increasing the risk of developing ALL. The exception would be postnatal exposure to high doses of therapeutic radiation used as a treatment modality, which was not indicated here. Diet would have little impact on risk factors at this stage in the child's life.

A client is taking large doses of aspirin daily to treat rheumatoid arthritis. The nurse should instruct the client to tell the health care provider (HCP) when having: abdominal cramps. tinnitus. rash. low blood pressure.

tinnitus. Explanation: Tinnitus or ringing in the ears is a sign of aspirin toxicity and should be reported. Clients should be instructed to take aspirin as prescribed and to avoid overdosage. Gastrointestinal symptoms associated with aspirin include nausea, heartburn, and epigastric discomfort caused by gastric irritation. Abdominal cramps, rash, and hypotension are not related to aspirin therapy.

An elderly client had a thrombotic cerebrovascular accident and now has flaccid hemiplegia of the right side. When planning care for this client, the nurse understands that rehabilitation begins: as soon as anticoagulant therapy is started. when the client is admitted to the hospital. when the client can first work cooperatively with health care personnel. as directed by the physical therapist.

when the client is admitted to the hospital. Explanation: Rehabilitation for a client who has sustained a cerebrovascular accident begins at the time the client is admitted to the hospital. The first goal of rehabilitation should be to help prevent deformities. This goal is achieved through such techniques as positioning the client properly in bed, changing the client's position frequently, and supporting all parts of the body in proper alignment. Passive range-of-motion exercises may also be started, unless contraindicated.

The nurse is assessing a client who is in her first trimester of pregnancy. The client states that her nausea has been problematic at times, but says that she is able to partially control it using ginger supplements. What is the nurse's best response? "Have you let your care provider know that you are taking ginger?" "Have you spoken with your care provider about the possibility of taking doxylamine?" "Take the lowest dose that you can because it can make your blood glucose levels fluctuate." "Where did you first learn that ginger might be helpful for treating your nausea?"

"Have you let your care provider know that you are taking ginger?" Explanation: A priority is ensuring that the care provider is aware of the client's use of a herbal supplement during pregnancy. Ginger is not associated with hyperglycemia or hypoglycemia. Exploring the source of the client's information or the possible use of pharmacologic alternatives are secondary to ensuring there is communication with the care provider.

A nurse caring for a client with schizophrenia goes into the client's room to administer medication. While looking out the window at the trees, the client remarks, "That school across the street has creatures in it that are waiting for me." Which of the following is the most appropriate response by the nurse? "The creatures will not hurt you." "You are delusional." "How do you feel when you see the creatures?" "It is time for your medication now."

"How do you feel when you see the creatures?" Explanation: The most appropriate response by the nurse is "How do you feel when you see the creatures?" The client is experiencing a delusion, a false belief that has no basis in reality. When the client experiences a delusion, it is important to acknowledge the delusion and to ask the client to describe it and how it makes them feel. These actions help identify the type of delusions so that the correct intervention can be implemented while establishing trust. If asked, the nurse should point out that they are not experiencing the same stimuli but should not argue with the client.

A client is receiving aspirin. Which statement made by the client needs follow-up? "I need to report if I have black stool." "I'll take the medication after a meal." "I can take Ginkgo biloba with aspirin." "I need to report loss of hearing in my ears."

"I can take Ginkgo biloba with aspirin." Explanation: Aspirin, also known as acetylsalicylic acid, is used for mild to moderate pain, fever, inflammation, and atrial fibrillation stroke prevention. Aspirin may increase the bleeding when taken with herbal supplement Ginkgo biloba. The medication can cause gastrointestinal bleeding and ototoxicity. Nausea, vomiting, diaphoresis, and tinnitus are the earliest signs and symptoms of salicylate toxicity. Other early symptoms and signs are vertigo, hyperventilation, tachycardia, and hyperactivity. It should be taken with food especially if it causes stomach upset.

A school-age client with rheumatic fever is on long-term aspirin therapy. Which client statement most indicates that the client is experiencing a serious adverse reaction to aspirin? "I hear ringing in my ears." "I put lotion on my itchy skin." "My stomach hurts after I take that medicine." "These pills make me cough."

"I hear ringing in my ears." Explanation: Tinnitus is an adverse effect of prolonged aspirin therapy, and the child should be examined by a health care provider (HCP) for hearing loss. Itchy skin commonly accompanies the rash associated with rheumatic fever and the nurse can encourage lotion use. The nurse teaches clients to take aspirin with food or milk to avoid abdominal discomfort. The nurse can also address the fact that coughing after ingesting aspirin can be caused by inadequate fluid intake during administration.

A client has been diagnosed with hypothyroidism. Which statement by the client would demonstrate appropriate teaching by the nurse? "I should stop attending group activities." "I will increase daily caloric consumption." "I will increase fiber and fluids in my diet." "I should stop taking the prescribed daily aspirin."

"I will increase fiber and fluids in my diet." Explanation: Clients with hypothyroidism typically have constipation. A diet high in fiber and fluids can help prevent this. Group activities have nothing to do with the current issue. A nurse would not change medical prescriptions by telling the client to stop taking the prescribed aspirin. Increasing caloric consumption is not appropriate with hypothyroidism.

A client signed a consent form for participation in a clinical trial for implantable cardioverter-defibrillators. Which statement by the client indicates the need for further teaching before true informed consent can be obtained? "This implanted defibrillator will protect me against some of those bad rhythms my heart goes into." "I wonder if there is any other way to prevent these bad rhythms." "The physician will make a small incision in my chest wall and place the generator there." "A wire from the generator will be attached to my heart."

"I wonder if there is any other way to prevent these bad rhythms." Explanation: The client wondering if there is another way to prevent the abnormal rhythms indicates that other treatment options weren't discussed with the client. Before participating in a clinical trial, the client must be informed of all other available treatment options. The other statements about implantable cardioverter-defibrillators are all true.

A nurse is caring for an adolescent involved in a motor vehicle crash. The adolescent has a chest tube in place. If the chest tube is accidentally removed, the nurse should immediately: reintroduce the tube and attach it to water seal drainage. call a physician and obtain a chest tray. cover the opening with petroleum gauze. clean the wound with povidone-iodine and apply a gauze dressing.

"The implant won't cure the virus, but it may help preserve his vision. Not being able to see you or his surroundings may worsen his dementia and make caring for him at home more difficult."

A 15-year-old female who is 26 weeks pregnant has been admitted to the labor and delivery unit with reports of abdominal pain. Her parents want to speak with a nurse about her condition. How should the nurse respond? "I'll need a signed consent from your daughter to give you medical information." "The health care provider can give you more information without consent." "She will be OK. It's just a stomachache." "She is experiencing Braxton Hicks contractions and is too young to understand the difference between these contractions and labor pains."

"I'll need a signed consent from your daughter to give you medical information." Explanation: A pregnant minor is emancipated from her parents so she can make decisions for herself and her baby. Therefore, the client's right to confidentiality means that neither the nurse nor the health care provider may divulge medical information without a signed consent.

The parents of a 3-week-old healthy newborn ask the nurse why their child is intermittently cross-eyed. What is the nurse's best response? "An eye patch may be necessary for 6 weeks to correct you child's vision." "Your child will likely need an ophthalmology consult." "It is normal to have eye crossing in the newborn period." "Surgery may be necessary to correct your child's vision."

"It is normal to have eye crossing in the newborn period." Explanation: During the first few months of life, an infant's eyes may wander and appear to be crossing. As the eye muscles mature, between 2 and 3 months of age, both eyes will focus on the same thing. No intervention is necessary, as crossing of the eyes is normal in the first few months of life.

