Module 10-Physiological Health Problems

A nurse is caring for a child with newly diagnosed type 1 DM who is receiving insulin. The child suddenly exhibits tachycardia and begins to sweat and tremble and the nurse determines that the child is experiencing a hypoglycemic reaction. the nurse would immediately give the child 1) ½ cup (118 mL) of fruit juice 2) A sugar cube 3) ½ cup (118 mL) of diet cola 4) A teaspoon of sugar

1/2 cup of fruit juice

A pediatric nurse finds a hospitalized child unresponsive. A quick assessment reveals that the child is not breathing and does not have a pulse. The nurse initiates CPR. How many compressions per min does the nurse deliver 1) 100 2) 50 3) 15 4) 30

100

A nurse arrives at the scene of a code and begins to assist with CPR of an adult. The nurse delivers compressions by pushing down on the chest to the depth of 1) 1½ inches (3.8 cm) 2) ½ inches (1.27 cm) 3) 4 inches (10 cm) 4) 2 inches (5 cm)

2inches Rationale: When CPR is being performed on an adult, the sternum should be depressed at least 2 inches (5 cm). The other options are incorrect because they are too shallow to be effective or too deep, which can cause damage to internal organs. The rescuer should allow complete recoil of the chest after each compression to allow the heart to fill completely before the next compression.

a nurse notes that a client has ST segment depression on the ECG monitor. with which serum K reading does the nurse associate this finding 1) 5.4 mEq/L (5.4 mmol/L) 2) 4.2 mEq/L (4.2 mmol/L) 3) 3.1 mEq/L (3.1 mmol/L) 4) 4.5 mEq/L (4.5 mmol/L)

3.1 mEq/L Rationale: A serum potassium level below 3.5 mEq/L(3.5 mmol/L) is indicative of hypokalemia, the most common electrolyte imbalance, which is potentially life threatening. ECG changes in hypokalemia include peaked P waves, flat T waves, a depressed ST segment, and prominent U waves. Readings of 4.5 mEq/L (4.5 mmol/L)and 4.2 mEq/L (4.2 mmol/L)are normal potassium levels; 5.4 mEq/L (5.4 mmol/L)indicates hyperkalemia.

The nurse is adminstering CPR to an adult client. Which compression-ventilation ratio is correct 1) 15:1 20 20:2 3) 30:2 4) 15:2

30:2

A nurse is assigned to care for 4 clients on the med-surg unit. Which client should the nurse see first on the shift assessment 1) A client undergoing long-term corticosteroid therapy with mild bruising on the anterior surfaces of the arms 2) A client with congestive heart failure with clear lung sounds on the previous shift 3) A client with new-onset of shortness of breath (SOB) and a history of pulmonary edema (PE) 4) A client admitted with pneumonia with a fever of 100° F (37.8°C) and some diaphoresis

A client with new-onset SOB and a hx of pulm edema Rationale: The client who should be seen first is the one with SOB and a history of pulmonary edema. In light of such a history, SOB could indicate that fluid-volume overload has once again developed. The client with a fever and who is diaphoretic is at risk for insufficient fluid volume as a result of loss of fluid through the skin, but this client is not the priority.Test-Taking Strategy: Use the process ofelimination and focus on the subject of the question. Note the strategic word "first." This indicates the most critical and important client the nurse should initially see. Recall the rule of assessment of the ABCs — airway, breathing, and circulation — which means that the client experiencing SOB should take precedence over the other clients on the unit. This client's condition could progress to respiratory arrest if the client were not assessed immediately on the basis of the signs/symptoms. Read each option and think about the client in most critical condition and review the disorders to determine which clients have the most critical needs. Review: pneumonia with fever, CHF, SOB, PE, corticosteroid therapy

a nurse notes that a client's serum K level is 5.8. The nurse interprets this as an expected finding in the client with 1) Wound drainage 2) Heart failure being treated with loop diuretics 3) Addison disease 4) Diarrhea

Addison's Disease Rationale: Adrenal insufficiency (Addison disease) is a cause of hyperkalemia. A serum potassium level greater than 5.0 mEq/L (5.0 mmol/L)indicates hyperkalemia, and the nurse would report the finding to the primary health care provider. Other common causes of hyperkalemia include tissue damage, such as that in burn injuries, renal failure, and the use of potassium-sparing diuretics. The client with diarrhea or wound drainage or the client being treated with diuretics is at risk for hypokalemia.

