HESI Practice Quizzes

A pregnant client is admitted with abdominal pain and heavy vaginal bleeding. Which is the immediate nursing action?

Administering oxygen Abdominal pain and heavy vaginal bleeding indicate significant blood loss. To compensate for decreased cardiac output, oxygen is given to maintain the well-being of both mother and fetus. Elevating the head of the bed will decrease blood flow to vital centers in the brain. Drawing blood for a hematocrit level is not the priority. Giving an intramuscular analgesic may mask abdominal pain and sedate an already compromised fetus; also, it requires a primary health care provider's prescription.

When a client has sinus tachycardia, which potential causes of the dysrhythmia would the nurse consider when assessing the client? Select all that apply. One, some, or all responses may be correct.

Anxiety Caffeine Exercise Anemia Causes of sinus tachycardia include hypovolemia, heart failure, anemia, exercise, use of stimulants (such as caffeine), fever, and sympathetic response to fear or pain (for example, anxiety). Hypothermia will cause sinus bradycardia.

When checking the cervical dilation of a client in labor, the nurse notes that the umbilical cord has prolapsed. Which action would the nurse take in response to this finding?

Assist the client into the Trendelenburg position.

Which nursing assessment would the nurse recognize as indicative of improved respiratory status in an infant who had corrective surgery for a diaphragmatic hernia?

Auscultation of breath sounds bilaterally Bilateral breath sounds indicate that the lungs are expanded and functioning. Lack of crying is not a reliable indicator that the respiratory status is improving; it may indicate that the infant is hypoxic and too fatigued to cry. The expected pH is 7.35 to 7.45; a decreasing pH indicates respiratory acidosis, which can be attributed to decreased gas exchange. Retention of formula is unrelated to gas exchange.

Which assessment would the nurse prioritize for a newborn with Down syndrome?

Cardiac irregularities for congenital heart disease Children with Down syndrome have a high incidence of congenital heart defects, indicated by altered heart sounds. Without treatment, a heart defect may become life threatening. The other options are expected but are not life threatening and therefore not prioritized.

Which is prevented by providing warm, humidified oxygen to a preterm infant?

Cold stress By warming and humidifying oxygen, the nurse will prevent cold stress and drying of the mucosa. Apnea and bronchopulmonary dysplasia are not associated with the administration of oxygen that is not warmed or humidified. Respiratory distress can develop in a preterm infant as a result of the cold stress.

The nurse provides education for a client who has received a prescription for spironolactone. The information includes a correlation between potassium intake and the medication, and a list of fluids and their potassium content. The nurse concludes that the teaching is effective when the client plans to consume which type of juice?

Cranberry juice Spironolactone is a potassium-sparing diuretic, and foods high in potassium should be avoided. Cranberry juice should be recommended because it contains the least potassium. Prune, orange, and tomato juices are all high in potassium.

When a client has a right pneumothorax, which type of breath sounds will the nurse expect to hear on the right chest?

Decreased sounds Because the right lung is collapsed with a right pneumothorax, the nurse would expect very decreased or absent breath sounds on the right. Crackles occur with movement of air through fluid, such as with pulmonary edema, and would not be expected with pneumothorax. Wheezes occur with air movement through narrowed airways and would not be heard when there is no air movement because of lung collapse. Vesicular sounds are the normal sounds heard with inspiration and expiration and would not be heard on the right side.

Which are symptoms of hyperglycemia? Select all that apply.

Dry skin Increased thirst Deep, rapid breathing Hyperglycemia acts as an osmotic diuretic, resulting in increased urine output (polyuria) and dehydration. Dry skin is a sign of hyperglycemia resulting from dehydration. Thirst is a compensatory mechanism that causes a person to drink increased amounts of fluid (polydipsia). Deep, rapid breathing (Kussmaul breathing) is the body's effort to blow off carbon dioxide in an attempt to correct the metabolic acidosis associated with hyperglycemia and ketoacidosis. Irritability is an autonomic nervous system response to hypoglycemia, not hyperglycemia. Sweating with pale, cool skin is an autonomic nervous system response associated with hypoglycemia, not hyperglycemia.

Which emergency severity index (ESI) level should be considered a high priority for the nurse caring for clients in the emergency department (ED)?

ESI-1 ESI-1 should be considered a high priority for care in the ED because the ESI-1 clients are in unstable condition. ESI-2 indicates that clients can wait 10 minutes for care in the ED. ESI-3 level clients can wait up to 1 hour because their conditions are stable. ESI-4 clients' treatment can be delayed for longer, depending on the cases in the ED.

The delegator, working in collaboration with a delegatee, assigns responsibilities and explains the various procedures and techniques needed to accomplish the task. Which action is the delegator performing, according to the Hersey model?

Explaining and persuading Hersey's model describes the leader's behavior as explaining or persuading, which is characterized as " selling." In this situation, the delegator is assigning the work to the delegatee and explaining the various procedures and techniques to accomplish the specified task. A leader's behavior described as guiding or directing is characterized as "telling," in which the delegate simply assigns the task to the delegatee. The leader's behavior of observing or monitoring is characterized as "delegating," in which the delegator is responsible and accountable for the entire task. A leader's behavior that is encouraging or problem-solving is characterized as "participating," in which the delegator establishes a working environment in which to complete the task in the specified time.

The nurse is caring for a school-aged child with cystic fibrosis. Which pathophysiologic factor has the greatest effect on the child's health status?

Extremely thick mucus causing obstructed airways Dysfunction of the exocrine glands leads to an excessive accumulation of thick mucus, a slower flow rate of mucus, and incomplete expectoration of mucus, all of which contribute to airway obstruction. Acute inflammation of the lung parenchyma is associated with pneumonia, not cystic fibrosis. The endocrine glands are not affected in cystic fibrosis. Increased irritability of the airways that causes obstruction is associated with asthma, not cystic fibrosis.

Which complication associated with type 1 diabetes should the nurse include in the teaching plan for parents of a newly diagnosed child?

Ketoacidosis Ketoacidosis is a complication of type 1 diabetes; children require close blood glucose monitoring because of the demands of growth and their erratic diets. Obesity is more often associated with children who have type 2 diabetes. Resistance to treatment during the school-aged years is not common; problems are related to the changing requirements associated with growth. Hypersensitivity to other medications is unrelated to either type 1 or type 2 diabetes.

Which factor in a client's history suggests a risk for preterm labor?

Multiple urinary tract infections Infections, especially urinary tract infections, are a risk factor for preterm labor. The number of pregnancies is not a risk factor for preterm labor. An android-shaped pelvis is more likely to cause dystocia than preterm labor. Clients receiving anticonvulsant medications are not at an increased risk for preterm labor.

Which type of vision problem would the nurse document when a client describes being able to see near objects clearly, but objects in the distance are blurry?

Myopia This client is describing myopia, which is nearsightedness. Hyperopia is farsightedness. Presbyopia is the loss of accommodation, which causes an inability to focus on near objects. Astigmatism is an uneven curvature of the cornea, which causes distorted vision.

A pregnant client's blood test reveals an increased alpha-fetoprotein (AFP) level. Which condition is indicated with this result?

Neural tube defect Increased levels of alpha-fetoprotein in pregnant women have been found to reflect open neural tube defects such as spina bifida and anencephaly. Cystic fibrosis is a genetic defect that is not associated with the AFP level. A Guthrie test soon after ingestion of formula can determine whether an infant has phenylketonuria. Down syndrome is a chromosomal defect that is associated with a low AFP level.

Which type of acid-base imbalance would the nurse expect in a child admitted with a severe asthma exacerbation?

Respiratory acidosis caused by impaired respirations and increased formation of carbonic acid The restricted ventilation accompanying an asthma attack limits the body's ability to blow off carbon dioxide. As carbon dioxide accumulates in the body fluids, it reacts with water to produce carbonic acid; the result is respiratory acidosis. The problem basic to asthma is respiratory, not metabolic. Respiratory alkalosis is caused by the exhalation of large amounts of carbon dioxide; asthma attacks cause carbon dioxide retention. Asthma is a respiratory problem, not a metabolic one; metabolic acidosis can result from an increase of nonvolatile acids or from a loss of base bicarbonate.

During a seizure, a client had sudden loss of muscle tone that lasted for a few seconds followed by confusion. Which statement about this type of seizures is true? Select all that apply. One, some, or all responses may be correct.

These seizures increase the risk for injuries from a fall. These seizures are most resistant to medication therapy. Atonic (akinetic) seizures are characterized by a sudden loss of muscle tone lasting for seconds followed by postictal confusion. These seizures cause the client to fall because of the decreased muscle tone, which may result in injury. This type of seizure tends to be most resistant to medication therapy. Amnesia is associated with complex partial seizures. In simple partial seizures, the client reports an aura and perception of unusual sensations, such as an offensive smell and sudden onset of pain. Simple partial seizures are also associated with one-sided movement of the extremities.

Which type of support provides immediate relief to the client with tongue occlusion, loss of gag reflex, alterations in level of consciousness, oxygen (O 2) saturation of 40 mm Hg, and carbon dioxide (CO 2) saturation of 75 mm Hg?

Tracheotomy Upper airway obstruction may occur with tongue occlusion, which is associated with loss of gag reflex and alterations in the level of consciousness. The client suffering from severe hypoxia (O 2saturation of 40 mm Hg) and who is hypercapnic (CO 2 saturation of 75 mm Hg) requires an emergency tracheotomy for relief within 2 minutes. Laryngeal repair is performed to prevent laryngeal stenosis and cover exposed cartilage. The abdominal thrust maneuver clears upper airway obstruction caused by a foreign body. Autotitrating positive airway pressure resets the pressure throughout the breathing cycle in a client with severe sleep apnea.

Five victims of a shooting are identified as needing urgent care. Which would the triage officer do first when these victims arrive in the emergency department (ED)?

Triage the victims. The triage officer rapidly evaluates each person who presents to the hospital, even those who come in with triage tags in place. Client acuity is reevaluated for appropriate disposition to the area within the ED or hospital best suited to meet the client's medical needs. The clients will need to be triaged before being sent to the operating room. The triage officer would not be responsible for conducting laboratory testing or notifying the next of kin of the victims.

A client who is admitted to the hospital and requires a colon resection states, "I want to be a do not resuscitate [DNR]." The nurse questions the client's understanding of a DNR order. Which response by the client best indicates to the nurse an understanding of a DNR order?

"If something happens to me, I do not want cardiopulmonary resuscitation [CPR]." The statement, "If something happens to me, I do not want CPR," specifically states that if cardiac or respiratory arrest occurs, the client would rather die peacefully and does not want cardiorespiratory resuscitation. If a DNR order is signed by the client, cardiopulmonary resuscitation will not be instituted. The response, "My doctor will know what to do," reflects an advance directive (e.g., durable power of attorney for health care), wherein a client gives power to another person (agent, surrogate, or proxy) to make health care decisions on the client's behalf. The response, "My family can make the decisions for me," reflects an advance directive (e.g., durable power of attorney for health care), wherein a client gives power to another person (agent, surrogate, or proxy) to make health care decisions on the client's behalf. The response, "If I have a heart attack, I do not want any medication," reflects an advance directive (e.g., living will), wherein the client directs treatment in accordance with personal wishes.

Which client statement indicates understanding of teaching about a nonstress test?

"If the heart reacts well, my baby should do OK when I give birth." The nonstress test is used to evaluate the response of the fetus to movement and activity. A reactive test indicates that the fetus is healthy. No injections of any kind are used during a nonstress test; it involves only the use of a fetal monitor to record the fetal heart rate during periods of activity. The nonstress test will not influence the activity of the fetus because no exogenous stimulus is used. Early labor is unlikely because the nonstress test is noninvasive.

During a routine second-trimester visit to the prenatal clinic a client expresses concern regarding gaining weight and losing her figure. She says to the nurse, "I'm going on a diet." Which is the nurse's best response?

"If you add 340 calories a day to your regular diet, you won't become overweight." Weight reduction is not advised during pregnancy; an additional 340 calories a day during the second trimester is recommended. When the client reaches the third trimester, another 120 calories should be added to her diet. A pregnant woman should not diet during pregnancy. Advising the client to eat a variety of foods provides insufficient information. The client should increase her protein and calorie intake during pregnancy. Dieting during pregnancy is harmful; the fetus may be deprived of essential nutrients. The client should not be limited to a specific weight gain. There is no specific recommendation for the amount of weight a pregnant woman should gain. However, 25 to 30 lb (11-16 kg) is the average generally suggested; this figure is based on the recommended caloric intake during pregnancy and the client's prepregnancy weight and metabolic rate.

Which instruction given by the nurse promotes healing in a client recovering after surgical removal of the pituitary gland by endoscopic transnasal approach?

"Increase high-fiber food intake." The nurse would instruct the client who is recovering after surgical removal of the pituitary gland to consume high-fiber food. Intracranial pressure is raised if the client strains during defecation. Fibrous foods reduce the risk of constipation and thereby reduce bowel strain. The client would be instructed to drink sufficient water to facilitate easy bowel movements and soften the stools. The nurse would teach the client to bend the knees and then lower the body to pick up fallen objects; bending at the waist increases intracranial pressure. The client would use dental floss and avoid brushing postoperatively for at least 2 weeks to prevent disturbance of the operative site.

The nurse knows that additional discharge instructions are needed for parents whose infant has just undergone corrective surgery for cleft palate when the parent makes which statement?

"Lying on the abdomen is prohibited, so we'll keep him in an infant seat." After cleft palate repair, the child is allowed to lie on the abdomen, especially immediately after surgery; this will allow drainage of secretions from the mouth. Children with cleft palate have an increased risk of middle ear infections, which can result in hearing loss, so hearing tests are scheduled early and repeated periodically throughout childhood. Until the infant adjusts to breathing through the mouth, he may exhibit difficulty breathing after surgery; this seldom requires more than positioning and support. Elbow restraints may be prescribed to keep the child's hands out of his mouth.

On the third postpartum day the nurse is preparing a breast-feeding mother of twins for discharge. Which statement by the client indicates a potential problem?

"My flow is bright red with small brown clots the size of my thumb." Bright-red lochia with thumb-sized brown clots indicates subinvolution and requires further assessment. Urination of large amounts is the expected postpartum diuresis. Breasts that feel full, heavy, and tingly before breast-feeding reflect the influence of the posterior pituitary hormone oxytocin, which causes the let-down reflex and is expected before each feeding. An increased appetite is expected with breast-feeding, especially of twins.

When a client with varicose veins asks the nurse, "What can I do to help myself?", how would the nurse respond?

"Put on compression hose before getting out of bed in the morning." Compression hose provide external pressure, thereby facilitating venous return and minimizing blood pooling in the veins. Because venous return is better at night when the legs are at the same level as the heart, the hose should be put on before getting out of bed in the morning and before the legs are in the dependent position. The client should engage in exercise such as walking or swimming because muscle contraction encourages venous return to the heart. Limiting fluid intake will not alter the leakage of fluid or blood into the interstitial space; this occurs in response to the increased hydrostatic pressure in the veins. Although applying moisturizing lotion may make the skin suppler, it will not treat enlarged and tortuous veins.

Which statement made by the nursing student indicates effective learning about victims exposed to chemical agents of terrorism who have burned or blistered skin and describes the agent as a brown gas that has a garlic-like odor?

"The clients were exposed to mustard gas." Mustard gas is yellow to brown and has a garlic-like odor. The gas irritates the eyes and causes skin burns and blisters. So, the nurse would conclude that the clients were exposed to mustard gas. Sarin is a nerve gas that causes death by paralyzing the respiratory muscles. Tularemia is a biological agent of warfare. It is not a gas and does not cause burned or blistered skin. Phosgene is a colorless gas that causes severe respiratory distress, pulmonary edema, and death.

The registered nurse (RN) and an unlicensed assistive personnel (UAP) are caring for a client with diarrhea. After 2 hours, the RN communicates with the UAP and decides that the client needs immediate assessment. Which statements by the UAP led the nurse to this conclusion? Select all that apply. One, some, or all responses may be correct.

"The temperature of the client is 105°F." "I have administered intravenous fluids to the client." Because the client's temperature is high, the client will require further nursing assessment. Administering intravenous fluidsshould not be performed by UAPs because they are unlicensed professionals; therefore the nurse would intervene immediately. Activities related to the client's hygiene can be performed by the UAP. A client suffering with diarrhea should not be allowed to eat foods such as pizza, because this may lead to a worsening condition. However, this finding does not call for immediate assessment. Activities such as changing client's clothes and cleaning the client's hands and legs can be performed by the UAP.

A primipara who was exhausted after a long labor requested time to rest before rooming in with her infant. After awakening and having the infant brought back to her, she asks whether she may undress him. How would the nurse respond?

"This is important for you. Of course you can undress your baby." One aspect of the attachment or bonding process is the parents' need to touch, hold, and observe their newborn; this is facilitated by encouraging the mother to undress, gaze at, and hold her newborn. If not asked for help, the nurse would honor the mother's request and encourage her to undress, touch, and hold her baby. A healthy naked newborn can withstand the temperature variation in the mother's room especially if placed skin to skin with the mother whose body warmth can help maintain the newborn's temperature.

The nurse is providing education about care of the residual limb to a client who had a below-the-elbow amputation. Which information will the nurse include in the teaching session?

"Wash and dry the residual limb at least once a day." Bathing removes microorganisms and promotes circulation, which facilitates wound healing; drying prevents maceration of skin and reduces moisture, which limits bacterial growth. A sling will interfere with comfort and mobility and can result in elbow or shoulder contractures. Lotion may facilitate adherence of bacteria to wound edges and promote maceration of the skin, which interferes with wound healing. Soaking may cause maceration of the skin and interfere with wound healing.

When ammonia is excreted by healthy kidneys, which mechanism usually is maintained?

Acid-base balance of the body The excreted ammonia combines with hydrogen ions in the glomerular filtrate to form ammonium ions, which are excreted from the body. This mechanism helps rid the body of excess hydrogen, maintaining acid-base balance. Osmotic pressure of the blood and normal red blood cell production are not affected by excretion of ammonia. Ammonia is formed by the decomposition of bacteria in the urine; ammonia excretion is not related to the process and does not control bacterial levels.

A gravida 1 client with B negative blood gives birth to a baby whose blood type is O positive. Which intervention would the nurse expect to be included in the client's plan of care?