A 2-year-old child with a low blood level of the immunosuppressive drug cyclosporine comes to a liver transplant clinic for her appointment. The mother says the child hasn't been vomiting and hasn't had diarrhea, but she admits that her daughter doesn't like taking the liquid medication. Which statement by the nurse is most appropriate? "Let your daughter take her medication only when she wants it; it's okay for her to miss some doses." "Offer the medication diluted with chocolate milk or orange juice to make it more palatable." "Insert a nasogastric (NG) tube and administer the medication using the tube as ordered by the physician." "Give the ordered dose a little bit at a time over 2 hours to ensure administration of the medication."

"Offer the medication diluted with chocolate milk or orange juice to make it more palatable." Explanation: Because liquid cyclosporine has a very unpleasant taste, diluting it with chocolate milk or orange juice will lessen the strong taste and help the child take the medication as ordered. It is not acceptable to miss a dose because the drug's effectiveness is based on therapeutic blood levels, and skipping a dose could lower the level. Cyclosporine should not be given by NG tube because it adheres to the plastic tube and, thus, all of the drug may not be administered. Taking the medication over a period of time could negatively affect the blood level.

A client with osteoarthritis tells the nurse she is concerned that the disease will prevent her from doing her chores. Which suggestion should the nurse offer? "Do all your chores in the morning, when pain and stiffness are least pronounced." "Do all your chores after performing morning exercises to loosen up." "Pace yourself and rest frequently, especially after activities." "Do all your chores in the evening, when pain and stiffness are least pronounced."

"Pace yourself and rest frequently, especially after activities." Explanation: A client with osteoarthritis must adapt to this chronic and disabling disease, which causes deterioration of the joint cartilage. The most common symptom of the disease is deep, aching joint pain, particularly in the morning and after exercise and weight-bearing activities. Because rest usually relieves the pain, the nurse should instruct the client to rest frequently, especially after activities, and to pace herself during daily activities. Telling the client to do her chores in the morning is incorrect because the pain and stiffness of osteoarthritis are most pronounced in the morning. Telling the client to do all chores after performing morning exercises or in the evening is incorrect because the client should pace herself and take frequent rests rather than doing all chores at once.

A client with chronic progressive multiple sclerosis is learning to use a walker. What instruction will best ensure the client's safety? "Place the walker directly in front of you and step into it as you move it forward." "When you move the walker, set the back legs down first. Then step forward." "Maintain a firm grip on the front bar as you step into the walker." "Use a walker with wheels to help you move forward."

"Place the walker directly in front of you and step into it as you move it forward." Explanation: When the client places the walker directly in front of him, he creates a stable base for forward movement and reduces the likelihood of falls. The client shouldn't set the back leg down first because this creates an unstable base that could lead to a fall. The client should firmly grip the side bars; doing so provides a more stable base of support than gripping the front bar. The nurse shouldn't suggest that the client use a walker with wheels. Only a physician or physical therapist may order a walker with wheels.

A client with rheumatoid arthritis tells the nurse, "I know it's important to exercise my joints so that I won't lose mobility, but my joints are so stiff and painful that exercising is difficult." Which response by the nurse would be most appropriate? "You're probably exercising too much. Decrease your exercise to every other day." "Tell the health care provider about your symptoms. Maybe your analgesic medication can be increased." "Stiffness and pain are part of the disease. Learn to cope by focusing on activities you enjoy." "Take a warm tub bath or shower before exercising. This may help with your discomfort."

"Take a warm tub bath or shower before exercising. This may help with your discomfort." Explanation: Superficial heat applications, such as tub baths, showers, and warm compresses, can be helpful in relieving pain and stiffness. Exercises can be performed more comfortably and more effectively after heat applications. The client with rheumatoid arthritis must balance rest with exercise every day, not every other day. Typically, large doses of analgesics, which can lead to hepatotoxic effects, are not necessary. Learning to cope with the pain by refocusing is inappropriate.

A client with brown hair is concerned about losing hair as a result of chemotherapy. What should the nurse tell the client? "The new growth of hair will be gray." "The hair loss is temporary." "New hair growth will always be the same texture and color as it was before chemotherapy." "Avoid use of wigs when possible."

"The hair loss is temporary." Explanation: Alopecia from chemotherapy is temporary. The new hair will not be necessarily gray, but the texture and color of new hair growth may be different. Clients who will be receiving chemotherapy should be encouraged to purchase a wig while they still have hair so that they can match the color and texture of their hair. Loss of hair, or alopecia, is a serious threat to self-esteem and should be addressed quickly before treatment.

A client states, "I have abdominal pain." Which assessment question would best determine the client's need for pain medication? "Are you having pain?" "Is the pain constant?" "How does the pain medication make you feel?" "What does the pain feel like?"

"What does the pain feel like?" Explanation: An open-ended question (one that cannot be answered with a simple "yes" or "no") provides more information than a closed-ended question, which limits the client's response. The other options are closed-ended questions. Having the client describe how the pain medication makes him/her feel does not address the issue of the client's present statement of pain.

A child is receiving IV gamma globulin for treatment of Kawasaki disease. The order is for 8 g over 12 hours. The concentration is 8 g in 300 ml of normal saline. How many milliliters per hour will this child receive? Record your answer using a whole number.

25

At 32 weeks' gestation, a client is admitted to the facility with a diagnosis of gestational hypertension. Based on this diagnosis, the nurse expects the assessment to reveal: 3+ edema in the lower extremities. temperature of 101.4° F (38.6° C). urine glucose of +2. inability to keep food down.

3+ edema in the lower extremities. Explanation: Classic signs of gestational hypertension include edema (especially of the face) and elevated blood pressure. Fever is a sign of infection. Glycosuria, evidenced by a +2 urine glucose level indicates hyperglycemia. Vomiting may be associated with various disorders.

A client has a sucking stab wound to the chest. Which action should the nurse take first? Draw blood for a hematocrit and hemoglobin level. Apply a dressing over the wound and tape it on three sides. Prepare a chest tube insertion tray. Prepare to start an I.V. line.

Apply a dressing over the wound and tape it on three sides. Explanation: The nurse should immediately apply a dressing over the stab wound and tape it on three sides to allow air to escape and to prevent tension pneumothorax (which is more life-threatening than an open chest wound). Only after covering and taping the wound should the nurse draw blood for laboratory tests, assist with chest tube insertion, and start an I.V. line.

The client has sore nares while a nasogastric (NG) tube is in place. Which nursing measure would be most appropriate to help alleviate the client's discomfort? Reposition the tube in the nares. Irrigate the tube with a cool solution. Apply a water-soluble lubricant to the nares. Have the client change position more frequently.

Apply a water-soluble lubricant to the nares. Explanation: Applying a water-soluble lubricant to the nares helps alleviate sore nares when an NG tube is in place. Repositioning the tube does not eliminate the possibility of irritating the nares. Irrigating the tube with a cool solution or changing positions will not relieve the local irritation from the NG tube.

A client is transferred to the intensive care unit after evacuation of a subdural hematoma. Which nursing intervention reduces the client's risk of increased intracranial pressure (ICP)? Encouraging oral fluid intake Suctioning the client once each shift Elevating the head of the bed 90 degrees Administering a stool softener as ordered

Administering a stool softener as ordered Explanation: To prevent the client from straining at stool, which may cause a Valsalva maneuver that increases ICP, the nurse should institute a regular bowel program that includes use of a stool softener. For a client at risk for increased ICP, the nurse should prevent, not encourage, oral fluid intake and should elevate the head of the bed only 30 degrees. Suctioning, indicated for a client with lung congestion, isn't necessary for this client.

he nursing team consists of one RN, one LPN, and one unlicensed assistive personnel (UAP). Which assignment should the RN delegate to the LPN? Passing dinner trays Emptying a Foley catheter bag Administering daily am medications Suctioning a client who is one-day postoperative following a tracheostomy

Administering daily am medications Explanation: LPNs should be assigned higher level skills in stable, predictable situations. Lower level custodial skills should be assigned to UAP. A new tracheostomy may be unstable. The task of suctioning should be retained by the RN.