A hospitalized client with chronic renal failure has returned to the nursing unit after a hemodialysis tx. Which parameters contained in the predialysis and postdialysis documentation does the nurse utilize to determine if the procedure was effective 1) Potassium and creatinine levels 2) Blood pressure and weight 3) Weight and BUN 4) Blood urea nitrogen (BUN) and creatinine levels

BP and wt Rationale: After hemodialysis, the client's vital signs are monitored to determine whether the client is remaining hemodynamically stable and for comparison with predialysis measurements. The client's blood pressure and weight are expected to be reduced as a result of fluid removal. Laboratory studies are performed as per protocol but are not necessarily done after the hemodialysis treatment has ended.

A client has just had a plaster leg cast applied and the nurse has given the client instructions on cast care. Which statement by the cleint indicates the need for further instruction 1) "I shouldn't use anything to scratch underneath the cast." 2) "I can dry the cast faster if I use a hairdryer on the hot setting." 3) "If I smell any odor from the cast, I should call the doctor." 4) "I may feel cool while the cast is drying."

I can dry the cast faster if I use a hairdryer on the hot setting Rationale: Using a blow dryer on the hot setting to dry the cast is not advised because it may burn the client's skin under the cast and crack the cast. While the cast is still damp, the client may feel cold and may experience a decrease in body temperature. The client should never insert any item under the cast because of the risk skin compromise. An odor coming from the cast could indicate the presence of infection, warranting health care provider notification.

The nurse has instructed a client who is about to begin external radiation therapy in how to maintain optimal skin integrity during therapy. Which statement by the client indicates a need for further instruction 1) "I need to keep the sun off the radiation site." 2) "I can use over-the-counter cortisone cream on the radiation site if it gets red." 3) "I need to wash the skin at the radiation site with a mild soap and water and pat it dry." 4) "I need to be careful not to wash off the marks that the radiologist made on my skin."

I can use OTC cortisone cream on the rad site if it gets red Rationale: The client should use no powders, ointments, lotions, or creams on the skin at the radiation site unless they have been prescribed by the primary health care provider. Avoiding sun exposure of the radiation site, not removing marks made on the skin by the radiologist, and washing the skin with mild soap and water and patting it dry are all correct measures. The client should also be instructed to avoid using harsh detergents to wash clothing.

A nurse provides instructions to a client about measures to prevent an acute attack of gout. The nurse determines that the client needs additional instructions if the client states 1) "It's important for me to drink a lot of fluids." 2) "Physical and emotional stress can cause an attack." 3) "A fad diet or starvation diet can cause an acute attack." 4) "I don't need medication unless I'm having a severe attack."

I don't need medication unless I'm having a severe attack Rationale: Treatment of gout includes both nutrition and medication therapy. The client should be encouraged to limit the use of alcohol and reduce the consumption of foods high in purines. Such foods include sardines, herring, mussels, liver, kidney, goose, venison, and sweetbreads. Medication therapy is a primary component of management for clients with gout, and the primary health care provider normally prescribes a medication that will promote uric acid excretion or reduce its production. Fluid intake is important in preventing the development of uric acid stones. Fad or starvation diets can precipitate an acute attack because of the rapid breakdown of cells they induce. Excessive physical and emotional stress can exacerbate the disease.

A nurse provides instructions to a client with RA about join exercises that are important to prevent deformity and reduce pain. Which statement by the client indicates the need for further instruction 1) "Doing range-of-motion exercises every day will ease the pain." 2) "I should stop my exercises if I get tired." 3) "I should avoid all exercise when my joints are inflamed." 4) "I should always maintain good posture."

I should avoid all exercise when my joints are inflamed Rationale: The client should avoid activities (other than gentle range of motion) when the joints are inflamed. Isometric exercises are also helpful when the joints are inflamed. Daily range-of-motion exercises are an important component of the program and will help relieve pain, but the client should exercise only to the point of fatigue or discomfort. All clients are taught to maintain good posture.