Administration of Rho (D) immune globulin Rho (D) immune globulin prevents sensitization from Rh incompatibility that may arise between an Rh-negative mother and an Rh-positive infant. Only the mother's and the newborn's blood types are relevant at this time, so the father's blood type would not be determined. ABO incompatibility occurs if the fetal blood type is A, B, or AB and the mother's blood type is O. Because there is no ABO incompatibility and the risk of an Rh incompatibility is minimal because this is the mother's first pregnancy, neither mother nor infant requires a transfusion.

Which emergency assessments are performed by the nurse in a primary survey for a client with injuries from a bomb blast? Select all that apply. One, some, or all responses may be correct.

Airway Breathing Circulation Identify deformities The primary survey focuses on the ABCs—airway-breathing-circulation—disability, and exposure or environmental control. Airway-breathing-circulation and identifying deformities are performed in a primary survey to identify life-threatening conditions to analyze the appropriate interventions. Assessing focused adjuncts and giving comfort measures are performed during a secondary survey.

Which causative agent is common to both hyperthermia and hypothermia?

Alcohol Alcohol is the causative agent that is common to both hyperthermia and hypothermia. Barbiturates and phenothiazines can cause hypothermia. Cardiovascular disease can cause hyperthermia.

Which nursing action best promotes parent-infant attachment with a newborn who is being transferred to a regional neonatal intensive care unit because of respiratory distress?

Allowing the parents to hold their infant before departure Because seeing and touching the newborn infant are species-specific behaviors for human attachment, allowing the parents to hold the infant will promote bonding. Although encouraging the parents to call the infant by name is a useful action, holding and touching will promote bonding more effectively. After touching and holding, having a picture of their infant in the intensive care unit contributes most to bonding. Actual holding and touching promote bonding more than just hearing about the infant's progress.

A client in her 36th week of gestation is admitted with vaginal bleeding, severe abdominal pain, a rigid fundus, and signs of impending shock. For which intervention would the nurse prepare?

An immediate cesarean birth The client's signs and symptoms are those of complete placental separation (abruptio placentae) for which an immediate cesarean birth is the ideal treatment. High-forceps birth is rarely used, because the forceps may further complicate the situation by tearing the cervix. The risk for fetal and maternal mortality is too high to delay action, so a fetal monitor would not be inserted. Administration of oxytocin would greatly increase the risk of fetal death.

When teaching about nutrition during pregnancy, which is the change in daily caloric intake the nurse would say the pregnant woman needs?

An increase of 300 calories per day An increase of 300 calories per day is the recommended caloric increase for adult women to meet the increased metabolic demands of pregnancy. A decrease of 100 to 200 calories per day will not meet the metabolic demands of pregnancy and may harm the fetus. An increase of 500 calories per day is the recommended caloric increase for breast-feeding mothers.

While changing a newborn girl's diaper the nurse observes a brick-red stain on the diaper. How would the nurse interpret this clinical finding?

An uncommon benign occurrence The brick-red color in the urine is caused by albumin and urates that are found in the first week of life. Iron is eliminated by way of the gastrointestinal tract. The finding is unrelated to the sex of the infant; it is not hormonally based. No medication administered during labor will cause this discoloration.

To prevent potential aspiration, which technique would the nurse use when cleaning a tracheostomy tube that has a nondisposable inner cannula?

Apply precut dressing around the insertion site with the flaps pointing upward. A precut dressing is used to prevent raveling and potential aspiration of small particles of the gauze into the airway. Only a precut dressing should be used around the site and should be positioned to collect expectorations. An obturator is used only for inserting the outer cannula. The use of sterile cotton balls to cleanse the outer cannula is contraindicated; cotton balls have small threads that may be inhaled. The status of the cuff has no effect on tracheostomy care.

A client required an extensive episiotomy because her newborn was large. Which nursing intervention will minimize edema and lessen discomfort associated with an episiotomy?

Applying ice packs to the perineum Application of cold causes vasoconstriction and reduces edema by lessening the accumulation of blood and lymph at the episiotomy site. Cold also deadens nerve endings and lessens the pain. Positioning the client off the incisional area in a side-lying position will not lessen pain or reduce edema. Analgesia may diminish the pain but will not lessen the edema. An anesthetic spray is not recommended after an episiotomy.

The nurse is caring for a client admitted with chronic obstructive pulmonary disease (COPD). Which laboratory test would the nurse monitor for hypoxia?

Arterial blood gas Red blood cell count, sputum culture, and total hemoglobin tests assist in the evaluation of a client with respiratory difficulties; however, arterial blood gas analysis is the only test that evaluates gas exchange in the lungs. This provides accurate information about the client's oxygenation status.

Which assessment findings signify correct placement of a nasogastric tube into a preterm infant's esophagus for feedings? Select all that apply. One, some, or all responses may be correct.

Aspiration produces a small quantity of light-yellow or light-green liquid. Testing of the aspirate with the use of a nitrazine strip reveals that the gastric fluid is acidic. Aspirated fluid that is either light green or yellow indicates gastric contents. The nitrazine strip test provides reliable proof that the tube is in the stomach. The tube is in the trachea, not the esophagus; when a tube crosses through the larynx, the infant is unable to vocalize. Although the tube being inserted to a depth from the ear to the tip of the nose to the sternum is the correct measurement of the length of tube to be inserted, it is not a guarantee that the tube is in the stomach. The "whoosh test" is no longer used to verify placement of the tube because evidence has shown that it is not reliable.

The charge nurse is communicating with the registered nurse (RN) about caring for a client with a respiratory disorder. Which instructions are delegated to the RN to provide effective care to the client? Select all that apply. One, some, or all responses may be correct.

Assess the client's respirations after 1 hour Provide intravenous medication every 3 hours. The RN can perform activities that include assessing vital signs like respiration rate and administering intravenous medications. Feeding and changing the client's clothes usually are performed by unlicensed assistive personnel. The RN will not inform the LPN if the vital signs are abnormal because LPNs do not have enough knowledge to identify abnormal changes.

Which information will the nurse include when teaching a client with intermittent claudication in the lower legs?

Assess the feet daily for injuries. Because decreased blood flow to the feet hinders healing of any breaks in the skin, the client should monitor the feet daily. Compression hose would decrease blood flow further and should be avoided. Exercise programs to improve collateral blood flow in intermittent claudication involve exercising until ischemic pain develops, then resting and repeating the exercise. Blood flow to the feet will be further decreased when the feet are elevated. The client would be taught to keep the feet in a dependent position to improve perfusion.

If a person's clothes catch on fire, which action is the most important to perform after the flames are extinguished?

Assess the person's breathing. Assessing the person's airway is the most important action to perform. A patent airway is most vital; if the person is not breathing, cardiopulmonary resuscitation (CPR) should be instituted. The other options are correct but not as important as airway. The person should be kept nothing by mouth because large burns decrease intestinal peristalsis and the person may vomit and aspirate. Covering the person with a light blanket or sheet is appropriate. Calculating the extent of the person's burns is not the priority; this assessment is done after transfer to a medical facility.

A client in early active labor at 40 weeks' gestation reports that her membranes ruptured 26 hours ago. Initial assessments of the fetal heart rate range between 168 and 174 beats/min. Which is the priority nursing action?

Assessing maternal vital signs A prolonged period after the rupture of membranes and fetal tachycardia indicate the possibility of maternal infection; the maternal vital signs should be assessed for fever and increased pulse and respirations. Planning for an emergency birth is premature unless the fetal status deteriorates and intrauterine resuscitation efforts fail. Administration of oxygen should be done with high-flow oxygen via nonrebreather if assessment of the external monitoring is not reassuring, but this is not demonstrated in this scenario. Fetal scalp blood testing may be done after additional data are collected and the cause of the tachycardia is determined.

An older adult client who is receiving chemotherapy for cancer has severe nausea and vomiting and becomes dehydrated. The client is admitted to the hospital for rehydration therapy. Which nursing actions have specific gerontological implications the nurse must consider? Select all that apply. One, some, or all responses may be correct.

Assessment of skin turgor Administration of antiemetic medications Replacement of fluid and electrolytes When skin turgor is assessed, the presence of tenting may be related to loss of subcutaneous tissue associated with aging rather than to dehydration; skin over the sternum should be used instead of skin on the arm for checking turgor. Older adults are susceptible to central nervous system side effects, such as confusion, associated with antiemetic medications; dosages must be reduced, and responses must be evaluated closely. Because many older adults have delicate fluid balance and may have cardiac and renal disease, replacement of fluid and electrolytes may result in adverse consequences, such as hypervolemia, pulmonary edema, and electrolyte imbalance. Vital signs can be obtained as with any other adult. Intake and output can be measured accurately in older adults.

Which nursing action is appropriate when conducting a secondary survey during the emergency assessment?

Assigning a nurse to support family members Rationale: A nursing action that is appropriate during the secondary survey is assigning a nurse or other team member to support family members. Maintaining privacy, having suction available, and giving supplemental O 2 are all interventions during the primary survey.

Which symptom would the client in a women's health educational session be taught to report as a possible early indication of cervical cancer?

Bloody spotting after intercourse Bloody spotting after intercourse may indicate cervical pathology and must be investigated. Discomfort and abdominal heaviness are late signs of cervical cancer, because there are few nerve endings in this area. The cancer must be extensive to cause pressure. Discharge becomes foul smelling after there is necrosis and infection; it is not an early sign.

Which assessment finding indicates that a client at 40 weeks' gestation is experiencing true labor?

Cervical dilation True labor is marked by cervical dilation, effacement, or both. It is not uncommon for membranes to rupture before true labor begins. A change in the fetal heart rate does not indicate true labor; the rate may be slowing because the fetus is resting or fetal compromise is occurring. The client's perception of the intensity of contractions is not an indication of true labor. Because of admission to the hospital and loss of diversionary activities, the client may perceive the contractions as becoming more intense.

When a client reports a sudden onset of chest pain that feels like a pressure or weight on the chest, which action would the nurse take first?

Check blood pressure and heart rate. Because there are multiple diagnoses that might cause chest pain, the nurse would first assess for cardiovascular symptoms such as changes in blood pressure or heart rate. Activation of the rapid response team may be needed, but this will depend on vital signs and other assessments. Administration of nitroglycerin may be needed, but blood pressure should be taken before giving nitroglycerin to avoid hypotension. More information about the client's past cardiac history will be helpful, but the priority action is to check the client's current physiologic status.

Which is the nurse's next action when the fundus of a healthy multipara at 16 weeks' gestation is palpated at one fingerbreadth above the umbilicus?

Check for two distinct fetal heart rates. Twins should be suspected with a faster-than-expected increase in fundal height; the nurse should assess the client for two distinct heartbeats. Fundal height, not the size of the fetus, should prompt the nurse to suspect a multiple pregnancy. The due date cannot be determined until ultrasonography has been performed. Weight gain does not influence the height of the fundus.

Which is the nurse's first action when a client in active labor starts screaming, "The baby is coming! Do something!"?

Check the perineal area for visibility of the presenting part. The first action by the nurse would be to confirm whether birth is imminent by checking the perineal area to determine whether the presenting part is emerging. Confirming the client's sensation is the priority; the nurse would remain with the client and ask a colleague to call the practitioner if birth is imminent. Stating that birth is not imminent demeans the client, and she may be correct. Holding the knees together is contraindicated. If birth is imminent, this could cause injury to the fetus, and if it is not imminent, this position is uncomfortable and unnecessary.

Which action would the nurse take first when an excessive amount of serosanguinous drainage is noted on the mastectomy dressing of a client who has just had a mastectomy and has a portable wound drainage system to the axillary area in place?

Checking the function of the drainage system If the tubing is patent and negative pressure is present, the wound should be free of exudate. Drainage is expected; it is the nurse's responsibility to maintain the drainage system. The surgeon would be notified if the excessive amount of drainage continues after the nurse has assessed the situation and corrected any problems with the drainage system. Pressure dressings are not used with portable wound drainage systems because the systems are effective in removing interstitial fluid. Although elevating the arm may facilitate drainage, it is not the priority in relation to the data presented.

Which action would the home health nurse take when caring for a client with a pink and moist left leg venous stasis ulcer?

Clean the wound with normal saline and apply prescribed hydrocolloid dressings weekly. For noninfected venous stasis ulcers, typical care includes cleaning with normal saline and applying a hydrocolloid dressing, which is left in place for at least 3 to 5 days to promote a moist environment for wound healing. Because venous stasis ulcers are associated with edema, not with poor arterial blood flow to the wound, clients are taught to keep the leg elevated for 20 minutes at least 4 to 5 times daily to reduce swelling. Anticoagulant medications are not prescribed for venous stasis ulcers, although they are prescribed for clients who have had venous thrombosis. Vascular surgery is used for arterial ulcers, but it is not effective for venous stasis ulcers.

The nurse plans to delegate some of the tasks for the discharge of a postpartum client to an unlicensed health care worker. Which activity must be performed by the nurse?

Comparing the identification bands of mother and infant It is the nurse's professional responsibility to compare the mother's and infant's identification bands one last time before discharge. This ensures that the correct infant is discharged with the mother. Taking the neonate's picture, arranging the client's postpartum appointment, and preparing the discharge packets and distributing them to parents are all within the role of the nursing assistant and may be delegated safely.

The nurse is obtaining consent from an unemancipated minor to perform an abortion. When would the nurse consider the consent-giving process to be appropriately completed? Select all that apply. One, some, or all responses may be correct.

Consent has been given specifically by a court. Self-consent has been granted by a court order. Consent has been obtained from at least one parent of the minor. An unemancipated minor is allowed to consent to an abortion if one of three conditions is fulfilled. The minor may give consent if consent has been obtained from at least one parent. The minor may also give consent if consent has been given specifically by a court or self-consent has been granted by a court order. The spouse or grandparents of unemancipated minors are not allowed to give consent for abortions.

A client is prepared for a supratentorial craniotomy with burr holes, and an intravenous infusion of mannitol is instituted. The nurse concludes that this medication is primarily given for which purpose?

Decrease fluid in the brain Osmotic diuretics remove excessive cerebrospinal fluid (CSF), reducing intracranial pressure. Osmotic diuretics increase, not decrease, the blood pressure by increasing the fluid in the intravascular compartment. Osmotic diuretics do not directly influence blood glucose levels. Although there is an increase in cardiac output when the vascular bed expands as CSF is removed, it is not the primary purpose of administering the medication.

When a client experiences increased serum cortisone levels, which physiological response would the nurse consider when caring for the client?

Decreased pituitary secretion of adrenocorticotropic hormone (ACTH) Cortisone and ACTH work together via a feedback loop. Increased levels of cortisone inhibit the pituitary secretion of ACTH. ACTH is released in response to decreased blood levels of cortisone. ACTH then stimulates release of additional adrenocortical hormone. Cortisone has anti-inflammatory properties that delay wound healing. As a glucocorticoid, cortisone increases gluconeogenesis in the liver. Cortisone assists the body in responding to stress.

How would the nurse classify burns that are painful, red to white, and edematous?

Deep partial-thickness burns In deep partial-thickness burns, destruction of the epidermis and part of the dermis occurs, leading to painful, red-to-white color. Eschar, a dry leathery covering of denatured protein, occurs with full-thickness burns. With deep full-thickness burns, total destruction of the epidermis, dermis, and some underlying tissue occurs; the area appears black and is painless. With superficial partial-thickness burns, the epidermis is destroyed or injured, leading to pink to red color.

Which clinical findings would cause the nurse to suspect that an adolescent child with type 1 diabetes is hypoglycemic?

Difficulty concentrating, hunger, and diaphoresis Difficulty concentrating, hunger, and diaphoresis are the most common signs and symptoms of hypoglycemia. Increased adrenergic nervous system activity and increased catecholamine secretion produce hunger and diaphoresis. Difficulty concentrating reflects central nervous system glucose deprivation. Increased thirst, sleepiness, and nausea are signs and symptoms of hyperglycemia as ketoacidosis develops. Confusion, dry mouth, and diminished reflexes are signs and symptoms of hyperglycemia; they reflect ketoacidosis. Flushed face, deep breathing, and abdominal pain are signs and symptoms of ketoacidosis.

A client gives birth to a full-term male with an 8/9 Apgar score. Which would be included in the immediate nursing care of this newborn?

Drying him off, assessing respirations, and identifying him Drying him off, establishing a patent airway, and identifying the newborn are the priorities. Application of eye prophylaxis and administration of vitamin K are often delayed to allow the parents to bond with the infant; a bath at this time will increase the risk of cold stress. Aspirating the oropharynx, rushing him to the nursery, and stimulating him frequently are measures appropriate for a compromised newborn; an 8/9 Apgar score is indicative of a healthy newborn. Weighing him, placing him in a crib, and waiting until the mother is ready to hold him are not the priority care for a newborn.

Which is a primary focus of teaching for a pregnant adolescent at her first prenatal clinic visit?

Encouraging her to continue regularly scheduled prenatal care It is not uncommon for adolescents to avoid prenatal care; many do not recognize the deleterious effect that lack of prenatal care can have on them and their infants. Instruction in the care of an infant can be done in the later part of pregnancy and reinforced during the postpartum period. Informing the client of the benefits of breast-feeding should come later in pregnancy but not before the client's feelings about breast-feeding have been ascertained. Advising the client to watch for danger signs of preeclampsia is necessary, but it is not the priority intervention at this time.

A client is hospitalized for an exacerbation of emphysema. The client is experiencing a fever, chills, and difficulty breathing on exertion. Which is an important nursing action?

Encouraging increased fluid intake Fluids will replace fluid loss from fever and decrease viscosity of secretions. Capillary refill relates to peripheral tissue perfusion. There are no data to suggest that secretions are blocking the airway; there is no support that suctioning is needed. High concentrations of oxygen generally are not administered to clients with chronic obstructive pulmonary disease (COPD); traditionally, the reason given for this was that clients with COPD become desensitized to carbon dioxide as a respiratory stimulus so that reduced oxygen levels act as the stimulus and high concentrations of oxygen levels may actually depress respirations. The newer theory suggests that the hypoxic drive is valid for a small number. The majority of cases involve the Haldane effect; as hemoglobin molecules become more saturated with oxygen, they are unable to transport carbon dioxide out of the body, leading to hypercapnia.

Which disease increases the risk of hyperkalemia?