In evaluating a client's response to nutrition therapy, which laboratory test would be of highest priority to examine? Serum potassium level Lymphocyte count Albumin level CBC differential

Albumin level Explanation: Protein and vitamin C help build and repair injured tissue. Albumin is a major plasma protein; therefore, a client's albumin level helps gauge his nutritional status. Potassium levels indicate fluid and electrolyte status. Lymphocyte count and differential count help assess for infection.

Which action should a nurse include in the care plan for a 2-month-old infant with heart failure? Allow the infant to rest before feeding. Bathe the infant and administer medications before feeding. Weigh and bathe the infant before feeding. Feed the infant when the infant cries.

Allow the infant to rest before feeding. Explanation: Because feeding requires so much energy, an infant with heart failure should rest before feeding. Bathing and weighing the infant and administering medications should be scheduled around feedings. An infant expends energy when crying; therefore, it's best if the infant doesn't cry.

A client is diagnosed with a chronic respiratory disorder. After assessing the client's knowledge of the disorder, the nurse prepares a teaching plan. This teaching plan is most likely to include which nursing diagnosis? Anxiety Imbalanced nutrition: More than body requirements Impaired swallowing Unilateral neglect

Anxiety Explanation: In a client with a respiratory disorder, anxiety worsens such problems as dyspnea and bronchospasm. Therefore, Anxiety is a likely nursing diagnosis. This client may have inadequate nutrition, making Imbalanced nutrition: More than body requirements an unlikely nursing diagnosis. Impaired swallowing may occur in a client with an acute respiratory disorder, such as upper airway obstruction, but not in one with a chronic respiratory disorder. Unilateral neglect may be an appropriate nursing diagnosis when neurologic illness or trauma causes a lack of awareness of a body part; however, this diagnosis doesn't occur in a chronic respiratory disorder.

Which of the following actions performed by a nurse will increase the risk of liability? Select all that apply. Witnessing a client sign a consent for an ordered medical procedure Withholding a medication to clarify the ordered dosage Assisting a client on ordered bed rest to walk to the toilet Asking unlicensed assistive personnel to assess a client's wound Providing information to a caller about a client's diagnosis and treatment

Assisting a client on ordered bed rest to walk to the toilet Asking unlicensed assistive personnel to assess a client's wound Providing information to a caller about a client's diagnosis and treatment Explanation: Nursing standards of practice are stated within the nurse practice act of each state, territory, or province. These standards include scope of practice, delegation, professional ethics, and code of conduct. A nurse increases the risk of professional liability when performing activities outside of these standards. A nurse may not delegate a nursing task to a person, such as unlicensed assistive personnel who do not have the proper training or skills to perform the task. The nurse should not act against physician orders without a professionally based reason, such as clarifying an order. Professional ethics requires protection of client privacy. Personal health information should not be provided to a caller without the client's consent.

A 4-year-old child continues to come to the nurses' station after being told children are not allowed there. What behavior is the child exhibiting? attention-seeking behavior aggressive behavior resistive behavior exaggerated stress behavior

Attention-seeking behavior Explanation: The child wants attention from the nurse, even if the behavior is met by a negative response. Aggression, resistance against authority, and exaggerated stress are behaviors that can be associated with a 4-year-old. However, coming to the nurses' station after being told not to do so is not an example of these behaviors.

A client is in the eighth month of pregnancy. To enhance cardiac output and renal function, the nurse should advise the client to use which body position?

left lateral Explanation: The left lateral position shifts the enlarged uterus away from the vena cava and aorta, enhancing cardiac output, kidney perfusion, and kidney function. The right lateral and semi-Fowler positions don't alleviate pressure of the enlarged uterus on the vena cava. The supine position reduces sodium and water excretion because the enlarged uterus compresses the vena cava and aorta; this decreases cardiac output, leading to decreased renal blood flow, which in turn impairs kidney function.

A nurse assesses a client with psychotic symptoms and determines that the client likely poses a safety threat and needs vest restraints. The client is adamantly opposed to this. What would be the best nursing action? Contact the physician and obtain necessary orders. Restrain the client with vest restraints. Ask a family member to come in to supervise the client. Apply wrist restraints instead of vest restraints.

Contact the physician and obtain necessary orders. Explanation: If a nurse feels that a client needs to be restrained, the nurse should inform the physician and obtain necessary orders. The nurse should also discuss this with the client's family members and ask their opinion. Applying a wrist restraint instead of a vest restraint is inappropriate if a vest restraint is genuinely necessary. It would be inappropriate to delegate this aspect of care to a family member.

When preparing to administer a tap water enema, in which position should the nurse place the client?

left sims' Explanation: When administering an enema, the nurse should position the client in a left Sims position. Placing the client in this position facilitates the flow of fluid into the rectum and colon. It also allows the client to flex the right leg forward, adequately exposing the rectal area.

While monitoring a client for the development of disseminated intravascular coagulation (DIC), the nurse should take note of which assessment parameters? Platelet count, prothrombin time, and partial thromboplastin time Platelet count, red blood cell count, and hemoglobin Thrombin time, fibronogen, and hemoglobin level D-dimer, red blood cell count, and partial thromboplastin time

Platelet count, prothrombin time, and partial thromboplastin time Explanation: The diagnosis of DIC is based on the results of laboratory studies of prothrombin time, platelet count, thrombin time, partial thromboplastin time, fibrinogen level, and D-dimer, as well as client history and other assessment factors. Red blood cell count and hemoglobin are not utilized in this diagnosis.

A 9-year-old child presents to a school nurse and reports arm and leg pain. Upon assessment, the nurse identifies numerous purple to yellow ecchymotic areas. When asked, the child says that the bruises are the result of "being in trouble at home." Which action by the nurse is most appropriate? Arrange for the child to speak with the school psychologist as soon as possible. Arrange for a meeting with the nurse, psychologist, school administrators, and the child's parents. Contact the authorities immediately. Contact an ambulance to transport the child to the emergency department.

Contact the authorities immediately. Explanation: When a nurse suspects abuse, the nurse must contact the authorities immediately. Although speaking with the school psychologist may be helpful, the nurse should not delay contacting the authorities. A family meeting might provide additional information, but the nurse must allow the authorities to investigate suspected abuse before confronting the child's parents. Because the child is not in imminent distress, there is no need for an ambulance.

A client was admitted to the hospital 2 weeks ago following an ischemic stroke. Following the early introduction of stroke rehabilitation, he has seen significant improvements in both his medical status and activities of daily living (ADLs). This morning, however, his nurse notes that the client has been coughing since eating a minced and pureed breakfast. Auscultation of the chest reveals coarse crackles. Which of the following practitioners should the nurse liaise with to obtain a swallowing assessment?

Speech therapist

The nurse is caring for a client with type 1 diabetes mellitus. At 3:00 AM, the nurse finds the client disoriented to time and place, diaphoretic, and complaining of palpitations. What is the nurse's priority intervention? Give 10 to15 g of carbohydrate orally Call the healthcare provider for additional insulin order Administer 1 mg of glucagon subcutaneously Check blood glucose level

Check blood glucose level Explanation: Check the blood glucose level first when symptoms arise, then proceed with treatment according to the results. If the client is hypoglycemic, administration of a simple carbohydrate is appropriate. If the client is conscious, the carbohydrate may be given orally. If consciousness is altered, subcutaneous or intramuscular glucagon is appropriate. This client is showing symptoms of hypoglycemia, additional insulin would further lower the blood glucose.

A client states that her "water broke." Which action requires the nurse to have specialialized training? Observing for pooling of straw-colored fluid Checking vaginal discharge with Nitrazine paper Conducting a bedside ultrasound for an amniotic fluid index Observing for flakes of vernix in the vaginal discharge

Conducting a bedside ultrasound for an amniotic fluid index Explanation: It isn't within a nurse's scope of practice to perform and interpret a bedside ultrasound under these conditions and without specialized training. Observing for pooling of straw-colored fluid, checking vaginal discharge with Nitrazine paper, and observing for flakes of vernix are appropriate nursing assessments for determining whether a client has ruptured membranes.