A nurse provides instructions to a client with COPD about the positions that are most effective in alleviating dyspnea. Which statement by the client indicates a need for further instruction 1) "I should sit up in my recliner." 2) "I should lie on my right side in bed." 3) "I should stand with my back and hips against the wall and my shoulders bent slightly forward." 4) "I should sit on the side of my bed and lean on the overbed table."

I should lie on my right side in bed Rationale: Positions that will help the client with COPD breathe more freely include sitting up and leaning on an overbed table, sitting up and resting with the elbows on the knees, sitting up in a chair, and standing and leaning against the wall. These positions allow for the greatest expansion of the lungs and respiratory cage in all directions. Lying on the side is not effective.

A home care nurse has provided instructions to the father of a child with croup regarding tx measures. Which statement by the father indicates a need for further instruction 1) "I should put a steam vaporizer in her room." 2) "I can run the hot water in my bathroom and cuddle her in the steamy room." 3) "I can open the freezer door and encourage her to breathe in the cool air." 4) "I'll take her out into the cool, humid night air."

I should put a steam vaporizer in her room Rationale: Steam from running water in a closed bathroom and cool mist from a bedside humidifier or a freezer are effective in reducing mucosal edema. A cool mist humidifier is recommended over a steam vaporizer, which presents a danger of scald burns. Taking the child out into the cool humid night air may also relieve mucosal swelling.

The nurses teaches a client with GERD about measures to prevent reflux during sleep. The nurse determines that the client needs additional instruction if the client states 1) "The histamine antagonist will help me." 2) "I should take an antacid at bedtime." 3) "I should sleep flat on my right side." 4) "I should avoid eating in the 3 hours before bedtime."

I should sleep flat on my right side Rationale: A side-lying position with head of the bed elevated is most likely to prevent reflux while sleeping. A flat position will increase reflux. The client is instructed to avoid eating in the 3 hours before bedtime because a full stomach may also cause reflux. Antacids and histamine antagonists may be prescribed for the client.

A nurse provides home care instructions to a client with a BKA about residual limb and prosthesis care. Which statement by the client indicates a need for further instruction 1) I can wash my leg with a mild soap." 2) "I need to check my leg for irritation every day." 3) "I'll put lotion on my leg a few times a day." 4) "I should wear a sock over my stump."

I'll put lotion on my leg a few times a day Rationale: The client should be instructed to don the prosthesis immediately on arising and to keep it on all day (once the incision has healed completely) to reduce residual limb swelling. "I can wash my leg with a mild soap," "I need to check my leg for irritation every day," and "I should wear a sock over my stump" are correct statements regarding residual limb and prosthesis care. The client should not use any lotions, alcohol-containing powders, or oils on the residual limb unless told to do so by the primary health care provider. The client should also perform range-of-motion exercises of the joints, as well as strengthening exercises, including the upper extremities, every day

A client who experiences frequent episodes of chest pain is admitted to the hospital for cardiac monitoring. The client suddenly complains of chest pain and the nurse obtains a 12 lead ECG. Which finding would the nurse expect to note in the event of an ischemic episode 1) Peaked T waves 2) ST-segment depression 3) An isolated premature ventricular contraction (PVC) 4) Widened QRS complex

ST-segment depression Rationale: An ECG taken in the presence of pain may reveal ischemic changes with ST-segment elevation or depression. Peaked T waves may indicate hyperkalemia. PVCs are caused by the firing of an irritable pacemaker in the ventricle. A widened QRS complex indicates a delay in intraventricular conduction, such as bundle branch block.

A nurse is working in the ED. Which client should be assessed first 1) A client admitted with a recent ear injury 2) A client who has been experiencing nausea and vomiting for 12 hours 3) A client with new-onset dizziness 4) A client with new-onset atrial fibrillation with a rate of 118 beats/min

a client with new-onset a-fib with a rate of 118bpm Rationale: The client with new-onset atrial fibrillation is at risk for complications associated with the tachydysrhythmia. This dysrhythmia may result in decreased cardiac output because of ineffective atrial contractions. Thrombi form in the atria as a result of the pooling of blood. All of the other clients will require the nurse's attention, but the client who requires immediate attention and is the most hemodynamically unstable is the one with atrial fibrillation.