End-stage renal disease One of the kidneys' functions is to eliminate potassium from the body; diseases of the kidneys often interfere with this function, and hyperkalemia may develop, necessitating dialysis. Clients with Crohn disease have diarrhea, resulting in potassium loss. Clients with Cushing disease will retain sodium and excrete potassium. Clients with gastroesophageal reflux disease are prone to vomiting that may lead to sodium and chloride loss with minimal loss of potassium.

Which intervention by the home health care nurse conforms to the use of safety competency while providing health care?

Ensures the furniture does not obstruct the client's movement The nurse assesses the client's home and ensures the home environment is safe for the client. The nurse conforms to the safety competency while ensuring that the furniture does not obstruct the client's movement. The nurse uses informatics competency to update the client's electronic health record. The nurse exhibits teamwork and collaboration competency by coordinating with the local pharmacy to supply medications for the client. The nurse applies patient-centered care while teaching the family caregiver to assist the client with range-of-motion exercises, for example.

Which care settings are more suitable for unlicensed nursing personnel (UNP)? Select all that apply. One, some, or all responses may be correct.

Extended care Long term care Rationale: Extended care and long-term care settings are more suitable for UNP. Acute care, surgical care, and emergency care settings require highly qualified and licensed nursing professionals. Acute care, surgical care, and emergency care are not suitable for UNPs because the clients are less stable compared with those in extended care and long-term care. Because acute care, surgical care, and emergency care settings require highly qualified and licensed nursing professionals, the UNP's role is very limited.

Which clinical manifestations does the nurse expect the client to report when admitted for surgical resection of a rectosigmoid colon cancer? Select all that apply. One, some, or all responses may be correct.

Feeling tired Rectal bleeding Change in the shape of stools Feeling of abdominal bloating Anemia may manifest as fatigue, feeling tired, and/or generalized weakness. Anemia is common with rectosigmoid colon cancer from the loss of blood rectally. Passage of red blood (hematochezia) is 1 of the cardinal signs of rectosigmoid colon cancer; ulceration of the tumor and straining to pass stool precipitate this clinical finding. A cancerous mass can grow into the lumen of the sigmoid colon, altering the shape of stool; stools may be ribbonlike or pencil thin. Tumors in the rectosigmoid colon cause partial and eventually complete obstruction of the intestinal lumen. Because there is less fluid in the stool of the descending and sigmoid colon, a formed mass develops; thus, the client strains to pass stools, and gas pains (causing a feeling of abdominal bloating), cramping, and incomplete evacuation commonly occur. An inability to digest fat is not specific to rectosigmoid colon cancer; therefore, stools will not float and will contain bile, which colors the stool brown.

Which major group of substances in human milk are of special importance to the newborn and cannot be reproduced in a bottle formula?

Gamma globulins The gamma globulin antibodies in human milk provide the infant with immunity against all or most of the pathogens that the mother has encountered. Amino acids and essential electrolytes are present in commercial formulas. Complex carbohydrates are not required by the infant.

Where would the fundal height be located in a pregnant client at 16 weeks' gestation?

Half the distance to the umbilicus Considering the growth of the fetus, the expected height of the fundus at 16 weeks' gestation is half the distance to the umbilicus. The height of the fundus in centimeters is approximately the same as the number of weeks of gestation if the woman's bladder is empty at the time of measurement. Above the umbilicus is where the fundus should be palpated after 24 weeks' gestation until term. At the level of the umbilicus is where the fundus should be palpated at 22 to 24 weeks' gestation. Between 12 and 14 weeks' gestation, the uterus outgrows the pelvic cavity and can be palpated just above the symphysis pubis.

The nurse is getting ready to perform an initial assessment interview of a Chinese older adult who does not speak English and is hard of hearing. Which would be available before starting the interview to minimize communication problems that may lead to health disparity?

Hearing aid and interpreter To minimize communication problems leading to health disparities between the client and the nurse, a hearing aid and an interpreter should be available. A client with a broken leg will have limited mobility and may need a wheelchair, but this has no role in eliminating communication barriers. A sphygmomanometer is required to measure blood pressure, but it will not improve communication.

Fetal heart rate tracing abnormalities are observed on the fetal monitor when a client in active labor turns to the supine position. Which nursing action is most beneficial at this time?

Helping the client change her position Rationale: Changing the maternal position is the most beneficial action, especially with late- and variable-deceleration patterns, because this position change will increase placental perfusion. Although the client should be kept informed of the fetus's condition, this may be done during or immediately after the position change; the needs of the fetus are the priority. If oxygen is used, the concentration should be greater than 2 L/min. Readjusting placement of the fetal monitor may be done after the position change; the immediate needs of the fetus are the priority.

A client with 35% of total body surface area burned in a fire is now 48 hours postburn. Which finding indicates that the client is moving from the emergent to the acute phase of burn management?

Hypokalemia Fluid remobilization during the acute phase of burn injury results in hypokalemia because of diuresis and the movement of potassium back into the intracellular compartment. Hyperglycemia occurs during the acute phase because of lipolysis, gluconeogenesis, and glycogenolysis and a relative insulin insensitivity. During the acute stage fluid shifts back into the intravascular compartment, resulting in an increased blood pressure and increase in the glomerular filtration rate. When the glomerular filtration rate increases, there is an increase in the urinary output. As the urinary output increases, the urine specific gravity decreases.

A client with a myocardial infarction receives intravenous nitroglycerin to relieve pain. The nurse will assess for which medication side effect?

Hypotension The major action of intravenous nitroglycerin is venous and then arterial dilation, leading to a decrease in blood pressure and resulting in decreased cardiac workload. Nausea is not a common side effect of intravenous nitroglycerin. Nitroglycerin does not cause delirium. Reflex tachycardia may occur with the decrease in blood pressure.

A child with a brain tumor diagnosed as an astrocytoma complains of a headache and begins to cry during a physical examination while lying in the supine position. Which would the nurse suspect as the most likely cause of the headache?

Increased intracranial pressure caused by blood pooling in the head A headache is a sign of increased intracranial pressure; lying supine increases blood flow to the brain, adding to the brain and tumor mass. There is no evidence that the child is fasting; however, if this were true, the child would complain of hunger and perhaps a headache at times other than when she was in the supine position. Although children at this age still suffer from a milder form of separation anxiety, the child's behavior does not indicate this type of anxiety. Although children of this age fear mutilation, the child's behavior does not indicate this kind of fear.

Which complication is the result of type 1 diabetes in a pregnant client?

Increased risk of hypertensive states The likelihood of gestational hypertension increases fourfold in the client with diabetes mellitus, probably because of a preexisting vascular disorder. Abnormal implantation occurs because of scarring or uterine abnormalities, not because of diabetes. Most pregnant women have an increased appetite; excessive weight gain may be caused by a macrosomic fetus and hydramnios. More than 2000 mL of amniotic fluid (hydramnios, polyhydramnios) is associated with diabetes; its exact cause is unknown. It also occurs with major congenital fetal anomalies, Rh sensitization, and infections (e.g., syphilis, toxoplasmosis, cytomegalovirus, herpes, and rubella).

The laboratory report of a client reveals increased levels of atrial natriuretic peptide. Which other finding would the nurse anticipate to find in the client?

Increased sodium excretion in urine Atrial natriuretic peptide is secreted by the myocyte cells in the right atrium. Atrial natriuretic peptide acts on the kidneys and causes an increase in the excretion of sodium by inhibiting aldosterone. Atrial natriuretic peptide increases urine output. Atrial natriuretic peptide causes inhibition of renin and angiotensin II, and therefore the resultant urine produced contains more water and is dilute. Because atrial natriuretic peptide relaxes the afferent arteriole in the nephron, glomerular filtration rate is increased.

Two days after delivery a client has a temperature of 101°F (38.3°C), general malaise, anorexia, and chills. Which clinical finding would the nurse expect to identify on the client's laboratory report?

Increased white blood cell (WBC) count An increased WBC count is indicative of an infectious process. In postpartum clients hemoglobin values usually decrease because of the typical blood loss during the birth process. C-reactive protein is increased during an infectious process. A right-shift differential WBC count occurs in clients with liver disease and pernicious anemia; a shift to the left occurs in an infectious process and is related to an increase in immature neutrophils.

For which condition would an infant born with exstrophy of the bladder be at risk?

Infection The greatest problem facing this infant is infection of the bladder mucosa and excoriation of the surrounding tissue; meticulous hygiene is necessary both before and after surgery. Dehydration is not a problem, because fluid intake and the amount of urine output are not affected. Urine retention is not a problem, because the urine drains continuously. The congenital abnormality involves the genitourinary system, not the intestines.

Which conditions are risk factors that may place infants at a higher risk for developing jaundice? Select all that apply. One, some, or all responses may be correct.

Infection Prematurity Breast-feeding Maternal diabetes Infants are at a higher risk of jaundice if they have an infection, are born prematurely, are exclusively breast-fed, or if their mothers have diabetes. Newborns of East Asian race have a higher risk factor than African-Americans to develop jaundice. Infants who are fed formula do not develop jaundice as often as breast-fed babies do.

Which function of limbic system is accurate?

Influence emotional behavior Located lateral to the hypothalamus, the limbic system influences emotional behavior and basic drives such as feeding and sexual behaviors. The regulation of endocrine and autonomic functions is the function of the hypothalamus. The control and facilitation of learned and automatic movements is the function of the basal ganglia. The thalamus relays sensory and motor input to and from the cerebrum.

The registered nurse (RN) is caring for a client with epilepsy. Which tasks delegated by the registered nurse (RN) to the members of the health care team indicate active delegation? Select all that apply. One, some, or all responses may be correct.

Instructing the licensed practical nurse (LPN) to monitor the vital signs Instructing the unlicensed assistive personnel (UAP) to reposition the client Instructing the unlicensed assistive personnel (UAP) to place the oxygen mask Passive delegation includes performing the tasks based on the position description, such as physician or pharmacist. The individual functioning in this role performs these tasks through passive delegation. Instructing the LPN to administer diazepam, medication that was already prescribed by the primary health care provider, is passive delegation. Instructing the LVN to administer sedatives that were already prescribed by the primary health care provider is passive delegation. Instructing the LPN to monitor vital signs is active delegation as the RN directs assistive personnel to perform certain tasks and holds the individual accountable. Instructing the UAP to reposition the client is also an active delegation as the UAP is carrying out certain tasks that are directed by the RN. Instructing the UAP to place the oxygen mask is an active delegation as the RN directs assistive personnel to perform certain tasks.

In the playroom of a pediatric unit, the nurse sees several toddlers seated at a table trying to copy the same picture from a book. They are not talking to each other or sharing their crayons. Which would the nurse conclude about this behavioral interaction?

It is a typical expression of toddlers' social development. As part of the socialization process, toddlers enjoy playing beside other children (parallel play); they are not developmentally ready for interactive (cooperative) play, which begins in the preschool years. This is not antisocial behavior; it is a misinterpretation of parallel play that is typical of toddlers' behavior. This is not an example of an ineffective parental role model; it is a misinterpretation of parallel play that is typical of toddlers' behavior. There are no data to indicate that the children are experiencing separation anxiety.

In the playroom of a pediatric unit, the nurse sees several toddlers seated at a table trying to copy the same picture from a book. They are not talking to each other or sharing their crayons. Which would the nurse conclude about this behavioral interaction?

It is a typical expression of toddlers' social development. The parents of a toddler-age client who has an easy temperament should be encouraged to make sustained eye contact with the child as a form of discipline. Ignoring the behavior is not effective for any temperament. Implementing a time-out and using physical containment is appropriate for the child with a difficult temperament.

Which parent teaching would the nurse provide to explain the rationale for a chest tube in an infant who underwent open repair of a fractured sternum?

It is inserted to drain the chest cavity of air. When the chest was opened during surgery for the sternal repair, air entered the thorax; the air must be removed to allow the lungs to reexpand. Chest tubes may be uncomfortable and saying the infant will feel no discomfort discounts the importance of the chest tube to the infant's respiratory status. The tube was inserted for a specific reason; the infant would not be subjected to this discomfort without a specific purpose for the tube's insertion. Placement of the chest tube is unrelated to the infant's ability to retain feedings.

A newborn who has remained in the hospital because the mother had a cesarean birth is to be tested for phenylketonuria (PKU) on the morning of discharge. How would the nurse explain the purpose of PKU testing to this mother?

It is used to measure protein metabolism. Phenylalanine, an essential amino acid, or protein, necessary for growth and development, cannot be metabolized by infants with PKU; early diagnosis and treatment may prevent neurodevelopmental disorders. Tests for thyroid deficiency are done at the same time as PKU testing, but there is no relationship between thyroid deficiency and PKU. Recognition and treatment of PKU early in life can help prevent, not detect, brain damage. Chromosomal damage cannot be detected with a PKU test.

The nurse is assessing a newborn for signs of hyperbilirubinemia (pathologic jaundice). Which clinical finding confirms this complication?

Jaundice that develops in the first 12 to 24 hours The development of jaundice in the first 24 hours indicates hemolytic disease of the newborn. Muscle irritability may or may not be present during the first 24 hours; usually it develops later. Neurologic signs may or may not be present during the first 24 hours; they are dependent on the bilirubin level. Serum bilirubin is expected to accumulate in the neonatal period because of the short life span of fetal erythrocytes, reaching a level of 7 mg/100 mL (100 mcmol/L) the second to third day when jaundice appears (physiologic jaundice).

During a wellness examination, the nurse notes black lines on the teeth at the gumline of a 6-year-old child. Which etiology would the nurse suspect as the cause of this finding?

Lead poisoning Black lines on the teeth at the gumline are a common finding in lead poisoning (plumbism). They are caused by the deposition of lead. Perthes disease is characterized by pain and hip dysfunction. Salicylate toxicity affects the eighth cranial nerve, causing tinnitus. Neonatal tetracycline administration may cause yellow-brown discoloration of the teeth.

A client with cervical cancer is undergoing a course of internal radiation. She has an indwelling urinary catheter and a vaginal applicator in place. Once the primary health care provider has loaded the applicator with the radiation source, which actions would the nursing care plan include?

Leaving the urinary catheter undisturbed Preventing the occurrence of complications is a major goal during internal radiation treatment. If the source of radiation is disturbed, injury to the client, as well as to the personnel caring for her, may result. The area surrounding the urinary catheter is not touched or cleansed. Linens are changed only when necessary; they are kept in the client's room until therapy is complete. As a means of preventing dislodgement of the radiation applicator, the area surrounding the source of internal radiation is not touched or cleansed. Displacement may result in unnecessary tissue damage or exposure of the nurse to radiation. Equipment is usually kept in the client's room until the source of radiation is removed.

Which is the priority intervention for the nurse to perform on a client who is noted to have a relaxed and boggy uterus 1 hour after delivery?

Massage the uterus until firm. The immediate action to prevent excessive bleeding involves massaging the uterine fundus until it is firm, which stimulates uterine muscle contraction. Obtaining the blood pressure is indicated if the bleeding persists. Obtaining a prescription for oxytocin may not be necessary if fundal massage is effective. Notifying the primary health care provider immediately is not necessary unless bleeding persists after uterine massage.

Which action would the nurse immediately perform 30 minutes after birth on a postpartum client who has excessive lochia and a relaxed uterus?

Massage the uterus. massaging the uterus will induce uterine contraction and cause expulsion of clots; frequent massage should be continued to keep the uterus firm and inhibit bleeding. Pulse and blood pressure should be monitored but may not change significantly unless large amounts of blood are lost. If bleeding continues after the fundus is massaged, the health care practitioner should be notified. Placing the client in the Trendelenburg position is appropriate if the client is in shock, but the data do not indicate shock.

A 26-year-old G1 P0 client at 29 weeks' gestation has gained 8 lb (3.6 kg) in 2 weeks; her blood pressure has increased from 128/74 Hg to 150/90 mm Hg; and she has developed 1+ proteinuria on urine dipstick. Which condition do these signs suggest?

Mild preeclampsia Preeclampsia is hypertension that develops after 20 weeks' gestation in a previously normotensive woman. With mild preeclampsia the systolic blood pressure is below 160 mm Hg and diastolic BP is below 110 mm Hg. Proteinuria is present, but there is no evidence of organ dysfunction. Severe preeclampsia is a systolic blood pressure of greater than 160 mm Hg or diastolic blood pressure of at least 110 mm Hg and proteinuria of 5 g or more per 24-hour specimen. Chronic hypertension is hypertension that is present before the pregnancy or diagnosed before 20 weeks' gestation. Gestational hypertension is the onset of hypertension during pregnancy without other signs or symptoms of preeclampsia and without preexisting hypertension.

Which phase of disaster management involves attempts to limit the disaster's impact on the population?

Mitigation Mitigation is the phase of disaster management where attempts are made to limit the impact of a disaster on human and community welfare. The recovery phase is associated with stabilizing the community after a disaster. The implementation phase of a disaster plan is the response phase. Preparedness is the protective plan, which assesses the risk and evaluates the damage.

The plan of care for a client with osteoporosis includes active and passive exercises, calcium supplements, and daily vitamins. Which finding would indicate that the therapy is helping?

Mobility increases. This regimen limits bone demineralization and reduces bone pain, thereby promoting increased mobility and activity. The occurrence of fewer muscle spasms is unrelated to osteoporosis; it would be an expected outcome if the client were receiving calcium for hypocalcemia. A more regular heartbeat is unrelated to osteoporosis or its therapy. The occurrence of fewer bruises than before therapy is unrelated to osteoporosis; it would be expected if the client were receiving vitamin C for capillary fragility.

During the initial assessment of a dark-skinned neonate the nurse observes several dark round areas on a newborn's skin in the buttocks area. How would this observation be documented?

Mongolian spots Mongolian spots are bluish-black areas of pigmentation commonly found on the skin in the back and buttocks of dark-skinned newborns; they are benign and fade gradually over time. Stork bites are short red marks commonly found near the base of the neck of the newborn. Forceps marks are red and have a distinctive imprint on the face and head matching the configuration of the instrument. These are not ecchymotic areas; ecchymosis represents the extravasation of blood into subcutaneous tissue.

During a routine prenatal office visit at 26 weeks' gestation, a client states that she is getting fat all over and that she even needed to buy bigger shoes. Which is the next nursing action?