The nurse is caring for a client after surgery. The surgeon has written "resume pre-op meds" as an order on a client's chart. What should the nurse do next? Contact the surgeon for clarification because this is not a complete order. Transcribe the preoperative medication orders the surgeon has ordered. Ask the pharmacist for a list of preoperative medications for the client. Obtain new orders for the client from the physician on call.

Contact the surgeon for clarification because this is not a complete order. Explanation: After surgery, all orders must be renewed as full orders. This requires complete orders, including the drug name, route, dose, frequency, and reason for administration (e.g., pain). The other options are incorrect because the most responsible physician needs to order interventions that are relevant to the postoperative client. Preoperative orders may contain orders that are not relevant postoperatively and would cause harm to the client. The other options could put the client at risk and the nurse in a position of negligence.

The nurse sees a client walking in the hallway who begins to have a seizure. What should the nurse do in order of priority from first to last? All options must be used. 1 Ease the client to the floor. 2 Maintain a patent airway. 3 Obtain vital signs. 4 Record the seizure activity observed.

Ease the client to the floor. Maintain a patent airway. Obtain vital signs. Record the seizure activity observed. Explanation: To protect the client from falling, the nurse first should ease the client to the floor. It is important to protect the head and maintain a patent airway since altered breathing and excessive salivation can occur. The assessment of the postictal period should include level of consciousness and vital signs. The nurse should record details of the seizure once the client is stable. The events preceding the seizure, timing with descriptions of each phase, body parts affected and sequence of involvement, and autonomic signs should be recorded.

A health care agency is applying for accreditation, and the accrediting agency is conducting audits of randomly selected medical records. To support the agency's accreditation, these medical records should include: Evidence of home care and nursing follow-up for 6 weeks following discharge. Self-reflection from nursing and other care providers about he quality of their care. Evidence that nurses have set goals for improving future practice. Evidence that nursing interventions have been evaluated in terms of the client's response.

Evidence that nursing interventions have been evaluated in terms of the client's response. Explanation: The medical record serves multiple purposes, including a role in accreditation. Accreditors look for evidence of evaluation following interventions. The medical record is not the correct venue for nurses' self-reflection or personal goal-setting. Many clients do not require community-based follow up after they have been discharged.

The nurse has asked the unlicensed assistive personnel (UAP) to ambulate a client with Parkinson's disease. The nurse observes the UAP pulling on the client's arms to get the client to walk forward. What should the nurse do?

Explain how to overcome a freezing gait by telling the client to march in place. Explanation: Clients with Parkinson's disease may experience a freezing gait when they are unable to move forward. Instructing the client to march in place, step over lines in the flooring, or visualize stepping over a log allows them to move forward. It is important to ambulate the client and not keep them on bed rest. A muscle relaxant is not indicated.

The daughter of an alert and oriented elderly client asks what her father's most recent blood glucose level was. What is the nurse's best response? Tell the client's daughter his blood glucose level because this test is performed on the nursing unit. Ask the client's daughter if she has her father's permission to have access to his health information. Have the daughter sign a "Disclosure of Health Information" form prior to giving her the information. Explain that this information cannot be disclosed without the client's permission.

Explain that this information cannot be disclosed without the client's permission. Explanation: The Health Insurance Portability and Accountability Act in the United States, and the Canadian Privacy Act and the Personal Information Protection and Electronic Documents Act (and often provincial/territorial legislation) prevents family members or friends from acquiring health information without consent of the client involved. Whether the test was performed on the nursing unit or others had given the client's daughter this information is irrelevant; the client's test results are still protected health information. The nurse should not ask the client's daughter if she has permission, the client should be asked. If a disclosure of health information form is signed, it should be the client signing, not the daughter. (Note: the caregiver of a client who is incapacitated CAN be given healthcare information.)

Which approach would be most effective when the nurse is communicating with a client who has a hearing impairment? When speaking, stand to one side of the client and direct the voice directly into the client's ear. Stand close to the client and speak as loudly as possible. Stand in front of the client and speak slowly and clearly. Ask only questions that the client can answer with a "yes" or "no" response.

Stand in front of the client and speak slowly and clearly. Explanation: Stand close to and directly in front of the client to greatly facilitate communication. Speak slowly and clearly and minimize distractions in the environment. The nurse should face the client; that way the client can see the nurse's mouth at all times for lip-reading. Yelling at the client distorts the voice and further hinders understanding. The nurse should have the client validate understanding of the conversation by repeating what was said.

A nulligravid client with gestational diabetes tells the nurse that she had a reactive nonstress test 3 days ago and asks, "What does that mean?" The nurse explains that a reactive nonstress test indicates which of the following about the fetus? Evidence of some compromise that will require birth soon. Fetal well-being at this point in the pregnancy. Evidence of late decelerations occurring during the test. No accelerations demonstrated within a 20-minute period.

Fetal well-being at this point in the pregnancy. Explanation: A reactive nonstress test is a positive sign indicating that the fetus is doing well at this point in the pregnancy. For a nonstress test to be a reactive test, at least two accelerations (15 beats or more) of the fetal heart rate lasting at least 15 seconds must occur after movement. If the fetus were compromised, the nonstress test would demonstrate no accelerations in fetal heart rate; a contraction stress test would show fetal heart rate decelerations during simulated labor. Late decelerations are associated with a positive or abnormal contraction stress test. No accelerations in a 20-minute period during a nonstress test may mean that the fetus is sleeping; however, this is interpreted as a nonreactive nonstress test.

The client with hepatitis A is experiencing fatigue, weakness, and a general feeling of malaise. The client tires rapidly during morning care. What is the most appropriate goal for this client? Increase mobility. Learn new self-care skills. Adapt to new levels of energy. Gradually increase activity tolerance.

Gradually increase activity tolerance. Explanation: The most appropriate goal for this client with hepatitis is to increase activity gradually as tolerated. Periods of alternating rest and activity should be included in the plan of care. There is no evidence that the client is physically immobile, unable to provide self-care, or needs to adapt to new energy levels.

How should a nurse position a 4-month-old infant when administering an oral medication? Seated in a high chair Restrained flat in the crib Held on the nurse's lap Held in the bottle-feeding position

Held in the bottle-feeding position Explanation: The nurse should hold an infant in the bottle-feeding position when administering an oral medication by placing the child's inner arm behind the back, supporting the head in the crook of the elbow, and holding the child's free hand with the hand of the supporting arm. A 4-month-old infant can't sit unsupported in a high chair. Administering medication to an infant lying flat could cause choking and aspiration. Holding the infant in the lap may cause the medication to spill.

Which finding indicates that a client who has been raped will have future adjustment problems and need additional counseling? She becomes upset when talking about the rape to anyone. She seeks support from formerly ignored relatives and friends. Her parents show shame and suspicion about her part in the rape. Her life becomes focused on helping other rape victims like herself.

Her parents show shame and suspicion about her part in the rape. Explanation: The potential for problems in adjusting after a rape will be increased when those around the victim treat her as though she is to blame for the rape, especially when she already may feel some guilt and shame about it. A rape victim is likely showing adjustment to her experience when she is upset about her experience, when she seeks out formerly ignored relatives and friends for support, or when she attempts to help other rape victims.

A 1-year-old child is admitted to the hospital with sickle cell crisis. Which intervention will be a part of the child's plan of care? parenteral iron therapy exchange transfusion IV fluid therapy fast-acting anticoagulant therapy

IV fluid therapy Explanation: During a sickle cell crisis, increasing the transport and availability of oxygen to the body's tissues is paramount. Administering a high volume of IV fluid and electrolytes to help compensate for the acidosis resulting from hypoxemia associated with sickle cell crisis is one way to accomplish this. Fluid administration also helps overcome dehydration, a possible predisposing factor common in children with sickle cell crisis. Iron therapy is contraindicated for this condition. Exchange transfusions are used only in certain situations, such as severe hyperbilirubinemia. Small amounts of blood are removed from the infant and replaced with whole blood. This helps to correct the anemia and lower bilirubin levels. Although anticoagulants have been suggested, they are not included in the usual treatment of sickle cell crisis.

