Final

That of assent

A 12-year-old child is being admitted to the unit for a surgical procedure. The child is accompanied by two parents and a younger sibling. The level of involvement in treatment decision making for this child is:

Critical clinical pathways

A 7-year-old child has been admitted for acute appendicitis. The parents are questioning the nurse about expectations during the child's recovery. Which information tool would be most useful in answering a parent's questions about timing of key events?

The babysitter with written proxy consent

A child is being prepared for an invasive procedure in the presence of the child's babysitter. The single mother of the child has legal custody but is not present. After details of the procedure are explained, the legal informed consent for treatment on behalf of a minor child will be obtained from

Intact skin and mucous membranes protect against microbial invasion.

A client comes to the emergency department with major burns over 40% of his body. Although all of the following are true, which one would provide the rationale for a nursing diagnosis of Risk for Infection?

allergic reaction

A client diagnosed with anemia is receiving a blood transfusion. The client develops urticaria accompanied by wheezing and dyspnea not long after the transfusion starts. The nurse interprets this as indicative of which of the following?

Chronic pain has far reaching effects on the client

A client having acute pain tells the nurse that her pain has gradually reduced, but that she fears it could recur and become chronic. What is a characteristic of chronic pain?

trigeminal nerve

A client tells the nurse that she is experiencing stabbing pain in her mouth, gums, teeth, and chin following brushing her teeth. These are symptoms of which of the following pain syndromes?

The disease is present but the client is not experiencing symptoms

A client who has breast cancer is said to be in remission. What does this term signify

chronic obstructive pulmonary disease (COPD)

A client's PaCO2 is abnormal on an ABG report. Which of is the most likely be the medical diagnosis?

Inability to take in adequate oral food or fluids within 7 days

A critical care nurse is caring for a patient diagnosed with acute pancreatitis. The nurse knows that the indications for starting parenteral nutrition (PN) for this patient are what?

Nosocomial

A female client is on isolation because she acquired a methicillin-resistant S. aureus (MRSA) infection after hospitalization for hip replacement surgery. What name is given to this type of infection?

Soil

A nurse caring for a client who has gas gangrene knows that this infection originated in which of the following reservoirs?

To prevent gastric irritation

A nurse is administering a medication that is formulated as enteric-coated tablets. What is the rationale for not crushing or chewing enteric-coated tablets?

Risk for imbalanced body temperature

A nurse is caring for a client with a serious bacterial infection. The client is dehydrated. Knowledge of the physical effects of the infection would support which of the following nursing diagnoses?

Decreased skin turgor over sternum Decreased blood pressure Low urine output Decreased pulse Decreased respiratory rate

A nurse is caring for a client with dehydration. Which of the following signs is observed in a client with dehydration? Select all that apply.

To remove gas from the stomach To remove toxins from the stomach To diagnose Gi motility disorders

A nurse is caring for a patient who has a gastrointestinal tube in place. Which of the following are indications for gastrointestinal intubation? Select all that apply

Administer an isotonic dextrose solution for 1 to 2 hours after discontinuing the PN.

A nurse is caring for a patient who has an order to discontinue the administration of parenteral nutrition. What should the nurse do to prevent the occurrence of rebound hypoglycemia in the patient?

direct contact

A nurse is caring for an adolescent who is diagnosed with mononucleosis, commonly called "the kissing disease." The nurse explains that the organisms causing this disease were transmitted by:

Decreased bladder contractility may lead to urine retention and stasis, which increase the likelihood of urinary tract infection.

A nurse is caring for older adult clients in an assisted-living facility. Which effect of aging should the nurse consider when performing a urinary assessment

Clotted or displaced catheter Pneumothorax Hyperglycemia Line sepsis

A nurse is creating a care plan for a patient who is receiving parenteral nutrition. The patient's care plan should include nursing actions relevant to what potential complications? Select all that apply.

A)Preparing the patient to troubleshoot for problems B) Teaching the patient and family strict aseptic technique C) Teaching the patient and family how to set up the infusion

A nurse is preparing to discharge a patient home on parenteral nutrition. What should an effective home care teaching program address? Select all that apply.