Obtaining the client's weight and blood pressure The client's weight and blood pressure help the nurse determine whether an unusual weight gain or an increase in blood pressure has occurred; both of these findings are early signs of preeclampsia. The data suggest a greater-than-expected weight gain. Supporting the client's decision to buy comfortable shoes ignores the possibility that the edema and weight gain are related to preeclampsia. The weight gain may not be caused by inappropriate dietary intake, such as fatty foods and sweets, but rather by an underlying pathologic condition.

A client is trying to become pregnant. The nurse would teach the client that a blood test for progesterone to evaluate fertility would be performed at which time?

One week after ovulation The progesterone is checked a week after suspected ovulation to determine if ovulation occurred. Progesterone is produced by the corpus luteum, which is the empty follicle remaining in the ovary after release of the egg with ovulation. A normal progesterone level 1 week after suspected ovulation is good evidence that the client did ovulate. Progesterone levels would be low immediately after the menses and would remain low until ovulation. Progesterone levels peak about 1 week after ovulation and then may start to fall if no pregnancy has occurred. Checking the progesterone within 1 to 2 days after ovulation would be too soon.

The nurse is caring for a client whose mechanical ventilator settings include the use of positive end-expiratory pressure (PEEP). This treatment improves oxygenation primarily through which mechanism of action?

Opening collapsed alveoli and keeping them open The primary mechanism of PEEP is to deliver positive pressure to the lung at the end of expiration. This helps open collapsed alveoli and keeps them open. With the primary mechanism of PEEP to open the alveoli and maintain them open, exchange of carbon dioxide and oxygen can take place more efficiently, thus improving oxygenation by providing more oxygen to the lung tissue and improving gas exchange. PEEP does not force pressure into lung tissue. PEEP may have an indirect effect on opening bronchioles.

A client asks the nurse what causes the sudden loss of vision common in persons with multiple sclerosis. Which factor would the nurse include in the explanation?

Optic nerve inflammation Optic nerve inflammation is a common early effect of multiple sclerosis caused by lesions in the optic nerves or their connections (demyelization). This effect may resolve during periods of remission. At present, there is no evidence of viral infection of the eyes in multiple sclerosis. Tumors of the brain and cerebral edema, not multiple sclerosis, cause increased intracranial pressure because the skull cannot expand. Closed-angle glaucoma causes blindness as a result of increased intraocular pressure, not inflammation of the optic nerve, which is commonly associated with multiple sclerosis. Closed-angle glaucoma is unrelated to multiple sclerosis.

Immediately after being placed in the supine position, an adolescent child experiences shortness of breath and must sit up to breathe. Which term would the nurse use to document this clinical phenomenon?

Orthopnea Orthopnea is shortness of breath in any position except the erect, sitting, or standing position. Apnea is a temporary cessation of breathing. Dyspnea is labored or difficult breathing regardless of the position. Hyperpnea is an increased respiratory rate, not shortness of breath.

How would the nurse document a drop in blood pressure when a client moves rapidly from a lying to a standing position?

Orthostatic hypotension Orthostatic hypotension specifically refers to an abnormally low blood pressure that occurs when an individual assumes a standing position. Orthostatic hypotension is also known as postural hypotension. It may be a result of internal bleeding, fluid depletion, or loss of neurovascular control preventing vasoconstriction from regulating blood pressure. Malignant hypotension and orthostatic dehydration are inaccurate terms that are not used. Vasomotor instability occurs during menopause and results in hot flashes and night sweats.

Which finding for a client who has just arrived in the emergency department and has a history of heart failure requires the most rapid action by the nurse?

Oxygen saturation 86% Because oxygen saturations less than 90% indicate severe hypoxemia, the nurse would notify the health care provider about the low saturation and start oxygen, typically using a nonrebreather mask. An irregular apical pulse is consistent with atrial fibrillation and indicates a need for treatment, but the first action by the nurse would be to improve oxygenation. Crackles in the lungs indicate a need for treatment such as a diuretic, but the priority action is rapid improvement in oxygenation. Atrial fibrillation does require treatments such as medications to control rate or cardioversion, but the initial action would be oxygen administration to improve tissue oxygenation.

A 32-year-old woman is admitted to the unit with a history of fibroids and menorrhagia. Which findings would the nurse expect to encounter during assessment of the client? Select all that apply. One, some, or all responses may be correct.

Pale mucous membranes Difficulty emptying the bladder Menorrhagia (heavy menstrual bleeding) can cause anemia, which may be evidenced by pale mucous membranes. Urinary frequency, urgency, and incontinence can be symptoms of fibroids caused by pressure of the fibroids on the urinary bladder. Constipation, not diarrhea, is a common symptom of fibroids. Menorrhagia would cause hypovolemia, not hypervolemia. Menorrhagia would cause the hemoglobin and hematocrit levels to decrease, not increase.

Which activity performed by the licensed practical nurse (LPN) would be appropriate based on the principle of right task of delegation when caring for a client?

Performing the task based on institutional policies Rationale: The principle of right task of delegation indicates if the task is appropriate to delegate based on institutional policies and procedures. Assessing whether the delegatee is willing to perform the task indicates the principle of right person. Providing feedback to the delegator and following supervision of the delegator indicates the right supervision of delegation.

A 47-year-old client comes to the clinic for a Papanicolaou (Pap) smear. She tells the nurse that she has been experiencing hot flashes and that her periods have been occurring at longer, less-regular intervals, with a scanty flow. Which condition would the nurse suspect to be the likely cause of these changes?

Perimenopause The adaptations described, along with the client's age, suggest that the client is experiencing perimenopausal symptoms, which are normal in the years preceding cessation of menses. Irregular spotting and bleeding occur with uterine cancer and are not associated with the menstrual cycle. Estrogen is reduced, not eliminated, during and after menopause; the adrenal glands produce a small amount of estrogen throughout life. Early cervical cancer is asymptomatic; an irregular bloody vaginal discharge is a late sign of cervical cancer.

Which clinical finding is associated with acute glomerulonephritis?

Periorbital edema Decreased filtration of plasma in the glomeruli results in an excess accumulation of fluid and sodium, producing edema that is first evident around the eyes. Oliguria, not polyuria, occurs. There is an excess, not a deficient amount, of body fluid. Hypertension, not hypotension, occurs.

Which physiological response occurs first when a client experiences sudden hypovolemia caused by hemorrhage?

Peripheral vasoconstriction The initial response to hemorrhage is activation of the sympathetic nervous system, leading to increases in heart rate and peripheral vasoconstriction, which shunts blood to essential core organs. The other responses also occur, but more slowly. Cortisol increases as part of the stress response, leading to fluid retention, but this process occurs more slowly. Immature red blood cells (erythrocytes) are released from the bone marrow, but this occurs more slowly than vasoconstriction. An increase in ADH causes fluid retention, but this occurs more slowly.

The nurse in the postpartum unit is teaching self-care to a group of new mothers. Which color would the nurse teach them that the lochial discharge will be on the fourth postpartum day?

Pinkish brown Lochia serosa is the expected vaginal discharge between the third and tenth postpartum days; it is pinkish to brownish and consists of serous exudate, shreds of degenerating decidua, erythrocytes, leukocytes, cervical mucus, and numerous microorganisms. Lochia rubra is the expected vaginal discharge on the first 2 or 3 postpartum days; it is dark red and consists of epithelial cells, erythrocytes, leukocytes, shreds of decidua, and occasionally fetal meconium, lanugo, and vernix caseosa. Lochia is never dark brown. Lochia alba is the expected vaginal discharge about 10 days postpartum; it persists for 1 to 2 weeks. A creamy or yellowish color, it consists of leukocytes, decidual cells, epithelial cells, fat, cervical mucus, cholesterol crystals, and bacteria.

A client is admitted to the hospital with deep partial-thickness burns to both hands and forearms after an accident. How would the nurse apply the prescribed antimicrobial medication?

Place the medication directly on the burn wound in a thin layer using sterile gloves. Sterile aseptic technique is necessary for an open wound, and a thin layer of ointment is applied directly to the affected area. Surgically aseptic, not medically aseptic, technique is used. Although some medications may be placed directly in the tank, antimicrobial medications are placed directly on the affected area using surgically aseptic technique.

The nurse is caring for a client with severe burns and determines that the client is at risk for hypovolemic shock. Which physiological finding supports the nurse's conclusion?

Plasma proteins moving out of the intravascular compartment The shift of plasma proteins into the burned area increases the shift of fluid from the intravascular to the interstitial compartment; the result is decreased blood volume and hypovolemic shock. Decreased glomerular filtration may occur because of hypovolemia; it does not cause hypovolemia. Extracellular fluid, not blood, is lost through burned tissue. Sodium is not retained; it passes to interstitial spaces and surrounding tissue.

The nurse teaches a client who is about to undergo an amniocentesis that ultrasonography will be performed just before the procedure to determine which?

Position of the fetus and the placenta The position of the fetus and placenta is located by means of ultrasonography to assist in preventing trauma from the needle during the amniocentesis. Although ultrasonography can be used to determine gestational age, this is not its purpose before an amniocentesis. Determining the amount of fluid in the amniotic sac is not the purpose of ultrasonography just before an amniocentesis. The position of the placenta and fetus, not just the cord and the placenta, is needed for safe introduction of the needle.

Which effect does the nurse expect after an amniotomy is performed on a client in active labor?

Progressive dilation and effacement Amniotomy permits more effective pressure of the fetal head on the cervix, enhancing dilation and effacement. Vaginal bleeding may increase because of the progression of labor. Discomfort may increase because contractions usually become more intense after amniotomy. Amniotomy should not affect maternal and fetal heart rates.

A client who has alcoholism becomes irritable, makes excuses, and blames family and friends for the drinking problem. Which defense mechanisms is the client using? Select all that apply. One, some, or all responses may be correct.

Projection Rationalization Clients with alcoholism commonly use projection and rationalization to make reality more acceptable. Projection is the unconscious denial of unacceptable feelings and emotions in one's self while attributing them to others. Rationalization is making acceptable excuses for undesirable behavior. Suppression, sublimation, and identification are not commonly used by clients with an alcohol problem. Suppression keeps uncomfortable thoughts, feelings, and wishes in the subconscious. Sublimation is the rechanneling of anxiety into constructive activities. Identification is the unconscious wish to be like another person.

Which verbalization by the parents of a child who has cystic fibrosis (CF) provides evidence that they understand the child's dietary needs?

Provide high-calorie foods between meals. The caloric intake should be 150% to 200% more than the expected intake for size and age because absorption of fats and nutrients is compromised by the disease process. Fluids are encouraged to keep bronchial secretions from becoming too thick and tenacious. Salt is added to the diet to compensate for excessive sodium losses in saliva and perspiration. Whole milk may not be tolerated because of its high fat content; skim milk products should be substituted.

Which intervention would the nurse implement when assisting a child with a history of aggressive behavior to regain control in the triggering phase of an assault cycle?

Provide the child with a quiet, low-stimulus environment. The nurse would provide the child with a quiet, low-stimulus environment. In the triggering phase, the client's behavior is nonthreatening and poses no danger to others. Minimizing environmental stimuli and providing a calm, nonthreatening environment likely will serve to help the client de-escalate and regain control. Discussion of substitute behaviors is effective once the crisis is over (postcrisis phase). As the client escalates, the nurse needs to begin to assume control by presenting a calm but firm tone of voice and demeanor. It is at this time that appropriate oral PRN medications may be helpful.

Which nursing intervention would be provided to a hospitalized client during the identity versus role confusion stage?

Providing information to the client about the treatment plan During the identity versus role confusion or puberty stage, the nurse would help hospitalized adolescents deal with their illness by giving them enough information to allow them to make decisions about their treatment plan. During the generativity versus self-absorption and stagnation stage, the nurse would help clients choose ways to promote social participation. This action helps clients find a sense of fulfillment. If an individual in the intimacy versus isolation stage is admitted to the hospital, the nurse would try involving the client's partners or family members in the caring process so that the client can have a strong support structure. During the industry versus inferiority stage, a nurse would ensure the active participation of a hospitalized client.

A newborn is admitted to the neonatal intensive care unit with a myelomeningocele located at the fourth lumbar vertebra (L4). Which is the priority nursing intervention while the infant is awaiting surgery?

Providing meticulous skin care Skin care is essential to prevent rupture of the sac and subsequent infection. There is no need to increase nutrition; there are no data to confirm that the infant is malnourished. Although sensory stimulation is important, it is not the priority. Exercises are not indicated at this time; they may be implemented after surgery.

While caring for a client with a burn injury and in the resuscitation phase, the nurse notices that the client is hoarse and produces audible breath sounds on exhalation. Which immediate action would be appropriate for the safe care of the client? Select all that apply. One, some, or all responses may be correct.

Providing oxygen immediately Notifying the rapid response team Hoarseness of voice, difficulty in swallowing, or an audible breath sound on exhalation after a burn injury indicates an impaired airway. The client should be given oxygen immediately. The rapid response team should also be notified for further management. This occurrence should not be considered a normal observation. An IV line should be initiated for fluid replacement only once the client's airway is patent. An ECG is obtained when the client suffers from electrical burns.

Which component of postpartum care is most important for the nurse to provide when helping a new mother on the postpartum unit develop her role as a parent?

Providing time for her and her baby to be together Parenting can begin only when the baby and the mother have gotten to know each other. To promote development, the nurse should provide time for mother-infant interaction. Teaching the mother to care for the baby, responding to questions, and demonstrating baby care and then evaluating the client's return demonstration are not priorities.

The nurse teaches a group of student nurses about the function of the loop of Henle. Which function would the nurse include?

Reabsorption of sodium in the ascending limb The reabsorption of sodium takes place in the ascending limb of the loop of Henle to maintain normal blood serum levels of sodium in the body. Ammonia is secreted from the distal tubule. The secretion of hydrogen occurs in the proximal and distal tubules of the nephron. Reabsorption of water is carried out in the descending limb of the loop of Henle.

Which goal would the nurse add to the plan of care for a forgetful, disoriented client who has dementia?

Rechannel the client's energies into more appropriate behaviors. The goal is to rechannel the client's energies into more appropriate behaviors. Disoriented clients need assistance in how they direct their energy to limit inappropriate behaviors. Restricting gross motor activity in a client with dementia can increase outbursts. The staff cannot prevent gross motor activity; the client needs to use the muscles, but their use must be controlled. Further deterioration cannot be prevented in dementia. Behavior modification methods do not work well with disoriented, forgetful clients. The client cannot remember the rewards and consequences, making this goal ineffective for a client with dementia.

The nurse is caring for a client with a burn injury and suspects atelectasis and hypoxia. Which age-related changes would the nurse associate with these findings?

Reduced thoracic compliance The reduction in thoracic and pulmonary compliance may increase the risk of atelectasis and hypoxia. Reduced mobility increases the risk for burn injuries. Reduced healing would have longer time with open areas, which results in greater risks for infection, metabolic derangements, and loss of function from contracture formation and scar tissue. Reduced inflammatory and immune responses would increase the risk for infection and sepsis.

The mammography results for a 37-year-old client with a breast mass are inconclusive. The client is undergoing further diagnostic tests to determine whether the mass is malignant. Which information would the nurse take into consideration before planning health teaching for this client?

Results of a biopsy are necessary before a specific form of therapy is selected. The therapy selected depends on whether there is a malignancy and, if so, the type of cancer cells, the extent of nodal involvement, and the presence and extent of metastasis. Adenocarcinomas, not squamous cell carcinomas, arise from glandular tissue; squamous cell carcinomas arise from epithelial tissue. Repeating a mammogram would only delay diagnosis. Only a biopsy will confirm the diagnosis of a malignancy. Waiting several weeks for a diagnosis is not advisable; an extended waiting period increases the client's stress and anxiety.

Which safety consideration is the nurse following when obtaining the client's family history and checking for a medical alert bracelet?

Risk for errors and adverse events Risk for errors and an adverse events is a safety consideration applied by nurses to identify any possible risks to a client's health. It involves obtaining the client's family history and checking the client for a medical alert bracelet. Client identification involves providing an identification (ID) bracelet for each client and using two unique identifiers. Injury prevention for staff is a safety consideration that involves use of standard precautions at all times to prevent any violence involving clients. Injury prevention for clients is a safety consideration that involves keeping rails on the stretcher or placing it in a lower position.

The nurse is planning to teach activities of daily living to a developmentally disabled 3-year-old child. Which activity would the nurse plan to teach to the child first?

Self-feeding According to the principles of growth and the development of skills, feeding is taught first, and this is no different for a child who is developmentally disabled. Dressing, toileting, and hair combing are more difficult skills than self-feeding.

Which positioning would the nurse use for a newborn with a diagnosis of tracheoesophageal fistula?

Semi-Fowler, to reduce the risk of chemical pneumonia Because of the connection between the lower esophagus and the trachea, this child is maintained in a semi- to high Fowler position to reduce the risk of acidic stomach contents entering the trachea and causing inflammation of the lung tissues. Vomiting may or may not occur with this type of defect, because the esophagus does connect to the stomach. The semi-Fowler position would be more effective than the prone position in reducing aspiration. The Trendelenburg position will increase the risk of pneumonia. The concern is the tracheoesophageal fistula, not the risk of sudden infant death syndrome.

Which type of abuse or neglect would the nurse suspect in a 5-year-old child with genital discharge and recurrent urinary tract infections?

Sexual abuse Genital discharge and recurrent urinary tract infections are signs of sexual abuse in children. Bruises, burns, fractures, or dislocation may indicate physical abuse. Malnutrition and poor hygiene may indicate physical neglect. Enuresis and sleep disorders may indicate emotional neglect.

Which routine screening would the nurse perform specifically for pregnant adolescents?

Sexual assault Routine screening for sexual assault and abuse is recommended for pregnant adolescents because pregnancy in minor adolescent girls can be the result of sexual assault and abuse. Screening for alcohol abuse, substance use, and occupational risks should be performed for all pregnant women, not specifically for pregnant adolescents.

A client in the active phase of the first stage of labor begins to tremble, becomes very tense during contractions, and is quite irritable, saying repeatedly, "I can't take this a minute longer." Which is the best explanation for this behavior?

She is entering the transition phase of labor. The contractions become stronger, last longer, and occur erratically during the transition phase; the intervals between contractions become shorter than the contractions themselves; the client needs to apply a great deal of concentration and effort to pace her breathing with each contraction. Even clients who have been adequately prepared will experience these behaviors during the transition phase of the first stage of labor. Administration of an analgesic at this time may reduce the effectiveness of labor and depress the fetus. There is no indication that the contractions are hypertonic.