The nurse is caring for a client who is confused about time and place. The client has intravenous fluid infusing. The nurse attempts to reorient the client, but the client remains unable to demonstrate appropriate use of the call light. In order to maintain client safety, what should the nurse do first? Ask family members to stay with the client. Contact the health care provider, and request a prescription for soft wrist restraints. Increase the frequency of client observation. Administer a sedative.

Increase the frequency of client observation. Explanation: The first intervention for a confused client is to increase the frequency of observation, moving the client closer to the nurses' station if possible and/or delegating the unlicensed assistive personnel (UAP) to check on the client more frequently. If the family is able to stay with the client, that is an option, but it is the nurse's responsibility, not the family's, to keep the client safe. Wrist restraints are not used simply because a client is confused; there is no mention of this client pulling at intravenous lines, which is one of the main reasons to use wrist restraints. Administering a sedative simply because a client is confused is not appropriate nursing care and may actually potentiate the problem.

A client with suspected severe acute respiratory syndrome (SARS) comes to the emergency department. Which physician order should the nurse implement first? Institute isolation precautions. Begin an I.V. infusion of dextrose 5% in half-normal saline solution at 100 ml/hour. Obtain a nasopharyngeal specimen for reverse-transcription polymerase chain reaction testing. Obtain a sputum specimen for enzyme immunoassay testing.

Institute isolation precautions. Explanation: SARS, a highly contagious viral respiratory illness, is spread by close person-to-person contact. Contained in airborne respiratory droplets, the virus is easily transmitted by touching surfaces and objects contaminated with infectious droplets. The nurse should give top priority to instituting infection-control measures to prevent the spread of infection to emergency department staff and clients. After isolation measures are carried out, the nurse can begin an I.V. infusion of dextrose 5% in half-normal saline and obtain nasopharyngeal and sputum specimens.

The client with recurring depression will be discharged from the psychiatric unit. Which suggestion to the family is most important to include in the plan of care? Discourage visitors while the client is at home. Provide for a schedule of activities outside the home. Involve the client in usual at-home activities. Encourage the client to sleep as much as possible.

Involve the client in usual at-home activities. Explanation: It is best to involve the client in usual at-home activities as much as the client can tolerate them. Discouraging visitors may not be in the client's best interest because visits with supportive significant others will help reinforce supportive relationships, which are important to the client's self-worth and self-esteem. Providing for a schedule of activities outside the home may be overwhelming for the client initially. Involving the client in planning for outside activities would be appropriate. Encouraging the client to sleep as much as possible is nontherapeutic and promotes withdrawal from others.

A nurse is teaching a client who receives nitrates for the relief of chest pain. Which instruction should the nurse emphasize? Repeat the dose of sublingual nitroglycerin every 15 minutes for three doses. Store the drug in a cool, well-lit place. Lie down or sit in a chair for 5 to 10 minutes after taking the drug. Restrict alcohol intake to two drinks per day.

Lie down or sit in a chair for 5 to 10 minutes after taking the drug. Explanation: Nitrates act primarily to relax coronary smooth muscle and produce vasodilation. They can cause hypotension, which makes the client dizzy and weak. The nurse should instruct the client to lie down or sit in a chair for 5 to 10 minutes after taking the drug. Nitrates are taken at the first sign of chest pain and before activities that might induce chest pain. Sublingual nitroglycerin is taken every 5 minutes for three doses. If the pain persists, the client should seek medical assistance immediately. Nitrates must be stored in a dark place in a closed container because sunlight causes the medication to lose its effectiveness. Alcohol is prohibited because nitrates may enhance the effects of the alcohol.

A client with eclampsia begins to experience a seizure. Which intervention should the nurse do immediately? Pad the side rails. Place a pillow under the left buttock. Insert a padded tongue blade into the mouth. Maintain a patent airway.

Maintain a patent airway. Explanation: The priority for the pregnant client having a seizure is to maintain a patent airway to ensure adequate oxygenation to the mother and the fetus. Additionally, oxygen may be administered by face mask to prevent fetal hypoxia. Because the client is diagnosed with eclampsia, she is at risk for seizures. Thus, seizure precautions, including padding the side rails, should have been instituted prior to the seizure. Placing a pillow under the client's left buttock would be of little help during a tonic-clonic seizure. Inserting a padded tongue blade is not recommended because injury to the client or nurse may occur during insertion attempts.

A nurse reporting for the scheduled shift finds an assignment that includes the nurse's aunt, who was admitted during the night with a fractured hip. What should the nurse do in response to the client assignment?

Notify the supervisor and provide care until another nurse can be assigned to the client.

A healthcare provider has entered orders for a client with chronic obstructive pulmonary disease (COPD). Which of the following orders should the nurse question? Oxygen via nasal canula at 2 L/minute Keep head of bed elevated 30-45° Albuterol nebulizer treatments every 4 hours as needed Oxygen increased to 3 L/minute if oxygen saturation is less than 94% on room air

Oxygen increased to 3 L/minute if oxygen saturation is less than 94% on room air Explanation: People with COPD retain CO2, which is the normal trigger for respiratory rate. In clients with COPD and high levels of CO2, oxygen levels trigger breathing. Too much oxygen and the body slows breathing. Clients with COPD may quit breathing completely when given oxygen at very high levels (greater than 2 L).

A client is in the geriatric psychiatry inpatient unit. The client has bilateral electroconvulsive therapy (ECT) scheduled for tomorrow. Which of the following interventions would be most important for the nurse to implement for this client? Encourage the family to accompany the client to the treatment. Encourage fluids 6 to 8 hours before the treatment. Encourage caffeine intake the day before treatment. Provide frequent, supportive reorientation after the treatment.

Provide frequent, supportive reorientation after the treatment. Explanation: Common side effects of bilateral ECT treatments are confusion, disorientation, and short-term memory loss. The nurse should plan frequent, brief, and succinct reorientation statements. The client is frequently NPO after midnight prior to ECT therapy. Caffeine augmentation to ECT therapy would occur immediately prior to the procedure via intravenous administration. Family would be helpful for the client postprocedure, but would not necessarily be part of the plan of care for the procedure.

A postmenopausal client is scheduled for a bone density scan. What should the nurse instruct the client to do? Remove all metal objects on the day of the scan. Consume foods and beverages with a high content of calcium for 2 days before the test. Ingest 600 mg of calcium gluconate by mouth for 2 weeks before the test. Report any significant pain to the health care provider at least 2 days before the test.

Remove all metal objects on the day of the scan. Explanation: Metal will interfere with the test. Metallic objects within the examination field, such as jewelry, earrings, and dental amalgams, may inhibit organ visualization and can produce unclear images. Ingesting foods and beverages days before the test will not affect bone mineral status. Short-term calcium gluconate intake will also not influence bone mineral status. The client may already have had chronic pain as a result of a bone fracture or from osteoporosis.

A diagnosis of hemophilia A is confirmed in an infant. Which of the instructions should the nurse provide the parents as the infant becomes more mobile and starts to crawl? Administer one-half of a children's aspirin for a temperature higher than 101° F (38.3° C). Sew thick padding into the elbows and knees of the child's clothing. Check the color of the child's urine every day. Expect the eruption of the primary teeth to produce moderate to severe bleeding.

Sew thick padding into the elbows and knees of the child's clothing. Explanation: As the hemophilic infant begins to acquire motor skills, falls and bumps increase that risk of bleeding. Such injuries can be minimized by padding vulnerable joints. Aspirin is contraindicated because of its antiplatelet properties, which increase the infant's risk for bleeding. Because genitourinary bleeding is not a typical problem in children with hemophilia, urine testing is not indicated. Although some bleeding may occur with tooth eruption, it does not normally cause moderate to severe bleeding episodes in children with hemophilia.