Wear a pair of sterile latex gloves

A nurse is required to clean the open wounds of a client who has been involved in an automobile accident. What intervention would the nurse need to perform when cleaning open wounds to protect himself from infection?

300mL Typical tidal volume for a dog is about 15 ml/kg

A nurse monitoring the intake and output of fluids for a client with severe diarrhea knows that normally how much body fluid is lost via the gastrointestinal tract?

changes in lifestyle Loss of eating as a social behavior Sleep disturbances related to frequent urination during nighttime infusions

A patient has been discharged home on parenteral nutrition (PN). Much of the nurse's discharge education focused on coping. What must a patient on PN likely learn to cope with? Select all that apply.

dilute concentration of feeding solution

A patient receiving tube feedings is experiencing diarrhea. The nurse and the physician suspect that the patient is experiencing dumping syndrome. appropriate?

Explain to the client why this is needed

A physician writes an order to "force fluids." What will be the first action the nurse will take in implementing this order?

Disconnect tubing from the suction before giving drugs, and clamp tubing for 20-30 min

A student nurse is administering medications through a nasogastric tube connected to continuous suction. How will the student do this accurately?

reservoir

A woman tests positive for the human immunodeficiency virus antibody but has no symptoms. She is considered a carrier. What component of the infection cycle does the woman illustrate?

Diminished kidney ability to concentrate urine

An older woman who is a resident of a long-term care facility has to get up and void several times during the night. This can be the result of what physiologic change with normal aging?

Severe inflammatory bowel disease, severe pancreatitis, aids

Reasons to give tpn

Trace the outline of the drainage on the dressing for future comparison.

The dressing surrounding a mastectomy patient's Jackson-Pratt drain has scant drainage on it. The nurse believes that the amount of drainage on the dressing may be increasing. How can the nurse best confirm this suspicion?

prodromal stage

The nurse is aware that an antiviral medication is most effective when given during which phase of the infectious process?

Gently rotate the tube

The nurse is caring for a patient who is postoperative from having a gastrostomy tube placed. What should the nurse do on a daily basis to prevent skin breakdown?

The patient expresses interest in the dressing change. The patient is willing to look at the incision during a dressing change The patient assists in opening the packages of dressing material for the nurse.

The nurse is caring for a postoperative patient who needs daily dressing changes. The patient is 3 days postoperative and is scheduled for discharge the next day. Until now, the patient has refused to learn how to change her dressing. What would indicate to the nurse the patient's possible readiness to learn how to change her dressing? Select all that apply.

Provide all discharge instructions in writing. Provide the nurse's or surgeon's contact information. Give prescriptions to the patient

The nurse is discharging a patient home from an outpatient surgery center. The nurse has reviewed all of the discharge instructions with the patient and her caregiver. What else should the nurse do before discharging the patient from the facility? Select all that apply.

The patient is agitated

The nurse is preparing to insert a patient's ordered NG tube. What factor should the nurse recognize as a risk for incorrect placement?

atelectasis

The perioperative nurse is providing care for a patient who is recovering on the postsurgical unit following a transurethral prostate resection (TUPR). The patient is reluctant to ambulate, citing the need to recover in bed. For what complication is the patient most at risk?

Unintentional injury

When discussing injury prevention with the parents of a toddler, which statement indicates teaching has been successful? "The leading cause of death in children is:

One who had thoracic surgery 4 days ago

Which client would benefit from a p.r.n. drug regimen?

Specific signs and symptoms are present. The organisms are growing and multiplying.

Which of the following are characteristics of the stage of infection known as full stage of illness? Select all that apply

Extracellular volume excess related to heart failure, as evidenced by edema and orthopnea

Which of the following statements is an appropriate nursing diagnosis for an client 80 years of age diagnosed with congestive heart failure, with symptoms of edema, orthopnea, and confusion?

2-3 months

You are caring for a patient who was admitted to have a low-profile gastrostomy device (LPGD) placed. How soon after the original gastrostomy tube placement can an LPGD be placed?