A client who sustained burn injuries due to a fire and an explosion has a carbon monoxide level of 14%. Which pathophysiological risk is increased in the client?

Slight breathlessness Slight breathlessness may occur when the carbon monoxide level is 14%. Stupor and vertigo may result when the carbon monoxide level is in between 21% and 40%. When the level of carbon monoxide reaches between 41% and 60%, coma or convulsions may occur.

An adolescent is admitted to the burn unit with partial-thickness burns of both arms and the chest. Which information about burns would guide the nurse's plan of care?

Spontaneous epithelial regeneration occurs within several weeks. If there is no subsequent infection of the burned areas, wound healing should be uneventful. Although partial-thickness burns are painful, they usually heal with little or no scarring. Regeneration will occur unless there is further insult to the burn injury, such as infection; grafting should not be necessary. Occlusive dressings may be applied to minimize the discomfort of frequent dressing changes; hydrotherapy is not required for partial-thickness burns.

The nurse is administering a histamine H 2 antagonist to a client who has extensive burns. Which complication will it prevent?

Stress ulcer An ulcer of the upper gastrointestinal tract is related to excessive secretion of stress-related hormones, which increases hydrochloric acid production. Histamine H 2 antagonists decrease acid secretion. Colitis is not a complication of burns. Gastritis is not a complication of burns. Metabolic acidosis is not a complication of burns unless hypermetabolism or renal failure occurs; metabolic acidosis is not treated with H 2 antagonists.

According to triage based on tier levels, which client conditions would receive higher priority? Select all that apply. One, some, or all responses may be correct.

Stroke Active hemorrhage Respiratory distress Chest pain with diaphoresis Clients presenting with signs of a stroke, active hemorrhage, respiratory distress, or chest pain with diaphoresis should be triaged under the emergent tier level because the conditions are life threatening. Clients with a skin rash are categorized as nonurgent because treatment can be delayed. Displaced or multiple fractures are triaged as urgent, which needs quick treatment but is not immediately life threatening.

Which information regarding hormonal influences would the nurse fully understand when teaching a client about breast-feeding?

Suckling stimulates the pituitary gland to release oxytocin, which initiates the let-down reflex. Suckling of the infant directly stimulates the pituitary gland to release oxytocin, which initiates the let-down reflex. Progesterone does not stimulate the secretion of oxytocin. A high level of estrogen inhibits anterior pituitary gland secretion of lactogenic hormones. Milk secretion is controlled by prolactin, which is also stimulated by suckling of the infant.

Which activity performed by the registered nurse (RN) indicates effective delegation?

Supervising and monitoring the licensed practical nurse (LPN) about the different activities Rationale: The delegator should supervise and monitor the delegatee when the work is being assigned to the delegatee. The communication between delegatee and delegator should always be two-way communication to get the expected outcome. The delegator should evaluate the ability of the delegatee and should supervise the different tasks before assigning the work to the new delegatee. The delegator should always provide feedback at the end of the task.

After assigning a task, the delegator makes sure that the instructions are clear so that the delegatee can provide feedback related to the task. Which delegation right is referred to in this situation?

Supervision Ensuring that the delegatee has a clear understanding of how to provide feedback related to the task refers to the right supervision. Knowing whether the task is appropriate to the delegatee based on institutional policies and procedures refers to the right task. Knowing whether the delegatee has the knowledge and experience to perform the specific task safely refers to the right person. Knowing whether the delegatee understands the assignment and directions of the task refers to the delegation of right direction.

Which assessment finding would the nurse recognize as needing immediate attention in a 2-week-old infant?

Tense anterior fontanel A tense or bulging fontanel is indicative of increased intracranial pressure, which is caused by the fluid accumulation associated with hydrocephalus. Conjugate gaze does not occur until 3 to 4 months of age, once the eye muscles have matured. The head is the largest part of the body at this age; the head circumference should be about 1 inch (2.5 cm) larger than chest circumference. An infant cannot support the head before 1 to 1½ months of age.

How would the nurse explain a contraction stress test (CST) result interpreted as negative in a client at 41 weeks' gestation?

The fetus at this time is likely to tolerate the stress of labor. A negative CST implies that placental support is adequate, and the fetus is likely to tolerate the stress of labor. A negative result for a CST would not indicate that hyperstimulation was present. Immediate birth would not be indicated with a negative CST. Fetal heart rate accelerations with movement constitute a negative CST; they are a sign of fetal well-being and do not require a trial induction.

A family has decided to withhold extraordinary care for a newborn with severe congenital abnormalities. How would the nurse interpret this decision?

The newborn is being allowed to die. The family's decision means that extraordinary care does not have to be employed; the infant's basic needs will be met, and nature will be allowed to take its course; the infant is being allowed to die. If the infant's physical needs are met and comfort is provided, the infant's rights are not being ignored; extraordinary, not all, care is being withheld. Euthanasia is a deliberate intervention to cause death. It is not illegal to withhold extraordinary treatment; once such treatment is started, discontinuing it may be a legal issue.

Which is the average optimal blood pressure of an adolescent?

The optimal blood pressure of an adolescent is 110/65 mm Hg. The average optimal blood pressure of an infant is 85/54 mm Hg. The average optimal pressure of a toddler is 95/65 mm Hg. The average optimal blood pressure seen in children between the ages of 6 and 13 years is 105/65 mm Hg.

Which is the nurse's priority action when caring for an obstetrical client experiencing eclampsia?

Turn the head to one side The airway should be kept patent by turning the client's head to one side or placing a pillow under the back or one shoulder if possible. Maternal stability is a priority. During eclampsia obtaining the fetal heart rate, administering magnesium sulfate, or preparing for an emergency delivery are not priority actions.

Which newborn assessment finding will probably necessitate prolonged follow-up care?

Umbilical cord with two blood vessels The congenital absence of a blood vessel in the umbilical cord is often associated with life-threatening congenital anomalies. There should be two arteries and one vein. An Apgar score of 8 will not require prolonged follow-up care. A weight of 3500 g is average for a full-term newborn. The expected glucose level in a healthy newborn is 40 to 69 mg/dL (1.7-3.3 mmol/L)

Within minutes of giving birth to a healthy infant, a client displays symptoms of respiratory distress, and an amniotic fluid embolism is suspected. For which other complication would the nurse assess this client?

Uncontrolled bleeding Disseminated intravascular coagulation is associated with amniotic fluid embolism (also known as anaphylactoid syndrome of pregnancy); both problems may occur after premature separation of the placenta. Hypotension, not hypertension, is expected. Uterine atony usually is not associated with amniotic fluid embolism. Thrombophlebitis is not a complication of amniotic fluid embolism.

Which assessment finding would the nurse expect to find in a full-term infant with a cardiac anomaly?

Unequal peripheral blood pressures A discrepancy in blood pressures from the arms to the legs indicates arterial stenosis caused by coarctation of the aorta, which is a cardiac anomaly. Projectile vomiting commonly results from pyloric stenosis; it is not of cardiac origin and does not occur immediately after birth. An irregular respiratory rhythm is common and expected in the healthy newborn. Hyperreflexia of the extremities may be indicative of a neurologic, not cardiac, problem.

Which interventions would the nurse employ when using spontaneous rewarming for the victims of a natural disaster who are all hypothermic? Select all that apply. One, some, or all responses may be correct.

Using radiant lights Moving the client to a warm and dry place Passive or spontaneous rewarming involves using radiant lights and moving the client to a warm and dry place. Active internal or core rewarming involves application of heat directly to the core. This includes administering humidified oxygen heated up to 111.2°F (44°C), administering intravenous fluids warmed to 98.6°F (37°C), and performing peritoneal lavage with fluids warmed to 113°F (45°C).

Which activities might cause chest pain in a client with stable angina? Select all that apply. One, some, or all responses may be correct.

Walking outside on a cold day Sexual activity Smoking a cigarette Use of an oral decongestant Clients with stable angina experience chest pain (or other angina equivalents) in response to activities that increase cardiac workload or decrease blood flow and oxygen availability to the heart. Cold temperatures cause vasoconstriction, increasing the cardiac workload during systole. Sexual activity increases heart rate and force of contraction, leading to increased cardiac workload. Tobacco use stimulates catecholamine release, increasing heart rate and causing vasoconstriction, and resulting in increased cardiac workload. In addition, tobacco use transiently increases carbon monoxide levels, resulting in a decrease in available oxygen for cardiac tissues. Oral decongestants are sympathetic nervous system stimulants, which increase heart rate and force of contraction and cause vasoconstriction, leading to increased cardiac workload. Deep breathing will increase oxygen availability and tends to lead to relaxation, resulting in reduced heart rate and force of contraction. Taking an afternoon nap will reduce cardiac workload.

Which technique for nipple cleansing would the nurse recommend to the breast-feeding client?

Wash the breasts and nipples with water when bathing. Daily washing of the breasts and nipples with water is sufficient for cleanliness. It is unnecessary to use sterile water; the infant's gastrointestinal tract is not sterile. Alcohol is drying and may cause the nipples to crack. Scrubbing, as well as the use of soap, may irritate and dry the nipples.

Which nursing action is most effective in controlling the spread of infection for an infant with diarrhea?

Washing hands before and after contact with the infant The most effective method of preventing the spread of infection is hand washing not only before and after care but also before and after using gloves. A gown and gloves are not required for contact precautions. The level of education of the caregiver does not guarantee the correct technique for preventing the spread of infection. The risk for spread of infection is not in the number of visitors but in the aseptic technique practiced by these visitors.

Which is the average optimal blood pressure of an adolescent?

110/65 mm Hg The optimal blood pressure of an adolescent is 110/65 mm Hg. The average optimal blood pressure of an infant is 85/54 mm Hg. The average optimal pressure of a toddler is 95/65 mm Hg. The average optimal blood pressure seen in children between the ages of 6 and 13 years is 105/65 mm Hg.

A client weighing 132 pounds (60 kilograms) with burns over 35% of the body arrives at the hospital an hour after being rescued from a fire. Which amount of lactated Ringer solution would the nurse anticipate being infused in the next 8 hours?

4200 mL In the first 8 hours, 4200 mL should be infused. According to the Parkland (Baxter) formula, one-half of the total daily amount of fluid should be administered in the first 8 hours. Because the client weighs 60 kg (132 pounds ÷ 2.2 kg = 60 kg), the calculation is 60 kg × 4 mL/kg × 35% burns = 8400 mL per day; half of this amount should be infused within the first 8 hours. 2100 mL, 6300 mL, and 8400 mL are incorrect calculations.

The nurse uses the rule of nines to estimate the percentage of the burn surface area (BSA) on a client who has burns covering the entire surface of both arms, the posterior trunk, the genitals, and the entire left leg. What is the percentage of burn injury for this client? Record your answer as a whole number.

55% The rule of nines is used to determine the BSA of a burn injury. Each arm accounts for 9%; the posterior torso is 18% and the entire left leg is 18%. The genitals account for 1%. 9 + 9 + 18 + 18 + 1 = 55%.

A woman in the third trimester of pregnancy presents with vaginal bleeding and states she snorted cocaine approximately 2 hours ago. Which complication would this client profile suggest?

Abruptio placentae Abruptio placentae is associated with cocaine use; it occurs in the third trimester. Placenta previa is seen in the third trimester; however, it is not associated with cocaine use. A tubal pregnancy is identified in the first trimester. Spontaneous abortion occurs in the first two trimesters.

A client who has a ureteral calculus is admitted to the hospital with severe flank pain, nausea, and hematuria. Which intervention would the nurse implement first?

Administer a prescribed analgesic. Rationale: Pain of renal colic may be excruciating; unless relief is obtained, the client will be unable to cooperate with other therapy. Urine can be saved and strained after the client's priority needs are met. Increasing fluid intake may or may not be helpful. If the stone is large the fluid can build up, leading to hydronephrosis; however, if the stone is small, fluids may help flush the stone. Although a culture generally is prescribed, this is not the priority when a client has severe pain.

Which condition will be given the highestpriority for a client admitted in the emergency department who has airway obstruction, chest wall trauma, external hemorrhage, and hypoglycemia?

Airway obstruction The highest priority intervention is to establish a patent airwaybecause inadequate oxygen supply to the brain may cause brain death. Assessing the metabolic conditions is done after the airway is cleared. Once the airway is cleared, then the chest wall of the client is assessed. Hemorrhage is assessed after the airway of the client is cleared.

A severely dehydrated infant with gastroenteritis is admitted to the hospital and nothing-by-mouth (NPO) status is prescribed. The nurse explains that this order is necessary for which reason?

Allow the intestinal tract to rest Withholding food reduces the need for intestinal activity, which rests the intestines and minimizes diarrhea and the loss of fluid. Although intravenous therapy will be started for rehydration and to correct electrolyte imbalances, this is not the reason for the NPO status. Stool cultures are used to determine the cause of the diarrhea. Perianal irritation is prevented with meticulous skin care, not by withholding food and fluids.

How would the nurse assess for unilateral injury of the laryngeal nerve when caring for a client immediately after a subtotal thyroidectomy?

Ask the client to say what the current time is. If the laryngeal nerve is damaged during surgery, the client will be hoarse and have difficulty speaking. Checking the throat for edema does not indicate injury to the laryngeal nerve; this is part of the assessment for a compromised airway. Eliciting the Chvostek sign (spasm in the facial muscle) assesses for hypocalcemia resulting from inadvertent removal of the parathyroid glands. Palpating the neck for seepage of blood assesses for bleeding and possible hemorrhage, not laryngeal nerve injury.

The health care team is caring for a client who has undergone surgery for lung cancer. The client needs respiratory therapy. Which task can be safely delegated to a respiratory therapist paired with a registered nurse (RN)?

Assessing the respirations Respiratory therapy is needed in clients who undergo surgery for lung cancer. Assessing respiration can be safely delegated to the respiratory therapist. Placing a Foley catheter, an IV catheter, or administering patient-controlled analgesia is within the scope of an RN's practice.

An infant is born with a life-threatening congenital heart defect and is admitted to the neonatal intensive care unit. Which is the priority nursing intervention at this time?

Assisting the parents with the grieving process Parental grieving is expected and necessary whenever an infant is born with severe problems; the parents are grieving the loss of a "normal baby." The parents should make the decision to meet with the chaplain. Obtaining a prescription for a sedative to ease the parents' anxiety may delay processing information and impede the grieving process. Arranging for a social worker to talk to the parents about available resources may be needed later; right now it is too soon to determine the outcome.

Which actions would the nurse expect to take for a client who has compartment syndrome? Select all that apply. One, some, or all responses may be correct.

Assisting with splitting the cast Monitoring urine output Evaluating pain using a pain scale Compartment syndrome is increased pressure in a limited space, which compromises the compartmental blood vessels, nerves, and tendons. The cast may be split to reduce the external circumferential pressures. The nurse would assess urine output because the myoglobin released from damaged muscle cells may precipitate and cause obstruction in renal tubules. The nurse would evaluate the pain on a scale from 0 to 10; this helps plan care. Application of external pressure by splints, casts, and dressing to the injured area may worsen the client's symptoms. Application of cold compresses may result in vasoconstriction and exacerbate the symptoms.

In which location is the presenting part of the fetus when it is at 0 station?

At the level of the ischial spines The ischial spines are used as landmarks in relation to the fetus's head because they reflect the progression of labor; 0 station indicates that the presenting part is at the ischial spines. When the head enters the vagina, it is below the ischial spines and its position is designated with positive numbers (+1 to +4). When the presenting part is floating, the fetus is at -5 station. A position above the ischial spines is designated by a minus number (-1 to -4).

A 25-year-old woman comes to the clinic complaining of increased vaginal discharge, milky gray in color with a "fishy" odor. A wet smear is performed and the presence of "clue cells" confirmed. Which type of infection would the nurse suspect?

Bacterial vaginosis Signs of bacterial vaginosis include a milky gray vaginal discharge that has a characteristic fishy odor. "Clue cells" noted on wet smear are indicative of bacterial vaginosis. Clue cells are vaginal epithelial cells coated with bacteria. Candidiasis is a yeast infection caused by the organism Candida albicans. The most common symptom of a yeast infection is vulvar and vaginal pruritus. Vaginal discharge in a candidal infection is thick, white, and lumpy. A woman with a trichomoniasis infection may present with a frothy yellowish-green vaginal discharge. Vulvar irritation, pruritus, and dyspareunia are usually present. Group B Streptococcus may be considered part of the normal vaginal flora in a woman who is not pregnant, and no treatment is necessary.

The nurse is instructing a client with peptic ulcer disease (PUD) about the diet that should be followed during the acute phase. Which type of diet would the nurse stress?

Bland foods A bland, nonirritating diet is recommended during the acute symptomatic phase. During the acute phase, a regular diet can cause discomfort. Clients should be instructed to avoid substances that increase gastric acid secretion, such as coffee, tea, and cola. Bedtime snacks should be avoided because they may stimulate gastric acid secretion as well. Gluten-free foods do not decrease gastric acid secretion. Low-carbohydrate foods do not decrease gastric acid secretion.

Which assessment finding is most significant in an infant of a diabetic mother (IDM) who is large for gestational age (LGA)?

Blood glucose level less than 40 mg/dL (2.2 mmol/L) At birth, circulating maternal glucose is removed; however, the IDM still has a high level of insulin, and rebound hypoglycemia may develop. The temperature-regulating ability of an IDM is similar to that of a healthy neonate, unless the IDM is preterm. A heart rate of 110 beats/min is within the expected range for a newborn. Pathologic jaundice is associated with hemolytic diseases such as Rh and ABO incompatibilities and sepsis, not maternal diabetes.

Which findings are consistent with hypercalcemia after prolonged immobility? Select all that apply. One, some, or all responses may be correct.

Bone pain Depressed deep tendon reflexes Increased serum calcium comes from bone demineralization, which results in bone pain. Depressed or absent deep tendon reflexes are associated with hypercalcemia. The body's excitable tissues are affected most (e.g., nerves, muscles, heart, intestinal smooth muscles). Convulsions are not a sign of hypercalcemia; convulsions can occur with hypocalcemia, hypernatremia, and hyponatremia. Muscle spasms are not a sign of hypercalcemia; muscle spasms can occur with hypocalcemia, hyponatremia, and hypokalemia. Tingling of extremities is not a sign of hypercalcemia; paresthesias are associated with hypocalcemia and hyperkalemia.