A woman in labor suddenly complains of abdominal tenderness and pain and states that she felt as though "something ripped." For which manifestations does the nurse, suspecting uterine rupture, assess the client? Select all that apply. a) absence of FHR b) bradypnea c) severe chest pain d) increased BP e) increased frequency of uterine contractions

a) absence of FHR c) severe CP Rationale: Signs/symptoms of uterine rupture vary with the degree of rupture. Signs/symptoms include abdominal pain and tenderness, chest pain, hypovolemic shock, signs/symptoms associated with impaired fetal oxygenation, an absence of fetal heart tones, cessation of uterine contractions, and palpation of the fetus outside the uterus if the rupture is complete. Signs/symptoms of hypovolemic shock include tachycardia; tachypnea; pallor; cool, clammy skin; and anxiety.

A nurse is monitoring a client with hyperparathyroidism for signs of hypercalcemia. For which clinical manifestations, associated with this electrolyte imbalance, does the nurse assess the client SATA a) increased UOP b) hyperactive DTR c) muscle weakness d) paresthesias e) Chvostek sign

a, c Rationale: Signs/symptoms of hypercalcemia include muscle weakness, diminished deep tendon reflexes or an absence thereof, increased urine output, decreased gastrointestinal motility, and increased heart rate and blood pressure. Hyperactive deep tendon reflexes, the presence of the Chvostek sign, and paresthesias are signs of hypocalcemia.

The ED nurse assesses a client who has a dx of left sided HF. Which findings does the nurse expect to note SATA a) dyspnea b) dependent edema c) crackles on auscultation of the lungs d) abdominal distention e) neck vein distention

a, c Rationale: Signs/symptoms of left-sided heart failure result from decreased cardiac output and increased pulmonary venous congestion, and the nurse would note signs/symptoms related to the respiratory system, such as cough, dyspnea, and crackles and wheezes on auscultation of the lungs. Right-sided heart failure is associated with increased systemic venous pressure and congestion, and the nurse would note signs/symptoms such as neck vein distention, dependent edema, abdominal distention, and weight gain.

a home care nurse is providing instructions to the mother of a 3 y/o with hemophillia regarding care of the child. Which statements by the mother indicate a need for further instructions SATA a) I will be so glad when my baby outgrows all of this bleeding b) I should move furniture with sharp corners out of the way and pad the corners of the furniture c) If he gets a cut, I should hold pressure on it until the bleeding stops d) I should check the house for any household items that could fall over easily e) I need to cancel all of the dental appts that I've made for him

a, e Rationale: Hemophilia is the term given to a group of bleeding disorders resulting from a deficiency of specific coagulation proteins. Identifying the specific coagulation deficiency is important because it allows definitive treatment with the specific replacement agent to be implemented; aggressive replacement therapy is initiated to prevent the chronic crippling effects of joint bleeding. The child does not outgrow the disorder, and lifetime management is needed. The nurse must stress the importance of immunizations, dental hygiene, and routine well-child care for the child with hemophilia. The remaining statements represent appropriate care measures.

An ED nurse receives a call from EMS and is told that a client who has sustained severe burns of the face and upper arms is being transported to the ED. Which action does the nurse, preparing for the arrival of the client, plan to implement first 1) Administering 100% humidified oxygen 2) Cleansing the burn wound 3) Inserting a Foley catheter 4) Initiating an intravenous (IV) line

administering 100% humidified oxygen Rationale: When a victim who sustains a burn injury arrives at the ED, breathing is assessed, a patent airway is established, and the client is given 100% humidified oxygen. Inserting a Foley catheter, initiating an IV line, and cleansing the burn wound are also components of the plan of care for a burned client, but these are not the immediate actions.