The nurse is preparing a client for a thoracentesis. How should the nurse position the client for the procedure?

Sitting forward with the arms supported on the bedside table. Explanation: In preparation for a thoracentesis, the client should be asked to sit forward and place his arms on the bedside table for support. This position provides access to the chest wall and intercostal spaces for insertion of the needle. The supine, Sims', or prone position would not provide adequate access to the chest wall or separate the intercostal spaces sufficiently for needle insertion.

The nurse is administering packed red blood cells (PRBCs) to a client. What should the nurse do first? Discontinue the IV catheter if a blood transfusion reaction occurs. Administer the PRBCs through a percutaneously inserted central catheter line with a 20-gauge needle. Flush PRBCs with 5% dextrose and 0.45% normal saline solution. Stay with the client during the first 15 minutes of infusion.

Stay with the client during the first 15 minutes of infusion. Explanation: The most likely time for a blood transfusion reaction to occur is during the first 15 minutes or first 50 ml of the infusion. If a blood transfusion reaction does occur, it is imperative to keep an established I.V. line so that medication can be administered to prevent or treat cardiovascular collapse in case of anaphylaxis. PRBCs should be administered through a 19-gauge or larger needle; a peripherally inserted central catheter line is not recommended, in order to avoid a slow flow. RBCs will hemolyze in dextrose or lactated Ringer's solution and should be infused with only normal saline solution.

What is the main reason desflurane and sevoflurane, volatile liquid anesthesia agents, are used for surgical clients who go home the day of surgery? These agents are better tolerated. These agents are predictable in their cardiovascular effects. These agents are nonirritating to the respiratory tract. These agents are rapidly eliminated.

These agents are rapidly eliminated. Explanation: Desflurane and sevoflurane are volatile liquid anesthesia agents that are used for outpatient surgeries primarily because they are rapidly eliminated. They have the added benefits of being better tolerated and nonirritating to the respiratory tract, and they have predictable cardiovascular effects. However, rapid elimination is an important consideration for outpatient procedures.

A nurse assesses a client shortly after living donor kidney transplant surgery. Which postoperative finding must the nurse report to the physician immediately? Serum potassium level of 4.9 mEq/L Serum sodium level of 135 mEq/L Temperature of 99.2° F (37.3° C) Urine output of 20 ml/hour

Urine output of 20 ml/hour Explanation: Because kidney transplantation carries the risk of transplant rejection, infection, and other serious complications, the nurse should monitor the client's urinary function closely. A decrease from the normal urine output of 30 ml/hour is significant and warrants immediate physician notification. A serum potassium level of 4.9 mEq/L, a serum sodium level of 135 mEq/L, and a temperature of 99.2° F are normal assessment findings.

A nurse is assessing a client with hyperthyroidism. What findings should the nurse expect? Weight gain, constipation, and lethargy Weight loss, nervousness, and tachycardia Exophthalmos, diarrhea, and cold intolerance Diaphoresis, fever, and decreased sweating

Weight loss, nervousness, and tachycardia Explanation: Weight loss, nervousness, and tachycardia are signs of hyperthyroidism. Other signs of hyperthyroidism include exophthalmos, diaphoresis, fever, and diarrhea. Weight gain, constipation, lethargy, decreased sweating, and cold intolerance are signs of hypothyroidism.

A client who is 18 weeks pregnant is losing weight. She tells a nurse that she's out of work and, after paying bills, has no money to buy healthy food. The nurse should offer the client information about: Women, Infants, and Children (WIC). Women in Distress. Medicaid. Healthy Mothers, Healthy Babies.

Women, Infants, and Children (WIC). Explanation: WIC is an organization that assists women and infants who are at nutritional risk. The client may be able to obtain nutritional foods through this program. Women in Distress is an organization that provides shelter and services to women who are victims of domestic violence. Medicaid provides financial assistance to eligible low-income families. Healthy Mothers, Healthy Babies offers case managers to help pregnant women access community services.

At 24 hours of age, assessment of the neonate reveals the following: eyes closed, skin pink, no sign of eye movements, heart rate of 120 bpm, and respiratory rate of 35 breaths/min. What is this neonate most likely experiencing? drug withdrawal first period of reactivity a state of deep sleep respiratory distress

a state of deep sleep Explanation: At 24 hours of age, the neonate is probably in a state of deep sleep, as evidenced by the closed eyes, lack of eye movements, normal skin color, and normal heart rate and respiratory rate. Jitteriness, a high-pitched cry, and tremors are associated with drug withdrawal. The first period of reactivity occurs in the first 30 minutes after birth, evidenced by alertness, sucking sounds, and rapid heart rate and respiratory rate. There is no evidence to suggest respiratory distress because the neonate's respiratory rate of 35 breaths/min is normal.

An older adult has pruritus on the arms and legs and is scratching the affected areas. Which is the priority nursing care for this client? preventing infection instructing the client not to scratch increasing fluid intake avoiding social isolation

eventing infection Explanation: The client is at risk for infection because of the pruritus, and the nurse should institute measures to help the client control the scratching such as cutting fingernails, using protective gloves or mitts, and, if necessary, using antianxiety medications. More information is required regarding the knowledge level of the client, but learning cannot take place when an individual's attention is distracted with pruritus. Increasing fluid intake is not a priority at this time. There are no data to indicate the client is experiencing social isolation.

An outpatient client who has a history of paranoid schizophrenia and chronic alcohol dependency has been taking risperidone for several months. She reports that she stopped drinking 4 days ago. The client is very frightened by the tactile hallucinations of bugs crawling under her skin. Which factor should the nurse incorporate into the plan of care when explaining the tactile hallucinations? alcohol intoxication ineffectiveness of risperidone alcohol withdrawal interaction of alcohol and risperidone

alcohol withdrawal Explanation: Tactile hallucinations are more common in alcohol withdrawal than in schizophrenia. Therefore, the nurse should explain that these hallucinations are the result of withdrawal from alcohol. Because the client stopped drinking 4 days ago, the client is not intoxicated. Risperidone has little effect on symptoms of alcohol withdrawal. It is prescribed for symptoms of schizophrenia. Alcohol and risperidone have an additive effect, not one of causing hallucinations.

A primigravid client visits the clinic at 12 weeks' gestation and tells the nurse that she has a cold and her nose is stuffy. The nurse should instruct the client to treat the nasal stuffiness by using: oral antihistamines. oral decongestants. ice packs to the nasal area. saline nose drops.

aline nose drops. Explanation: Saline nose drops are a natural remedy and can alleviate the discomfort. Clients who are pregnant should not take any medications without consulting the health care provider; therefore, oral antihistamines and oral decongestions should be avoided. Ice packs are not helpful in alleviating congestion. Warm moist towels might be helpful.

A young adult has been bitten by a human, and the skin on the forearm is broken. The client's last tetanus shot was about 8 years ago. The nurse should prepare the client for: an injection of tetanus toxoid. application of a corticosteroid cream. closure of the wound with sutures. testing for tuberculosis.

an injection of tetanus toxoid. Explanation: Tetanus toxoid is indicated, since there has been no booster in the last 5 years. With a human bite there is a risk of severe infection; application of a steroid cream does not prevent infection. The closure of the wound should be delayed until it is determined that there is no infection, in approximately 24 to 48 hours. Tuberculosis is not transmitted through human bites.