A neonate is born with exstrophy of the bladder, and the parents are visibly upset. They are told that corrective surgery will be performed as soon as possible. Which nursing action would assist the parents at this time?

Caring for the newborn in the same manner as any other newborn The nurse's role-modeling of acceptance of the infant, even with the newborn's altered physical appearance, can help the parents adjust. Teaching the parents about preoperative and postoperative care is appropriate later; the parents first need to deal with their feelings regarding the newborn's appearance. The parents' current major adjustment concern is the appearance of the infant; odor is secondary. Reassuring the parents that after surgery their newborn will grow and develop without any after-effects is false reassurance; there are no guarantees related to the outcome of the surgery.

Which laboratory test is conducted during the initial prenatal visit? Select all that apply. One, some, or all responses may be correct.

Cervical culture for Neisseria gonorrhoeae During the initial prenatal visit, a cervical culture for N. gonorrhoeae is obtained. A 1-hour glucose tolerance test is completed at 24 to 28 weeks of gestation. A 3-hour glucose tolerance test is completed if a pregnant client fails the 1-hour glucose tolerance test. A chest x-ray is required after 20 weeks of gestation if the client has a positive TST. Vaginal and anal cultures for GBS are obtained at 35 to 37 weeks of gestation.

Which action would the nurse take when caring for a client with pneumothorax who has a chest tube and closed drainage system in place?

Check the water-seal chamber for evidence of bubbling during expiration. Rationale: With a pneumothorax, air will escape from the pleural space and into the water-seal chamber; because intrapleural pressure increases with expiration, bubbling in the water-seal chamber is usually seen during expiration. Water evaporates from the suction control chamber and the nurse will need to add water to keep the suction at the prescribed level. Milking chest tubes should generally be avoided and will not be needed with a pneumothorax because there will be only a few milliliters of bleeding. Bubbling in the suction control chamber is expected.

Which factors contribute to development of osteoporosis in female clients? Select all that apply. One, some, or all responses may be correct.

Cigarette smoking Familial predisposition Inadequate intake of dietary calcium Cigarette smoking is a high-risk behavior associated with an increased incidence of osteoporosis in later life. Familial predisposition is considered a risk factor for the development of osteoporosis. Inadequate calcium intake during the premenopausal years is a risk factor for the development of osteoporosis after menopause. Moderate exercise is not considered a risk factor for the development of osteoporosis, although a sedentary lifestyle is. Use of street drugs is not considered a risk factor for osteoporosis.

A person on the beach sustains a deep partial-thickness sunburn. Which first-aid measure would the nurse recommend before the client seeks health care?

Cool, moist towels Cool, moist towels will decrease edema and minimize pain. Dry dressings, when removed, may further damage the burn site. Although pain is temporarily alleviated, removal of the spray is necessary before further treatment can be instituted; removal may cause injury. Ointments are contraindicated on burns because they have an oil base.

Which gross motor skill would the nurse anticipate when assessing a 15-month-old child during a scheduled health maintenance visit?

Creeping up stairs Creeping up the stairs is a gross motor skill the nurse expects when assessing a 15-month-old toddler-age client during a scheduled health maintenance visit. Using a cup well, scribbling spontaneously, and building a tower with two blocks are all fine, not gross, motor skills the nurse expects when assessing a 15-month-old toddler-age client.

When a client who has sickle cell anemia has been admitted with acute chest syndrome, which prescribed treatment would the nurse question?

Daily iron supplement. The nurse would question the use of iron supplements in sickle cell anemia because sickle cell disease is not caused by iron deficiency. In addition, many clients with sickle cell anemia receive blood transfusions and iron toxicity can develop secondary to frequent transfusions. Oxygen administration would be appropriate for a client with a pulmonary complication such as acute chest syndrome. Folic acid supplements are recommended for clients with sickle cell disease, because folic acid is needed in the production of new red blood cells to replace cells lost to hemolysis. Morphine sulfate is frequently prescribed to treat ischemic pain caused by sickled cells.

A client who has just had a cesarean birth is receiving intravenous fluids and has an indwelling catheter. Which finding would indicate a need for an increase in the client's fluid intake?

Dark-amber urine A dark amber or tea color indicates highly concentrated urine and requires additional hydration of the client. Urinary suppression is not related to fluid status. Tinges of blood in the urine may indicate bladder injury and are not related to the client's fluid status. Cloudy urine indicates urinary infection or hematuria; it is not related to dehydration.

Which condition would the nurse suspect is the cause of the increased temperature in a client with a temperature of 100.4°F (38°C) 12 hours after a spontaneous vaginal birth?

Dehydration A client's temperature may be elevated to 100.4°F (38°C) during the first 24 hours after delivery because of dehydration resulting from the exertion and stress of labor. Mastitis usually develops after breast-feeding is established and the milk supply is present. Puerperal infection usually begins with a fever of 100.4°F (38°C) or higher on 2 successive days, excluding the first 24 hours after delivery. Urinary tract infection usually becomes evident later in the postpartum period.

The registered nurse is teaching the student nurse about delegation. Which response by the student nurse indicates the need for further teaching?

Delegation is the transfer of accountability while retaining responsibility. Delegation is the transfer of responsibility for the task, while final accountability always is retained by the delegator. Delegation involves the delegator and the delegatee. It is an important strategy for ensuring client safety and quality of care. Delegation has 5 rights that are to be followed throughout the process: right task, right person, right circumstance, right direction/communication, and right supervision.

Which action would the nurse anticipate implementing when caring for a client with acute respiratory distress syndrome who is intubated and on mechanical ventilation?

Determine need for suctioning based on client assessments. Suction is likely to be needed and will be done based on assessment data such as client oxygen saturation, breath sounds, and activation of the high pressure alarm signifying endotracheal tube obstruction. The endotracheal tube cuff is kept inflated to protect the lower airways and improve delivery of breaths to the lungs. Research indicates that daily changes in ventilator tubing increase the risk for ventilator-associated pneumonia; the ventilator tubing should be changed only when soiled. Because high FiO 2 levels can cause damage to the lungs, the FiO 2 is reduced as the client's oxygenation improves.

A newborn weighing 9 lb 14 oz (4479 g) is delivered by cesarean because of cephalopelvic disproportion. The Apgar scores are 7 at 1 minute and 9 at 5 minutes. Which priority nursing action would be taken after the initial physical assessment?

Determine the blood glucose level. The simple measure of determining the infant's blood glucose level will reveal hypoglycemia in this large-for-gestational-age infant. There are no data that indicate a need for oxygen. Formula will not be given at this time, and there are no data that indicate a need for gavage feeding. The Apgar scores demonstrate that this infant is adapting to extrauterine life and does not indicate the need for transfer to the neonatal intensive care unit.

The nurse completes a thorough assessment to find the reason for a client's anxiety. Which critical thinking attitude is involved in this situation?

Discipline The nurse shows discipline in collecting a thorough assessment to find the source of the client's anxiety. Confidence involves completing a task or goal such as performing a procedure or making a diagnostic decision. Responsibility is applicable when performing a nursing skill by following standard care practices. Thinking independently involves reading the nursing literature, talking with other nurses, and sharing ideas about nursing interventions.

Which is the most common cause of vehicle injuries in children?

Disobeying common traffic safety regulations Most injuries occur when children disobey common traffic safety regulations or misinterpret traffic signs. Inappropriate seat belt restraints, sitting in the front seat of the car, and walking in the opposite direction of the traffic are not the most common cause of motor vehicle injuries in children.

When assessing a client with cardiogenic shock, which clinical manifestations will the nurse expect to find? Select all that apply. One, some, or all responses may be correct.

Dyspnea Diaphoresis Tachycardia Shortness of breath and an increase in the respiratory rate occur with cardiogenic shock. Cold, clammy (diaphoresis) skin occurs because of vasoconstriction associated with stimulation of the sympathetic nervous system. The heart rate increases (tachycardia) as the heart attempts to maintain cardiac output and circulating blood volume. A decrease in circulation of blood to the kidneys results in oliguria, not polyuria. Hypotension, not hypertension, is a sign of cardiogenic shock; the systolic reading is often below 90 mm Hg.

Which type of burn or injury may cause a client to have a cervical spine injury?

Electrical burns Electrical burns may cause injuries to the cervical spine because intense electrical currents can fracture long bones and vertebrae. Chemical burns may cause eye and tissue damage. Inhalation injuries may damage the respiratory tract. Cold thermal injuries may cause tissue damage.

Which intervention would the nurse implement for an infant with increased intracranial pressure?

Elevating the head higher than the hips Elevation of the head helps decrease intracranial pressure by way of gravity. The infant is weighed daily before feedings after the insertion of a shunt; if the infant is in the intensive care unit, this is done routinely. Checking reflexes at regular intervals may be disturbing to the infant and impair the infant's ability to rest. Frequent stimulation may cause further irritability to an already traumatized central nervous system.

Which bacteria colonies are commonly found in a client's large intestine?

Escherichia coli Escherichia coli are bacteria that are part of the normal flora in the large intestine. Neisseria gonorrhoeae causes gonorrhea and pelvic inflammatory disease. Staphylococcus aureus secretes toxins that damage cells and causes skin infections, pneumonia, urinary tract infections, acute osteomyelitis, and toxic shock syndrome. Haemophilus influenzae causes nasopharyngitis, meningitis, and pneumonia.

Hydramnios is diagnosed in a primigravida at 35 weeks' gestation. For which condition would the nurse assess the newborn?

Esophageal atresia Esophageal atresia is associated with hydramnios. There is usually a history of polyhydramnios because the fetus is unable to swallow the amniotic fluid. Cardiac defects are not associated with hydramnios. Kidney disorders are associated with oligohydramnios, not hydramnios. Diabetes in the newborn is not associated with hydramnios.

Which nursing intervention will be priority when caring for a client with status epilepticus?

Establish an airway. The priority for a client with status epilepticus is establishing an airway to provide oxygenation after the seizure. Blood drawn for arterial blood gases and metabolic indicators, as well as placement of a large-bore IV for medication and fluids, can be completed after the client's airway is secure. Treatment with phenytoin may be prescribed to prevent further seizure activity but does not take priority over securing a client's airway.

What should the nurse tell the mother concerning an exercise program for her child diagnosed with idiopathic scoliosis who has a mild structural curve?

Exercise is used in conjunction with a brace. Rationale: An exercise program and a brace are the treatments of choice for mild structural scoliosis. Although compliance will affect the ultimate outcome of treatment, exercises alone are not helpful in this type of scoliosis. Exercises are to be encouraged, regardless of the type or extent of scoliosis. Exercises alone are used only with postural-related, not structural-related, scoliosis.

Which clinical findings would the nurse expect to find during the assessment of a child with acute glomerulonephritis (AGN)? Select all that apply. One, some, or all responses may be correct.

Flank pain Periorbital edema Flank pain is caused by inflammatory and degenerative changes in renal tissue; renal damage occurs because antigen-antibody complexes become trapped in the glomeruli. Because of glomerular dysfunction, filtration of plasma is decreased, causing fluid accumulation and sodium retention; this leads to congestion and edema. Fevers do not occur with AGN. There is usually a decrease, not an increase, in urine volume. Decreased joint mobility does not occur with AGN.

A client has a small pustule at a hair follicle opening with minimal erythema on the scalp. Which condition would the nurse suspect?

Folliculitis Folliculitis is the condition that forms a small pustule at the hair follicle opening; it has minimal erythema and is most commonly seen on the scalp, beard, and extremities. A furuncle is a condition in which there is a tender erythematous area around the hair follicle. Cellulitis is the condition in which there is a hot, tender, erythematous, and edematous area on the skin with diffuse borders. A carbuncle is the condition in which many pustules appear in an erythematous area, most commonly at the nape of the neck.

Where will the nurse place the V 1 lead when obtaining a 12-lead electrocardiogram?

Fourth intercostal space, right sternal border Positions for these 6 leads are as follows: V 1: fourth intercostal space, right sternal border; V 2: fourth intercostal space, left sternal border; V 3: halfway between V 2 and V 4; V 4: fifth intercostal space, left midclavicular line; V 5: fifth intercostal space, left anterior axillary line; V 6: fifth intercostal space, left midaxillary line.

The clinic nurse is providing home care instructions for a client with pelvic inflammatory disease. Which optimal resting position would the nurse recommend?

Fowler The Fowler position facilitates localization of the infection by pooling exudate and promoting drainage in the lower pelvis. The Sims position and supine position with knees flexed do not use gravity to promote pooling of exudate in the lower pelvis. The lithotomy position with head elevated does not use gravity to promote pelvic drainage despite an elevated head.

Which hormone aids in regulating intestinal calcium and phosphorous absorption?

Glucocorticoids Adrenal glucocorticoids aid in regulating intestinal calcium and phosphorous absorption by increasing or decreasing protein metabolism. Insulin acts together with growth hormone to build and maintain healthy bone tissue. Thyroxine increases the rate of protein synthesis in all types of tissues. Parathyroid hormone secretion increases in response to decreased serum calcium concentration and stimulates the bones to promote osteoclastic activity.

A client with a pulmonary embolus is intubated and placed on mechanical ventilation. Which nursing action is important when suctioning the endotracheal tube?

Hyperoxygenating with 100% oxygen before and after suctioning Suctioning also removes oxygen, which can cause cardiac dysrhythmias; the nurse should try to prevent this by hyperoxygenating the client before and after suctioning. Suction should be applied only while removing the catheter to prevent trauma to the trachea. Suction only as needed; excessive suctioning irritates the mucosa, which increases secretion production. Using rapid movements of the suction catheter to loosen secretions may cause tracheal damage.

Which arterial blood gas finding would be expected of a child with an acute asthma exacerbation?

Increased carbon dioxide level Gas exchange is limited because of narrowing and swelling of the bronchi; the carbon dioxide level increases. The oxygen level will be decreased, not increased. The pH will decrease; the child is in respiratory acidosis, not alkalosis. The bicarbonate level will be increased to compensate for acidosis.

Which is the nurse's primary concern when caring for a pregnant woman with class II cardiac disease and a hemoglobin level of 8 g/dL (80 mmol/L)?

Impending heart failure A hemoglobin of 8 g/dL is anemia, which reduces the capacity of the blood to carry oxygen and thus increases demands on the heart. Heart block is caused by a disturbance in the conduction of impulses, not the oxygen-carrying capacity of blood. Cardiac irregularity such as atrial fibrillation is not associated with anemia. Imminent ventricular fibrillation is a grave complication; adequate treatment should prevent this.

Which is an early indication of decompensation in a pregnant woman with cardiac disease?

Increase in fatigue An increase in fatigue is one of the early signs of decompensating resulting from an increased cardiac workload. Hemoptysis is a later sign of cardiac decompensation that is associated with pulmonary edema. Tachycardia and generalized edema are later signs of cardiac decompensation and may be accompanied by other signs of heart failure.

Which nutritional advice would the nurse provide to the pregnant client in the second trimester of pregnancy who is 5 ft 4 in tall (163 cm) and whose prepregnancy weight was 120 lb (54 kg)?

Increase total daily caloric intake by 340 calories more than before pregnancy. A daily increase of 340 calories is recommended for adult women with a normal body mass index (BMI) during the second trimester of pregnancy. Decreasing fat in the diet is not recommended during pregnancy. A daily increase of 450 calories is recommended for adult women during the third trimester of pregnancy. Carbohydrates provide needed energy, and a decreased intake would not be recommended in a client with a normal BMI.

A client is receiving mechanical ventilation. The nurse suspects that the client is experiencing poor oxygenation based on which assessment finding?

Increased restlessness Signs of poor oxygenation in the client on a ventilator may include increased restlessness or agitation. They may also include, but are not limited to, PaO 2 less than 90; cyanosis; skin pale, cool, and clammy; and thick, tenacious secretions present when suctioned.

Which statement about radiological dispersal devices (RDDs) made by the nursing student indicates effective learning?

Ionizing radiation released by an RDD does not cause immediate serious illness to people nearby. The radioactive materials used in an RRD do not release enough ionizing radiation to cause immediate serious illness, except to those victims who are in close proximity to the explosion. An RDD consists of a mix of explosives and radioactive material; the main danger from an RRD results from the explosion. ARS develops after a substantial exposure to ionizing radiation, such as that from a nuclear bomb or damage to a nuclear reactor. Uranium and iodine-131, generally used in an RDD, do not release enough ionizing radiation to cause serious harm to people who are not in close proximity to the explosion.

A 15-year-old adolescent is found to have type 1 diabetes. Which would the nurse include when teaching the adolescent about type 1 diabetes?

It has a more rapid onset than does type 2 diabetes. A characteristic difference between type 1 and type 2 diabetes is the rapid onset of type 1 diabetes. Type 1 diabetes often is first diagnosed during an episode of acute ketoacidosis. Children, adolescents, and adults with type 1 diabetes are insulin dependent. Vascular changes are complications associated with long-standing diabetes. Maturity-onset diabetes of the young (MODY), similar to type 2 diabetes, is more often seen in obese teenagers. Adolescents with type 1 diabetes tend to be at or below the expected weight for their height and bone structure.

Which method of swaddling could cause risk for injury?

Legs extended Swaddling an infant tightly with the legs extended is associated with an increased risk for hip dislocation. The correct way to swaddle an infant is with the hips in slight flexion and abducted and allowing for freedom of movement of the knees. Swaddling the infant with the arms either flexed or extended does not place the newborn at risk for injury.

Which information would the nurse include in a discharge teaching plan for a client who recently had a laryngectomy?

Keep the stoma covered with a scarf. Rationale: A stoma cover or scarf allows air to move into and out of the trachea but prevents particles of dirt and insects from entering the stoma. Fluids should not be limited; adequate fluids help liquefy respiratory secretions. Humidified air is not necessary because maintenance of hydration keeps secretions liquefied and mobile so that they can be expelled. Cotton-tipped swabs should not be used because cotton threads may be inhaled.

The nurse is teaching pursed-lip breathing to a client with chronic obstructive pulmonary disease (COPD). The client asks about the benefit of the exercises. Which explanation would the nurse give?