A client arrives at the ED with reports of a headache, hives, itching and dysphagia. The client states that he took ibuprofen 1 hour earlier and believes that he is experiencing an allergic reaction to this med. After ensuring that the client has a patent airway, which intervention does the nurse prepare the client for first 1) Administration of a subcutaneous injection of epinephrine 2) Administration of normal saline solution 3) Administration of pain medication to relieve the client's headache 4) Administration of an intravenous (IV) glucocorticoid

administration of a SQ injection of epi Rationale: Once airway has been established, the client would first be given subcutaneous epinephrine. IV corticosteroids and IV fluids may also be prescribed. Pain medication may or may not be prescribed.

A client who is recovering from a brain attack (stroke) has residual dysphagia. Which measure does the nurse plan to implement at mealtimes 1) Giving foods that are primarily liquid 2) Giving the client thin liquids 3) Alternating liquids with solids 4) Placing food in the affected side of the client's mouth

alternating liquids with solids Rationale: The client with dysphagia may be started on a diet once the gag and swallow reflexes have returned. Liquids should be thickened to help prevent aspiration. Food is placed on the unaffected side of the mouth. Liquids are alternated with solids whenever possible to prevent food from being left in the mouth. The client is assisted with meals as needed and is given ample time to chew and swallow.

a nurse is reviewing the medical records of the clients whom she is assigned on the 7a-7p shift. Which client will the nurse monitor most closely for excessive fluid vol? 1) A 65-year-old client with a nasogastric tube attached to low suction following partial gastrectomy 2) A 35-year old client who is vomiting undigested food after eating 3) A 48-year-old client receiving diuretics to treat hypertension 4) An 85-year-old client receiving intravenous (IV) therapy at a rate of 100 mL/hr

an 85 y/o client receiving IV therapy at a rate of 100mL/hr Rationale: The older adult client receiving IV therapy at 100 mL/hr is at the greatest risk for excessive fluid volume because of the diminished cardiovascular and renal function that occur with aging. Other causes of excessive fluid volume include renal failure, heart failure, liver disorders, excessive use of hypotonic IV fluids to replace isotonic losses, excessive irrigation of body fluids, and excessive ingestion of table salt. A client who is receiving diuretics, vomiting, or has a nasogastric tube attached to suction is at risk for deficient fluid volume.Test-Taking Strategy: Read the question carefully, noting that the subject asks for the client at risk for excessive fluid volume. Read each option and think about the fluid imbalance that could occur in each situation; in the case of the incorrect options, it is fluid-volume deficiency; the only option reflecting conditions that could result in an excess is the correct option.

A client in the third trimester of pregnancy is experiencing painless vaginal bleeding, and placenta previa is suspected. For which of the following interventions does the nurse prepare the client? 1) Internal fetal monitoring 2) An ultrasound examination 3) Administration of oxytocin 4) A manual (digital) pelvic examination

an ultrasound examination Rationale: A manual pelvic examination or any action that would stimulate uterine activity is contraindicated when vaginal bleeding is apparent in the third trimester until a diagnosis is made and placental previa is ruled out. Digital examination of the cervix can lead to maternal and fetal hemorrhage. A diagnosis of placental previa is made with the use of ultrasound. Electronic fetal monitoring (external) is crucial in evaluating the status of the fetus that is at risk for severe hypoxia, but internal fetal monitoring is contraindicated. Oxytocin would stimulate uterine contractions and is therefore contraindicated.

A nurse attending a recertification course in BLS for healthcare professionals in practicing BLS on an infant mannequin. Where does the nurse place the fingers to assess the infant's pulse 1) Antecubital fossa of the arm 2) Neck 3) Wrist 4) Behind the knee

antecubital fossa of the arm

A nurse receives a call from a neighbor, who says that her child was just hit in the eye with a swing. The nurse advises the child's mother to immediately 1) Irrigate the eye with cool water 2) Call an optometrist 3) Call an ambulance 4) Apply ice to the affected eye

apply ice to the affected area

A client who sustained a fx of the left arm requires the application of a plaster cast. The nurse tells the client that the procedure for applying the cast involves 1) Debriding any open wounds and applying antibiotic ointment before the cast material is applied 2) Administering a local anesthetic to the fractured arm 3) Soaking the left arm in a warm-water bath for 2 hours before cast application 4) Applying soft padding and stockinette over the fractured arm, followed by the application of the cast material