An adolescent with cystic fibrosis has been hospitalized several times. On the latest admission, the client has labored respirations, fatigue, malnutrition, and failure to thrive. Which initial nursing actions are most important? placing the client on bed rest and obtaining a prescription for a blood gas analysis implementing a high-calorie, high-protein, low-fat, vitamin-enriched diet and pancreatic granules applying an oximeter and initiating respiratory therapy inserting an IV line and initiating antibiotic therapy

applying an oximeter and initiating respiratory therapy Explanation: Clients with cystic fibrosis commonly die from respiratory problems. The mucus in the lungs is tenacious and difficult to expel, leading to lung infections and interference with oxygen and carbon dioxide exchange. The client will likely need supplemental oxygen and respiratory treatments to maintain adequate gas exchange, as identified by the oximeter reading. The child will be on bed rest due to respiratory distress. However, although blood gases will probably be prescribed, the oximeter readings will be used to determine oxygen deficit and are, therefore, more of a priority. A diet high in calories, proteins, and vitamins with pancreatic granules added to all foods ingested will increase nutrient absorption and help the malnutrition; however, this intervention is not the priority at this time. Inserting an IV to administer antibiotics is important, and can be done after ensuring adequate respiratory function.

The nurse is caring for a client that is experiencing increasing shortness of breath. The client is pale and slight circumoral cyanosis is developing. Which laboratory test best measures the adequacy of tissue oxygenation? arterial blood gases red blood cell count pulmonary function test hemoglobin level

arterial blood gases Explanation: Arterial blood levels include levels of oxygen in the body and determines the adequacy of alveolar gas exchange. Red blood cell count provides information on the quantity of red blood cells in the system. Pulmonary function tests measures lung volume and capacity. Although hemoglobin is the red pigment in the red blood cells that carries oxygen, it is not the best measurement of tissue oxygenation.

A nurse is caring for an adolescent involved in a motor vehicle crash. The adolescent has a chest tube in place. If the chest tube is accidentally removed, the nurse should immediately: reintroduce the tube and attach it to water seal drainage. call a physician and obtain a chest tray. cover the opening with petroleum gauze. clean the wound with povidone-iodine and apply a gauze dressing.

cover the opening with petroleum gauze. Explanation: If a chest tube is accidentally removed, the nurse should cover the insertion site with sterile petroleum gauze. The nurse should then observe the client for respiratory distress because tension pneumothorax may develop. If tension pneumothorax does develop, the nurse should remove the gauze to allow air to escape. The nurse shouldn't reintroduce the tube. Rather, the nurse should have another staff member call a physician so another tube can be introduced by the physician under sterile conditions.

An older adult is having abdominal surgery. The nurse should assess the client for which postoperative concern related to normal changes in the integumentary system of an older adult? increased scarring decreased melanin and melanocytes decreased healing increased immunocompetence

decreased healing Explanation: Normal aging consists of decreased proliferative capacity of the skin. Decreased collagen synthesis slows capillary growth, impairs phagocytosis among older clients, and results in slow healing. Increased scarring is not a result of age-related skin changes. Both melanin and melanocytes give color to the skin and hair but are increased with aging. There is a decrease in the immunocompetence of the aging client.

A client is scheduled for a laparoscopic cholecystectomy and is surprised to learn that he will be discharged later the same day, provided there are no complications. When caring for a client who will be discharged shortly after a procedure, the nurse must: ensure that health education is begun as early as possible. ensure that this is specified in the client's informed consent document. administer prophylactic antibiotics four to six hours prior to surgery. ensure that the client is safe to drive before being discharged.

ensure that health education is begun as early as possible. Explanation: Trends towards early hospital discharge heighten the need to begin health education as early as possible and to reinforce it often. Clients cannot drive themselves home safely on the day of surgery, and it is not the nurse's responsibility to review the specific provisions of informed consent documentation. Antibiotics will be prescribed on a case by case basis; their use and the timing of administration will vary.

A 25-year-old woman who is in the first stage of labor receives a continuous lumbar epidural block when the cervix is 6 cm dilated. After administration of this anesthesia, which assessment would be most important? fetal heart rate maternal pulse level of anesthesia level of consciousness

fetal heart rate Explanation: The anesthetic used for the epidural block may cause relaxation of maternal blood vessels, leading to lower maternal blood pressure. The decrease in maternal blood pressure causes oxygenated blood to move more slowly to the fetus, commonly leading to a lower fetal heart rate and hypoxia. A major complication is a decreased fetal heart rate. Thus, assessment of fetal heart rate is most important. While measuring maternal pulse is important, this vital sign does not tell the nurse as much about fetal perfusion as the fetal heart rate or maternal blood pressure. Epidural anesthesia has no effect on the status of the membranes or the color of the amniotic fluid. The membranes may rupture spontaneously or by amniotomy. The person responsible for administering the anesthesia would be responsible for determining the level of anesthesia. Although some clients may sleep after an epidural, the client normally remains conscious while under the influence of regional anesthesia, such as an epidural block. Assessing the level of consciousness, although important for any client, is not the priority following epidural anesthesia.

A client with cervical cancer is undergoing internal radium implant therapy. A lead-lined container and a pair of long forceps have been placed in the client's hospital room. What should the nurse tell the client about how these will be used? The forceps and container will be used for: disposal of emesis or other bodily secretions. handling of the dislodged radiation source. disposal of the client's eating utensils. storage of the radiation dose.

handling of the dislodged radiation source. Explanation: Dislodged radioactive materials should not be touched with bare or gloved hands. Forceps are used to place the material in the lead-lined container, which shields the radiation. Exposure to radiation can occur only by direct exposure to the encased radioactive substance; it cannot result from contact with emesis or urine or from touching the client. Disposal of eating utensils cannot lead to radiation exposure. Radioactive dose materials are kept only in the radiation department.

The nurse observes that when a client with Parkinson's disease unbuttons the shirt, the upper arm tremors disappear. Which statement best guides the nurse's analysis of this observation about the client's tremors? The tremors are probably psychological and can be controlled at will. The tremors sometimes disappear with purposeful and voluntary movements. The tremors disappear when the client's attention is diverted by some activity. There is no explanation for the observation; it is a chance occurrence.

he tremors sometimes disappear with purposeful and voluntary movements. Explanation: Voluntary and purposeful movements often temporarily decrease or stop the tremors associated with Parkinson's disease. In some clients, however, tremors may increase with voluntary effort. Tremors associated with Parkinson's disease are not psychogenic but are related to an imbalance between dopamine and acetylcholine. Tremors cannot be reduced by distracting the client.

A multigravida client has given birth to a large-for-gestational age infant with Apgar scores of 8 and 9. The priority nursing assessment for this infant is for: jaundice passage of meconium hypoglycemia failure to thrive

hypoglycemia Explanation: A large-for-gestational-age infant is at risk for hypoglycemia due to the possibility of a mother having diabetes (may or may not be diagnosed or related to gestation). The fetus makes insulin in response to the blood glucose that crosses the placenta; after birth, the fetus continues to make insulin even though high maternal blood glucose is no longer present. The result is neonatal hypoglycemia. The nurse will continue to monitor for passage of meconium in the newborn, but it may take several hours and is not a priority at this time. While nurses assess amniotic fluid for meconium so they can suction the airway at birth and attempt to prevent meconium aspiration of the newborn, this infant is already at least 5 minutes of age and breathing (according to the Apgar scores). The infant may develop jaundice, or failure to thrive, but there is no information to suggest these findings at this time.

A 14-year-old client in skeletal traction for treatment of a fractured femur is expected to be hospitalized for several weeks. When planning care, the nurse should take into account the client's need to achieve what developmental milestone? autonomy initiative industry identity

identity Explanation: According to Erikson's theory of personal development, the adolescent is in the stage of identity versus role confusion. During this stage, the body is changing as secondary sex characteristics emerge. The adolescent is trying to develop a sense of identity, and peer groups take on more importance. The hospitalized adolescent is separated from the peer group and the adolescent's body image may be altered. This alteration in body image may interfere with the ongoing development of the adolescent's identity. Toddlers are in the developmental stage of autonomy versus shame and doubt. Preschool children are in the stage of initiative versus guilt. School-age children are in the stage of industry versus inferiority.