Keeps the airway open longer to decrease the work that goes into breathing Pursed-lip breathing keeps the airway open longer to decrease the work that goes into breathing. Clients with COPD are taught to breathe out through pursed lips to help keep the air passages open until exhalation is complete. Pursed-lip breathing does not prevent COPD complications. Pursed-lip breathing may relieve shortness of breath by decreasing the breath rate. Pursed-lip breathing does not increase the amount of air taken in during inspiration.

The nurse admits a client to the birthing unit at 40 weeks' gestation and determines that her contractions are 10 minutes apart and her cervix is dilated 2 cm. Which stage of labor is the client in?

Latent first stage Regular contractions occurring 10 minutes apart with a cervix dilated 2 cm indicate that the client is in the latent phase of the first stage of labor. The second stage of labor begins with full dilation and ends with expulsion of the fetus. Contractions occur more frequently and the cervix is more dilated in the active stage of labor. Contractions are intense and occur every 1 to 2 minutes in the transition phase of the first stage of labor, and cervical dilation would be 8 to 9 cm.

Which conditions of the client with chronic pain who is on opioid treatment would the nurse consider as the highest priority? Select all that apply. One, some, or all responses may be correct.

Level 3 sedation Respiratory rate of 8 breaths per minute Chronic use of opioids for pain may lead to constipation, nausea, vomiting, sedation, and respiratory distress. The client with a level 3 of sedation has frequent drowsiness, arousals, and episodes of sleep during conversation and needs immediate intervention. A respiratory rate of 8 breaths per minute leads to respiratory distress, which must be supported by adequate oxygenation. Pruritus can be resolved slowly because it is less life threatening. Constipation can be relieved by providing the client with a stimulant laxative and a stool softener. Nausea and vomiting may be resolved by providing antiemetics to the client.

Which is an example of an internal disaster in a hospital?

Loss of communications capabilities Rationale: Loss of critical utilities, such as communications capabilities, is an internal disaster. A hurricane is an external natural disaster. An oil spill from a marine oil tanker and malfunction of a nuclear reactor with radiation exposure are examples of technological external disasters.

Which nursing intervention is priority for a client during the immediate postoperative period?

Maintaining a patent airway Maintenance of a patent airway is always the priority, because airway obstruction impedes breathing and may result in death. Monitoring vital signs, observing for hemorrhage, and recording the intake and output are important; however, a patent airway is the priority.

Which nursing action is the priority in the care of a young child with severe diarrhea?

Maintaining fluid and electrolyte balance Maintaining fluid and electrolyte balance is the priority intervention to reduce risk of harm to the client. Measuring daily urine output is important as a means of checking kidney function, but maintaining overall fluid and electrolyte balance is the priority. If a child is severely dehydrated, urine output needs to be checked more often than daily. Nutrition is not a priority above fluid and electrolyte balance at this time. Although important, skin integrity is not the priority.

A client is admitted to the postanesthesia care unit after a segmental resection of the right lower lobe of the lung. A chest tube drainage system is in place. When caring for this tube, what would the nurse do?

Mark the time and fluid level on the side of the drainage chamber The fluid level and time must be marked so that the amount of drainage in the chest tube drainage system can be evaluated. The drainage system must be kept below chest level to promote drainage of the pleural space so the lungs can expand. Clamping the tube can produce backpressure, which may cause fluid to move into the pleural space from which it came, producing a tension pneumothorax. The catheter is secured by skin sutures, not to a dressing with a safety pin.

After a newborn has skin-to-skin contact with the mother, the nurse places the newborn under a radiant warmer. Which complication is the nurse attempting to prevent?

Metabolic acidosis Uncorrected cold stress increases anaerobic glycolysis, which increases acid production, resulting in metabolic acidosis. Metabolic acidosis, not metabolic alkalosis, occurs when a neonate is stressed by cold. Cold stress causes a metabolic, not a respiratory, problem; metabolic acidosis, not respiratory acidosis, occurs. Cold stress causes a metabolic, not a respiratory, problem; metabolic acidosis, not respiratory alkalosis, occurs.

A client sustained minor skin injuries after an accident. Which event occurs close to the time of injury?

Migration of leukocytes to the site of injury Beginning at the time of injury and lasting 3 to 5 days is the inflammatory phase in which migration of leucocytes takes place. Scar tissue is formed in the maturation phase. Formation of granulation tissue and migration of fibroblasts occurs in the proliferative phase.

Which intervention would the nurse include in the care of a child with Wilms tumor?

Monitoring blood pressure Blood pressure monitoring is important because the tumor is of renal origin and the renin-angiotensin mechanism may be involved. Palpating the liver should be avoided; it puts pressure on the involved area, increasing the risk of rupture of the tumor and seeding of cancer cells. There are no data to indicate that the child has a urinary tract infection. Lying in the prone position puts pressure on the involved area, increasing the risk of rupture of the tumor and seeding of cancer cells.

A health care team is caring for a client with diabetes insipidus. Which task is most suitable to be delegated to a licensed practical nurse (LPN) to provide effective client care? Select all that apply. One, some, or all responses may be correct.

Monitoring urine output Administering oral rehydration medication The LPN scope of practice includes monitoring urine output. Administration of any type of oral medication can also be performed by the LPN. Activities related to a client's hygiene, such as emptying the drainage, are usually performed by unlicensed assistive personnel (UAP). Feeding the client is usually performed by a UAP. Administration of intravenous fluids is the responsibility of the registered nurse.

For which reason may insulin requirements of a client with type 1 diabetes decrease during the first trimester?

Morning sickness may result in decreased food intake. Morning sickness, a common occurrence during pregnancy, contributes to decreased food intake; the insulin dosage must be reduced to prevent hypoglycemia. The body's metabolism increases during pregnancy, because the needs of the fetus, as well as those of the mother, must be met. Rapid organogenesis requires large amounts of glucose. During the first trimester the blood glucose level is reduced and glycemic control is enhanced; glycemic control is more difficult to maintain later in the pregnancy.

A client has been diagnosed as brain dead. Which understanding would the nurse have of this condition?

No cortical functioning with some reflex breathing A client who is diagnosed brain dead has no function of the cerebral cortex and a flat electroencephalogram (EEG). The client may have some spontaneous breathing and a heartbeat. The guidelines established by the American Association of Neurology include coma or unresponsiveness, absence of brainstem reflexes, and apnea. There are specific assessments to validate the findings. No spontaneous reflexes, shallow and slow breathing, and deep tendon reflexes only and no independent breathing do not fit the definition of brain dead.

The nurse is administering a prescribed antidepressant medication to a client in an inpatient mental health facility. Which action would the nurse perform to ensure the client is not stashing doses of medication?

Observe the client swallowing the medication. Clients in inpatient mental health facilities may attempt to stash doses of prescribed medication for use in a suicide attempt. The nurse will need to watch the client to ensure the medication is swallowed and not "cheeked." It is the nurse's responsibility to oversee medication administration, not a sitter or family member. A client will never be left to take medication unsupervised; therefore, the nurse would not leave the dose in a client's room or on a meal tray.

Which important intervention would be included in the nursing care provided immediately after a sexual assault?

Obtaining the assault history from the client Obtaining the assault history from the client provides a basis for assessing trauma; in a client of childbearing age it also is necessary to assess the risk for pregnancy. Examination may precede reporting; the decision to report is mandated by law. Urination may wash away spermatic or bloody evidence. A test for seminal acid phosphate, not seminal alkaline phosphatase, is performed.

Where would the nurse find the area of involvement associated with parietal swelling?

On the top of the skull The parietal areas behind the frontal bone form the top surfaces of the cranial cavity. A swelling in one of these areas that does not cross the suture line is a cephalhematoma. The frontal area is the area over the eyes. The temporal area is the area behind the ears. The occipital area is the area at the back of the head.

Which precaution would the nurse institute for a client with a diagnosis of severe preeclampsia?

Padding the side rails on the bed A client with severe preeclampsia is at risk for developing seizures. Padded side rails help prevent injury during the clonic-tonic phase of a seizure. The client must be protected from injury if there is a seizure. Although some clients experience an aura before a seizure, there is not enough time to use a call button and wait for help. Oxygen is useless during a seizure when the client is not breathing or is thrashing about. Assigning a staff member to stay with the client in anticipation of a seizure is impractical and unproductive.

The nurse changed a dressing on a client's wound with vancomycin-resistant enterococci (VRE). Which step would the nurse take to ensure proper disposal of the soiled dressing?

Place the dressing in a red bag/hazardous materials bag. Contact precautions must be used for clients with known or suspected infections transmitted by direct contact or contact with items in the environment; thus the dressing should be placed in a red bag or hazardous materials bag. The soiled dressing should not be placed in a single bag and left in the trash can. Infection control is every health care worker's responsibility, not just environmental services'. The laboratory is not responsible for disposal of hazardous wastes that occur as a result of normal nursing activities.

The nurse is caring for a client with a history of alcoholism and cirrhosis who is hospitalized with severe dyspnea as a result of ascites. An increase in which process most likely caused the ascites?

Pressure in the portal vein The enlarged cirrhotic liver impinges on the portal system, causing increased hydrostatic pressure from increased pressure in the portal vein, resulting in ascites. Bile salts are not responsible for fluid shifts; increased serum bile results from biliary obstruction, not increased secretion of bile. Interstitial osmotic pressure is unchanged; decreased intravascular osmotic pressure accounts for fluid movement into interstitial spaces. The liver's production of serum albumin is decreased with cirrhosis of the liver.

Which goal is the nurse trying to achieve when placing a client with severe burns on a circulating air bed?

Preventing pressure on peripheral blood vessels The circulating air bed disperses body weight over a larger surface, which reduces pressure against the capillary beds, allowing for tissue perfusion. These beds are used for clients who are immobile; they do not increase mobility. Limiting orthostatic hypotension is achieved by dangling, not by this type of bed. Range-of-motion exercises, not the type of bed, will help prevent contracture.

Which parent education would the nurse provide the parents of a 9-month-old about the cause of diaper dermatitis?

Prolonged contact with an irritant Diaper dermatitis is caused by prolonged repetitive contact with an irritant (e.g., urine, feces, soaps, detergents, ointments, friction). Both cloth and disposable diapers can cause diaper dermatitis if they are not changed frequently. The increased pH (i.e., alkaline) of urine can contribute to diaper dermatitis. A change in diet may contribute, but there is no evidence that this is directly related.

Which intervention would be included in the plan of care for a child with nephrotic syndrome?

Providing meticulous skin care Massive edema, typical of nephrotic syndrome, predisposes the child to skin breakdown. The child requires more fluid than 4 oz (120 mL) each shift to maintain hydration. Carbohydrates and proteins are not restricted. Children with nephrotic syndrome usually do not receive blood transfusions.

The nurse is caring for a client who has experienced a near-drowning. Which potential danger would the nurse assess the client?

Pulmonary edema Additional fluid from surrounding tissues will be drawn into the lung because of the high osmotic pressure exerted by the salt content of the aspirated ocean water; this results in pulmonary edema. Hypoxia and acidosis may occur after a near-drowning, not alkalosis. Renal failure is not a sequela of near-drowning. Hypovolemia occurs because fluid is drawn into the lungs by the hypertonic saltwater.

Which procedure would the nurse use to elevate the head of an infant in a spica cast?

Raising the entire mattress at the head of the crib When elevation of the head is desired, the entire mattress or crib should be raised at the head of the crib. A donut head pad is used to diminish pressure, not elevate the head. Pillows under the head or shoulders of a child in a spica cast will thrust the chest forward against the cast, resulting in discomfort and respiratory distress. Padding the edge of the cast with folded diapers will not help elevate the infant's head.

Which is the appropriate intervention for a pregnant client whose monitor strip shows fetal heart rate decelerations characterized by a rapid descent and ascent to and from the lowest point of the deceleration?

Repositioning the client from side to side A deceleration with a rapid descent and ascent to and from the lowest point of the deceleration is a variable deceleration caused by cord compression. Changing the client's position from side to side promotes release of the compression. Elevating the legs and increasing the rate of intravenous fluid administration are interventions for placental perfusion problems and do not affect cord compression. Oxygen given while the cord remains compressed will not provide fetal oxygenation.

Which assessment finding in a 5-month-old infant would the nurse report to the health care provider?

Respiratory rate of 70 breaths per minute The average respiratory rate for infants is 35 breaths per minute. An infant with 70 breaths per minute has tachypnea. Tachypnea requires further investigation. The nurse should report this to the health care provider. A heart rate of 100 beats per minute, blood pressure of 75/48 mm Hg, and temperature of 99.5°F (37.5°C) are all within the expected ranges for infants.

When responding to the scene of a tornado, the nurse finds a victim lying next to a broken natural gas main. The victim is not breathing and is bleeding heavily from a wound on the foot. Which would be the nurse's first intervention?

Safely remove the victim from the immediate vicinity. The first action should be to safely remove the victim from the source of further injury. Treating the victim for shock is not the priority. Breathing is the priority once further injury is avoided. Applying surface pressure to the foot wound should be the last concern. The guidelines for CPR should be followed.

The nurse is planning to teach activities of daily living to a developmentally disabled 3-year-old child. Which activity would the nurse plan to teach to the child first?

Self-feeding According to the principles of growth and the development of skills, feeding is taught first, and this is no different for a child who is developmentally disabled. Dressing, toileting, and hair combing are more difficult skills than self-feeding.

Which weight assessment would the nurse make for an infant who weighed 7.5 lb (3.4 kg) at birth who weighs 15 lb (6.8 kg) at 1 year?

Signifies an inadequate weight gain The infant's weight signifies inadequate weight gain, according to the weight charts of the National Center for Health Statistics. An infant's total weight at the end of the first year should be three times the birth weight. Suggesting maternal neglect is a judgmental reaction; more evidence is needed to come to this conclusion. There are not enough data to determine whether the infant has an insufficient intake of dietary protein.

Which client response is most important for the nurse in the postanesthesia care unit to monitor when caring for a client who had a thyroidectomy?

Signs of respiratory obstruction The first and most important observation should be for respiratory obstruction. If this occurs, treatment must be instituted immediately. Urinary retention is a later concern; urinary retention will not occur in the immediate postoperative period. Signs of restlessness may result from the anesthesia; however, it is not life threatening and usually passes. The blood pressure is not significantly affected by this type of surgery; however, surgery itself can influence blood pressure. If the blood pressure significantly increases, other symptoms of thyroid crisis (storm) will be present.

Which nursing intervention is the priority when the nurse notices that the client receiving a blood transfusion is having an acute hemolytic reaction?

Stop the blood transfusion immediately. An incompatible blood transfusion can result in an acute hemolytic reaction in the client. During acute hemolytic reactions, the nurse would stop a blood transfusion as a priority nursing intervention. After stopping the blood transfusion, the nurse would report it to the primary health care provider. The nurse can then recheck the client's identifying tags and numbers and maintain a patent IV line with saline solution.

Which is the expected color and consistency of amniotic fluid at 36 weeks' gestation?

Straw colored, clear, and containing little white specks By 36 weeks' gestation, amniotic fluid should be pale yellow or straw-colored with small particles of vernix caseosa present. Dark amber-colored fluid suggests the presence of bilirubin, an ominous sign. Greenish-yellow fluid may indicate the presence of meconium and suggests fetal compromise. Cloudy fluid suggests the presence of purulent material.

The nurse is caring for a preterm infant who is receiving oxygen therapy. Which would the nurse do to prevent retinopathy of prematurity (ROP)?

Support the neonate's oxygen saturation while providing minimal FiO 2. ROP is a complex disease of the preterm infant; hyperoxemia is one of the numerous causes implicated. Oxygen therapy is maintained at the lowest level necessary to support respiratory status. If the oxygen concentration needs to be increased to maintain life, ROP may not be preventable. Using a shield over the neonate's eyes will not prevent the development of ROP, nor does positioning or assessment of the neonate every hour with a pulse oximeter alone. If the pulse oximetry results are within an acceptable range, the oxygen concentration may be reduced.

Using the functional model of nursing, which task will the registered nurse (RN) delegate to the unlicensed assistive personnel (UAP) on a team of nurses that includes two licensed practical nurses (LPNs) and one UAP?

Taking vital signs When working in an environment that uses the functional model of nursing, each team member will be delegated tasks for a group of clients by the team leader, the RN. The RN will delegate taking vital signs to the UAP. One of the LPNs can provide basic wound care and administer oral medications. Typically, the RN is the member of the team who will conduct discharge teaching.

Which condition is consistent with a client's report of posterior leg pain while walking that worsens upon rest?

Tendonitis The Achilles tendon attaches the calf muscle to the heel. An inflammation to the Achilles tendon, Achilles tendonitis, may lead to pain in the posterior leg upon movement that worsens at rest. A frequent, audible crackling sound with palpable grating that accompanies movement is crepitus. Chronic joint inflammation and destruction resulting in stiffness is ankylosis. A contracture is a condition in which the muscles and joints become rigid because of fibrosis of the supporting soft tissues.

A client returns from a radical neck dissection with a tracheotomy and two portable wound drainage systems at the operative site. Inspection of the neck incision reveals moderate edema of the tissues. Which assessment finding is a priorityrequiring immediate nursing intervention?

The client is at risk for airway obstruction; restlessness and dyspnea indicate hypoxia. Cloudy drainage may indicate infection, which is not an immediate postoperative complication. Loss of the gag reflex is unimportant. The pharyngeal opening is sutured closed, and a tracheal stoma is formed; the trachea is anatomically separate from the esophagus. Decreased urinary output needs to be monitored but does not take priority.

After assessing the delegatee's inability to perform an assigned task, the delegator explains the procedure and demonstrates the task to the delegatee. Which response can be inferred about the delegatee?

The delegatee may have an ongoing relationship with the delegator, but a new task is assigned. When the delegatee has an ongoing relationship with the delegator, but a new task is assigned, the delegator should explain and demonstrate the procedure. When the delegatee has limited knowledge and ability to perform the task, the delegator should provide more guidance. When the delegatee has an established relationship with the delegator and the expertise, little guidance is needed from the delegator to perform the task. When the delegatee has the willingness and ability to perform a task, but the relationship is new, it requires both individuals to create mutual expectations and the conditions for performance.

Which purpose would the nurse explain to a client as the reason for using Buck traction before surgery?