A 3-month-old infant with meningococcal meningitis has just been admitted to the pediatric unit. Which nursing intervention has the highest priority? instituting droplet precautions administering acetaminophen obtaining history information from the parents orienting the parents to the pediatric unit

instituting droplet precautions Explanation: Instituting droplet precautions is the priority for a newly admitted infant with meningococcal meningitis. Acetaminophen may be prescribed, but administering it does not take priority over instituting droplet precautions. Obtaining history information and orienting the parents to the unit do not take priority.

A nurse is caring for a client with a history of falls. The nurse's first priority when caring for a client at risk for falls is: placing the call light on the bedside table. keeping the bed in the lowest possible position. instructing the client not to get out of bed without assistance. keeping the bedpan available so that the client doesn't have to get out of bed.

keeping the bed in the lowest possible position. Explanation: Keeping the bed at the lowest possible position is the first priority for clients at risk for falling. The call light should be placed so that it is easily accessible. Instructing the client not to get out of bed may not effectively prevent falls — for example, if the client is confused. Even when the client needs assistance to get out of bed, the nurse should place the bed in the lowest position. The client may not require a bedpan.

A client is being prepared for a bronchoscopy. The nurse can delegate which task to the unlicensed assistive personnel (UAP)? obtaining the signed consent form placing the client on NPO status instructing the client about the procedure evaluating the client's level of anxiety

placing the client on NPO status Explanation: It would be appropriate for the nurse to instruct the UAP to place the client on NPO status. It is the responsibility of the health care provider performing the procedure to obtain the client's informed consent and have the form signed. It is the responsibility of the registered nurse to teach clients and evaluate their health status. These responsibilities cannot be delegated to a UAP.

Which client requires immediate nursing intervention? The client who: complains of epigastric pain after eating. complains of anorexia and periumbilical pain. presents with a rigid, boardlike abdomen. presents with ribbonlike stools.

presents with a rigid, boardlike abdomen. Explanation: A rigid, boardlike abdomen is a sign of peritonitis, a possibly life-threatening condition. Epigastric pain occurring 90 minutes to 3 hours after eating may indicate a duodenal ulcer. Anorexia and periumbilical pain are characteristic of appendicitis. A client with a large-bowel obstruction may have ribbonlike stools.

Before discharge from the hospital after a myocardial infarction, a client is taught to exercise by gradually increasing the distance walked. Which vital sign should the nurse teach the client to monitor to determine whether to increase or decrease the exercise level? pulse rate blood pressure body temperature respiratory rate

pulse rate Explanation: The client who is on a progressive exercise program at home after a myocardial infarction should be taught to monitor the pulse rate. The pulse rate can be expected to increase with exercise, but exercise should not be increased if the pulse rate increases more than about 25 bpm from baseline or exceeds 100 to 125 bpm. The client should also be taught to discontinue exercise if chest pain occurs.

The Orthodox Jewish family of a client admitted for cochlear implantation expresses outrage at their child being served a pork dish after they identified their religion to the nursing staff. The best response of the nurse would be to: quickly remove the offending food and order a replacement. apologize and reassure them that it won't happen again. reciprocate their anger and call the kitchen to complain. recognize their request and respectfully take corrective action.

recognize their request and respectfully take corrective action.

A client with multiple sclerosis (MS) lives with her daughter and 3-year-old granddaughter. The daughter asks the nurse what she can do at home to help her mother. Which measure would be most beneficial? psychotherapy regular exercise day care for the granddaughter weekly visits by another person with MS

regular exercise Explanation: An individualized regular exercise program helps the client to relieve muscle spasms. The client can be trained to use unaffected muscles to promote coordination because MS is a progressive, debilitating condition. The data do not indicate that the client needs psychotherapy, day care for the granddaughter, or visits from other clients.

Which approach is the best way for the nurse to begin the preoperative interview? Walk in the client's room: and ask, "Are you Mrs. Smith?" sit down, and take the client's blood pressure. sit down, maintain eye contact, and make an introduction. and ask the client's name.

sit down, maintain eye contact, and make an introduction. Explanation: Nurses should provide the preoperative client individual and sincere attention by meeting the client at eye level and introducing themselves by name and role. The nurse should ask the client to tell her full name rather than asking if she is Mrs. Smith because there might be another client by that name on the schedule. Nurses should not start the physical assessment or ask the client's name without first identifying themselves and their role out of courtesy and to relieve the client's anxiety in the new environment of the surgical experience.

The nurse assigns an unlicensed assistive personnel (UAP) to the care of a client who has just returned from surgery for repair of a fractured right wrist and application of an arm cast. The nurse should stress to the UAP the importance of reporting: the client cannot move the fingers on the right hand. results of hourly neurovascular assessments. intake and output record for the shift. the client is feeling heat from the plaster cast.

the client cannot move the fingers on the right hand. Explanation: The UAP should report immediately to the nurse any sign that the client cannot move the fingers on the casted arm, numbness or tingling, or feelings of tightness because these may indicate impaired neurovascular status. The nurse, not the UAP, is responsible for neurovascular assessments. Intake and output would usually not be particularly significant in a client with a fractured arm. It is normal for the client to feel heat immediately after application of a plaster cast.

When examining a client who has abdominal pain, a nurse should assess: any quadrant first. the symptomatic quadrant first. the symptomatic quadrant last. the symptomatic quadrant either second or third.

the symptomatic quadrant last. Explanation: The nurse should systematically assess all areas of the abdomen, if time and the client's condition permit, concluding with the symptomatic area. Otherwise, the nurse may elicit pain in the symptomatic area, causing the muscles in other areas to tighten. This tightening would interfere with further assessment.

A client undergoes an amniotomy. Shortly afterward, the nurse detects large variable decelerations in the fetal heart rate (FHR) on the external electronic fetal monitor (EFM). These findings signify: an infection. umbilical cord prolapse. the start of the second stage of labor. the need for labor induction.

umbilical cord prolapse. Explanation: After an amniotomy, a significant change in the FHR may indicate umbilical cord prolapse; an EFM may show large variable decelerations during cord compressions. Infection, the start of the second stage of labor, and the need for labor induction aren't associated with FHR changes. An infection causes temperature elevation. The second stage of labor starts with complete cervical dilation. Labor induction is indicated if the client's labor fails to progress.

A client has extreme fatigue and is malnourished, and laboratory tests reveal a hemoglobin level of 8.5 g/dL (85 g/L). The nurse should specifically ask the client about the intake of food low in which nutrients? vitamins A, E, and C vitamins B6 and B12, folate, iron, and copper thiamine, riboflavin, and niacin vitamins A and B

vitamins B6 and B12, folate, iron, and copper Explanation: Many vitamin and mineral deficiencies can result in anemia. All of these vitamins and minerals need to be assessed, preferably through a nutrition assessment. Deficiencies of vitamins A, B6, and C result in a small cell, microcytic anemia. Folate and vitamin B12 deficiencies result in a large cell, macrocytic anemia. Iron, copper, and vitamin E deficiencies can also result in anemia.

The health care team determines that the family of an infant with failure to thrive who is to be discharged will need follow-up care. Which approach would be the most effective method of follow-up? daily phone calls from the hospital nurse enrollment in community parenting classes twice-weekly clinic appointments weekly visits by a community health nurse

weekly visits by a community health nurse Explanation: The most effective follow-up care would occur in the home environment. The community health nurse can be supportive of the parents and will be able to observe parent-infant interactions in a natural environment. The community health nurse can evaluate the infant's progress in gaining weight, offer suggestions to the parents, and help the family solve problems as they arise.

A 14-year-old with rheumatic fever who is on bed rest is receiving an IV infusion of dextrose 5% r administered by an infusion pump. The nurse should verify the alarm settings on the infusion pump at which times? Select all that apply. when the infusion is started at the beginning of each shift when the child returns from X-ray when the child moves in the bed when the child is sleeping

when the infusion is started at the beginning of each shift when the child returns from X-ray Explanation: The alarm settings on infusion pumps should be verified at the time the infusion is started, at the beginning of each shift, and when the client is moved. The child can move in bed or sleep, but if the alarm is triggered, the nurse should verify the settings.