To immobilize the fracture A continuous pull on the lower extremity keeps bone fragments from moving and causing further trauma, pain, and edema. The fracture will be reduced by surgery; Buck traction is a temporary measure before surgery. Moving the leg away from the midline will not keep the leg in alignment; it is not the purpose of Buck traction. External rotation of the femur may still occur with Buck traction.

A client with an above-the-knee amputation asks why the residual limb needs to be wrapped with an elastic bandage. Which rationale for the treatment would the nurse provide?

To support the soft tissue and minimize swelling Pressure supports tissue, promotes venous return, and limits edema, thus promoting shrinkage of the distal part of the residual limb. Although it may limit clot formation, its primary purpose is to promote venous return, prevent edema, and shrink the distal part of the residual limb. Bandaging does not decrease the occurrence of phantom limb sensation. Although pressure may prevent hemorrhage, this is not its primary purpose.

Which complication would the nurse anticipate finding during the assessment of a client admitted with a diagnosis of severe procidentia (prolapse of the uterus)?

Ulcerations Ulcerations may occur when the vagina and uterus are displaced and exposed. Edema is not usually the problem. Fistulas are not associated with procidentia. Exudate is not present with prolapse of the uterus.

There are five clients in the emergency unit. Which client conditions require immediate treatment? Select all that apply. One, some, or all responses may be correct.

Unstable vital signs Severe abdominal pain Chest pain with diaphoresis A client with unstable vital signs requires immediate treatment. A client with severe abdominal pain could be experiencing aneurysm or ectopic pregnancy that is rupturing and should be treated immediately. A client with chest pain and diaphoresis may have cardiac arrest and should be treated immediately. A client with skin rash can wait for several hours if needed without any fear of deterioration. A client with multiple complex soft tissue injuries does not need immediate treatment because the injuries are not likely to be life threatening.

Which is the first action the nurse would take when responding to an apnea monitor alarm that signifies a 10-second cessation of respirations?

Use tactile stimuli on the chest or extremities. The nurse applies tactile stimulation after confirming that respirations are absent; this action may be sufficient to reestablish respirations in the high-risk neonate with frequent episodes of apnea. Assessment will not interrupt the period of apnea; respirations must be reestablished immediately. The monitor should be assessed for proper function before use. Resuscitation with a bag-valve mask is too invasive and aggressive for an initial intervention; gentle stimulation should be attempted first.

Which instruction does the nurse give to a client who arrives in the birthing room with the fetal head crowning?

Use the pant-breathing pattern. Panting will slow the process so the nurse can support the head as the baby is born. Pushing will speed the birth, which could result in injury to both mother and fetus. Turning the mother on her left side will have no effect on the progress of the second stage of labor, and it is difficult to accomplish when the fetal head is crowning. Having the mother assume the knee-chest position will have no effect on the progress of the second stage of labor, and it is difficult to accomplish when the fetal head is crowning.

Which clinical indicators would the nurse consider evidence of increasing intracranial pressure? Select all that apply. One, some, or all responses may be correct.

Vomiting Irritability Decreased level of consciousness Anorexia, nausea, and vomiting occur because of pressure on the brain. Increasing pressure on the vital centers in the brain and irritation of cerebral tissue result in irritability and seizures. Increased intracranial pressure disrupts neurons and neurotransmitters, resulting in faulty impulse transmission and an altered level of consciousness. The blood pressure will be increased, not decreased, because of pressure on the vital centers in the brain. Also, the pulse pressure increases. Pressure on the respiratory center in the medulla results in a decreased, not increased, respiratory rate. As the intracranial pressure increases, the client may exhibit Cheyne-Stokes respirations.

Which question asked by the nurse is most appropriate to assess the nature of the client's pain?

"Can you describe your pain to me?" To get detailed information about pain, the nurse would ask the client to describe the pain using his or her own words. This open-ended question does not lead the client and provides the most clinical detail. Asking whether the pain is associated with movement and asking whether the client notices pain worsening with activity are closed-ended questions, which may not result in detailed answers and which require follow-up questions. Rating pain on a scale of 0 to 10 is appropriate but would be asked after the client is given the opportunity to describe the nature of the pain using his or her own words.

The Joint Commission is surveying an organization's nursing care. Which question is the surveyor most likely to ask regarding right supervision and delegating?

"Do you monitor and evaluate the client's condition appropriately?" Monitoring and evaluating clients' conditions should be performed by the delegator. This falls under right of supervision of delegation. Assessing the delegatee's knowledge regarding the importance of providing results falls under right communication of delegation. Maintaining open lines of communication with the delegatee and providing clear and concise directions to the delegatee falls under right communication of delegation.

The nurse receives an order to prepare a solution for administering a cleansing enema for an adolescent client. Which is the volume of solution that would be prepared?

500 to 750 mL In adolescents, the volume of solution required is 500 to 750 mL. The nurse would prepare 150 to 250 mL of warmed solution for infants. The nurse would prepare 250 to 350 mL of warmed solution for administering a cleansing enema in a toddler. In school-age children, the volume of warmed solution is 300 to 500 mL.

One minute after birth, a neonate's heart rate is 106 beats per minute; acrocyanosis and muscle tone with flexion are observed; flicking the sole triggers crying, and the cry is strong. What is the neonate's Apgar score?

9 The Apgar score is calculated from scores in five areas: heart rate, respiratory effort, muscle tone, reflex irritability, and color. Each area is given a score of 0, 1, or 2. Pulse over 100 = 2 points; good cry = 2 points; good muscle tone = 2 points; excellent reflex irritability (stimulus precipitates a cry) = 2 points; bluish extremities (acrocyanosis) = 1 point.

An abandoned infant has been brought to the hospital and diagnosed with ophthalmia neonatorum. Which is the nurse's estimate of the infant's age?

About 3 to 4 days Untreated ophthalmia neonatorum becomes apparent on the third or fourth postnatal day and provides evidence that the mother may have had gonorrhea or a chlamydial infection. The most common presentation of ophthalmia neonatorum occurs by day 3 after birth, not less than 24 hours, at 24 hours, or at 2 days.

Which assessment would the nurse perform first for a client with severe trauma?

Airway Rationale: Airway is assessed first in a client with severe trauma because inadequate oxygen supply can lead to brain injury that can progress to anoxic brain death. Disability is assessed after the vital signs are assessed. Breathing is assessed after the airway is assessed and cleared. Circulation is assessed after effective breathing is ensured.

Which finding in a newborn whose temperature over the past 4 hours has fluctuated between 98.0°F (36.7°C) and 97.4°F (36.3°C) would be considered critical?

Blood glucose level of 26 mg/dL (1.4 mmol/L) Instability of the newborn's temperature is an indication of hypoglycemia. A glucose level below 30 mg/dL (1.7 mmol/L) does not provide enough energy to maintain the body temperature at a normal level. A serum calcium level of 8 mg/dL (2 mmol/L), respiratory rate of 60 breaths/min, and a white blood cell count greater than 15,000 mm 3 are all normal findings and do not affect body temperature.

A client who had a cesarean birth is unable to void 3 hours after the removal of an indwelling catheter. How would the nurse evaluate the client for bladder distension?

By palpating the client's suprapubic area gently Palpation will indicate whether bladder distention is present. The increased intra-abdominal space available after birth can result in bladder distention without discomfort. Assessment should be done before interventions. Trauma to the area makes surrounding organs atonic; the client may have a full bladder and not feel the urge to void.

How would the nurse prepare a factual record when performing client documentation?

By recording descriptive and objective information of what he or she sees, hears, feels, and smells A factual record contains descriptive and objective information about what the nurse sees, hears, feels, and smells. An organized record communicates the information in a logical order. The use of exact measurements establishes accuracy. The nurse prepares a complete record by providing a comprehensive record that includes all essential information.

Which information about malignant tumors of the colon would the nurse consider when providing care for a client with an obstruction of the colon?

Colon obstructions are usually malignant. Obliteration of the lumen of the intestine by malignant cells is the most common cause of mechanical obstructions. The most common cause of colon obstruction is colorectal cancer. In the early stages, symptoms of cancer of the colon are vague or absent. Localized tumors are usually benign. Cancer of the lower bowel is more common in men than in women; however, the incidence is increasing in women.

Which intervention is the highest priority for an assault victim who presents to the emergency department?

Ensuring the client's emotional and physical safety An assault survivor will be in shock and confused, so ensuring the client's emotional and physical safety is considered as the highest priority. The client's vital signs are monitored after ensuring the client's emotional and physical safety. Once the client's emotional and physical safety is ensured, a general physical examination is performed and then the client is counseled regarding sexually transmitted infections.

A student with type 1 diabetes asks the nurse which hormone causes the blood glucose level to rise. Which hormone would the nurse report?

Glucagon Glucagon promotes liver glycogenolysis, resulting in the release of glucose into the blood. ACTH is not directly related to glycogenolysis; it is released from the anterior pituitary. Insulin production is not directly related to glycogenolysis; in healthy individuals the level of insulin will increase as the glucose level increases. Epinephrine is not directly related to glycogenolysis; it is released from the adrenal medulla and sympathetic nerve endings.

Which condition would the nurse document when a newborn infant is noted to have small, flat pink spots on the nape of the neck?

Nevi Nevi, described as small, flat pink spots, are the result of a superficial capillary defect and are most commonly found on the upper eyelids, nose, upper lip, and nape of the neck. Desquamation is peeling skin that occurs a few days after birth. Mongolian spots are bluish-black areas of pigmentation. Erythema toxicum is a transient rash that appears 24 to 72 hours after birth that can last up to 3 weeks of age.

Which parent education would the nurse provide when teaching an infant's parents about the major cause of iron-deficiency anemia?

Overfeeding of milk Milk is an inadequate source of iron. Milk ingested in large amounts to the exclusion of solid foods after 4 to 6 months of age often results in iron-deficiency anemia. Anemia is a type of blood disorder. Iron stores received from the mother in the last trimester usually are adequate for the infant's first 4 to 5 months. Lack of absorption of solid foods that are introduced too early is not the cause of anemia in infants.

Which serum laboratory value in a client with urinary problems may indicate the risk of developing muscle weakness and cardiac arrhythmias?

Potassium of 7.02 mEq/L (7.02 mmol/L) The normal level of serum potassium is between 3.5 to 5.0 mEq/L (3.5 and 5.0 mmol/L). Elevated potassium levels greater than 6 mEq/L (mmol/L) can lead to muscle weakness and cardiac arrhythmias. The normal levels of serum phosphorus are between 2.4 and 4.4 mg/dL (0.78 and 1.42 mmol/L). The normal levels of serum calcium are usually between 8.6 and 10.2 mg/dL (2.15 and 2.55 mmol/L). The normal level of serum bicarbonate is between 22 and 26 mEq/L or mmol/L. These findings are not associated with the risk of developing muscle weakness and cardiac arrhythmias.

Which interventions would be expected in the immediate postoperative period after a vaginal hysterectomy and anterior and posterior repair of the vaginal wall?

Presence of a urinary catheter After surgery the urethral orifice may be distorted and edematous; a urine retention catheter keeps the bladder empty, limiting pressure on the operative site. A pessary placed in the vagina is used for a displaced uterus; after an anteroposterior repair (colporrhaphy), vaginal packing is used to support the surgical repair. A rectal tube is used for abdominal distention caused by flatulence; it is rarely necessary. A cleansing douche may be prescribed before, not after, surgery.

Which is the priority nursing action for a client in the second stage of labor?

Promote effective pushing by the client. Effective pushing will hasten the passage of the fetus's presenting part through the birth canal. The fetal position is established before the second stage. Birth is imminent, and medication given at this time will depress the newborn's respirations. Although the mother may breast-feed after the birth, during the second stage of labor she should be concentrating on the birth process, not feeding the infant.

Which clinical manifestations of signs of withdrawal would the nurse expect to identify in a newborn of a known opioid user? Select all that apply. One, some, or all responses may be correct.

Sneezing Hyperactivity High-pitched cry Exaggerated Moro reflex Neurologic signs of withdrawal in the neonate of an opioid-addicted mother are manifested by sneezing, hyperactivity, jitteriness, and a high-pitched cry. The Moro reflex usually becomes exaggerated as the signs of withdrawal become apparent. The deep tendon reflexes are exaggerated during opioid withdrawal.

A pregnant client is admitted to the high-risk unit with abdominal pain and heavy vaginal bleeding. Which is the nurse's priority intervention?

Starting oxygen therapy The client is hemorrhaging and has decreased cardiac output. Oxygen is necessary to prevent further maternal and fetal compromise. Administering an opioid will sedate an already compromised fetus. Elevating the head of the bed will decrease blood flow to vital centers in the brain. Although blood should eventually be drawn for laboratory tests, it is not the priority.

The nurse is caring for a primigravid client during labor. Which physiological finding would the nurse observe that indicates birth is about to take place?

The perineum has begun to bulge with each contraction. The bulging perineum indicates that the fetal head is on the pelvic floor and birth is imminent. An increase in bloody show (discharge from the vagina) and an increasingly irritable client are seen during the transition phase or at the beginning of the second stage. Contractions occurring more frequently that are stronger and last longer are part of the progress of labor, not a sign that birth is imminent.

Which assessment would the nurse perform to assess the magnitude of an infant's fluid loss from diarrhea?

Weight compared with prior weight Loss of weight is the most accurate measurement of the magnitude of fluid loss; 1 L of fluid weighs 2.2 lb. Tissue turgor is subjective measure of dehydration and not as accurate as a comparison with the pre-illness weight. Although an increased hematocrit and dry mucous membranes each indicate dehydration, neither is an effective tool for assessing the amount of fluid loss.

Which assessment finding alerts the nurse to increasing intracranial pressure?

Widening pulse pressure Pressure on the vital centers in the brain causes an increase in the systolic blood pressure, widening the difference between the systolic and diastolic pressures. The client will be lethargic and have a lowered level of consciousness. The pupils will be unequal or dilated, not constricted. Pressure on the vital centers in the brain results in a decreased, not increased, heart rate.

The nurse suspects that a client has diabetes mellitus. Which statements made by the client helped the nurse reach this conclusion? Select all that apply. One, some, or all responses may be correct.

"I am 65 years old." "I quite often feel thirsty." "I eat food every 2 hours." Diabetes mellitus is more common in older clients. Clients with diabetes mellitus may feel excessive thirst due to frequent urination and may also experience excessive hunger. Excessive sweating and respiratory disorders are mostly observed in clients with hyperthyroidism.

The nurse is teaching a group of nursing students about the use of monoamine oxidase inhibitors (MAOIs). Which statement made by a student indicates the need for further teaching?

"I should encourage the client to eat food high in tyramine." Because of the potential for a dangerous hypertensive crisis, the nurse would tell the client to avoid foods high in tyramine when taking MAOIs. The nurse would advise the client to report any problem in vision. The nurse would advise the client to report any symptoms of seizures. The nurse would encourage the client to wear a medical alert necklace.

Which statement regarding interventions for clients with inhalation burns shows a nurse needs further education?

"I would immediately calculate the burned surface area with the rule of nines." Inhalation injury burns occur in the nose, mouth, throat, and airway. The nurse would administer intravenous analgesia and anticipate both endotracheal intubation and a need for fiberoptic bronchoscopy. Inhalation burns are not visible or limited to the nose, mouth, throat, and airway; there are not any calculations, because the surface area is internal.

A 16-year-old girl at 28-weeks' gestation arrives with her mother for a routine sonogram and has asked the nurse not to reveal the sex of the fetus if it becomes apparent. Afterward, the mother asks the nurse the sex of the fetus. Which response would the nurse provide?

"That information is not available at this time." Stating that the information is not available at this time supports the client's right to confidentiality without antagonizing the client's mother. Because the expectant mother has requested that the sex of the fetus not be revealed, she has legally and ethically made this information unavailable. Although stating that the nurse is not allowed to divulge that information or that the client has asked it not be given protect the client's right to confidentiality, these responses could disrupt the relationship between the client and her mother. Stating that the sex of the baby isn't the most important information at this time is a judgmental, nontherapeutic statement.

Which complications would the nurse monitor in a client who sustained a transection of the spinal cord, but no other injuries?

Autonomic hyperreflexia Autonomic hyperreflexia, an uninhibited and exaggerated response of the autonomic nervous system to stimulation, results in a blood pressure greater than 200 mm Hg systolic; it is a medical emergency. Although hemorrhage and hypovolemic shock could occur from the trauma, the scenario stated that no other injuries occurred. Although gastrointestinal atony can result from immobility, it is not a medical emergency.

Which foods would the nurse recommend for a client who is to begin a 2-g sodium diet?

Beef steaks Mushrooms Cooked broccoli Beef is low in sodium. Broccoli and mushrooms do not have significant sodium levels. Aged cheeses are high in sodium and saturated fat. Luncheon meat is processed and has high sodium levels to help with its preservation.

Which rationale would the nurse use when teaching a client with chronic obstructive pulmonary disease (COPD) to use pursed-lip breathing?

Decrease air trapping Pursed-lip breathing prolongs the expiratory phase and increases airway positive pressure, leading to more complete expiration and reduced air trapping. Bronchi and bronchioles stay open longer and are expanded during pursed-lip breathing. Pursed-lip breathing does not strengthen the intercostal muscles or reduce diaphragmatic excursion.

Which is the most common cause of vehicle injuries in children?

Disobeying common traffic safety regulations Most injuries occur when children disobey common traffic safety regulations or misinterpret traffic signs. Inappropriate seat belt restraints, sitting in the front seat of the car, and walking in the opposite direction of the traffic are not the most common cause of motor vehicle injuries in children.

Which would the nurse instruct the parents of a child with irritable bowel disease (IBD) who is anorexic to ensure sufficient intake of calories?

Frequent snacks of high-protein, high-calorie foods Small quantities of food are better tolerated than large meals. High-fiber foods, even taken in small amounts, may exacerbate the illness. Seasoned foods may be irritating and difficult for the child to tolerate; bland foods are advised. Three meals a day may not supply sufficient calories, unless the meals are large, and large meals may be difficult for the child to tolerate.

Which priority teaching intervention would the nurse include in the care plan for a client who has insomnia?

Sleep and cognitive changes The nurse would first teach about sleep and cognitive changes to the client with insomnia. The nurse can teach about medication administration procedures, but this is not the priority. The nurse can teach dietary measures to be followed at night after teaching about sleep and behavioral changes. Teaching about nonpharmacological procedures is also not the priority nursing intervention.