applying soft padding and stockinette over the fractured arm, followed by the application of the cast material Rationale: To apply a cast, the skin is washed and dried well, but it is not soaked in a warm-water bath. Padding is applied and a stockinette is placed smoothly and evenly over the area to be casted. The plaster is then rolled onto the padding and the edges are trimmed or smoothed as needed. Local anesthesia of the fractured extremity is not necessary, although an analgesic may be administered to alleviate pain. A local anesthetic will block nerve sensation, and it is important for the client to be able to report any changes in sensations after the cast is applied. If the client has open wounds on the fractured extremity, a window will be cut in the cast to allow visualization and treatment of the wound. A wound would not be covered with cast material.

A cardiac monitor alarm sounds and a nurse notes a straight line on the monitor screen. The nurse immediately 1) Check the cardiac leads and wires 2) Obtain a rhythm strip from the monitor device 3) Assess the client 4) Call a code

assesses the client

A client arrives at the ED for tx of a surface injury sustained when sand blew into the eye. Which action does the nurse take first 1) Placing ice on the eye 2) Irrigating the eye with sterile saline solution 3) Assessing the client's vision 4) Removing the sand particles

assessing the client's vision Rationale: When a client has sustained a surface injury of the eye as a result of the introduction of a foreign body, the nurse must first assess visual acuity. The eye is then assessed for corneal abrasions; this is followed by irrigation with sterile normal saline solution to gently remove the particles. Ice would be placed on the eye if the client had sustained an eye contusion.

a child with a dx of pertussis (whooping cough) is being admitted to the pediatric unit. As soon as the child arrives to the unit, the nurse first 1) Attach the child to a pulse oximeter 2) Take the child's temperature 3) Administer the prescribed antibiotic 4) Weigh the child

attaches the child to a pulse ox Rationale: To adequately determine whether the child is getting enough oxygen, the nurse attaches the child to a pulse oximeter. The pulse oximeter will then provide ongoing information on the child's oxygen level. The child is also immediately attached to a cardiorespiratory monitor to provide early identification of periods of apnea and bradycardia. Next, the nurse performs an assessment, including the child's temperature and weight, and asks the parents about the child. An antibiotic may be prescribed, but the child's airway status must be assessed first.

A stepdectomy is performed on a client with otosclerosis. During the preparations for d/c, which home care instruction does the nurse give the client 1) Avoid rapidly moving the head and bending over for at least 3 weeks. 2) Rinse the ear canal at least twice a day to clear out any excess drainage. 3) Expect excessive ear drainage for about 2 weeks. 4) It is all right to shower as long as the ear dressing is changed immediately after the shower.

avoid rapidly moving the head and bending over for at least 3 weeks Rationale: The client must avoid rapidly moving the head, bouncing, and bending over for at least 3 weeks to prevent disruption of the surgical site. The client should keep the affected ear dry at all times and should avoid getting the head wet, washing the hair, or showering for 1 week. The client should not rinse out the ear. The client also needs to avoid drinking through a straw for 2 to 3 weeks because the sucking action necessary to use the straw could cause disruption of the surgical site. The client should notify the primary health care provider if excessive ear drainage is noted.

A nurse is caring for a client experiencing hyponatremia who was admitted to the med-surg unit with FVO. For which clinical manifestations of this electrolyte imbalance does the nurse monitor this client SATA a) decreased UOP b) hyperactive bs c) skeletal muscle weakness d) hyperactive DTR e) slow HR

b, c Rationale: Signs/symptoms of hyponatremia include a rapid, thready pulse; skeletal muscle weakness; diminished deep tendon reflexes; abdominal cramping and hyperactive bowel sounds; increased urine output; headache; and personality changes. The nurse must assess these changes from baseline. If muscle weakness is detected, the nurse should immediately check respiratory effectiveness, because ventilation depends on strength of the respiratory muscles.

A nurse is caring for a client with Crohn disease whose mag level is 1.0. Which assessment findings does the nurse expect to note SATA a) hypotension b) Trousseau sign c) skeletal muscle weakness d) abdominal distention e) decreased DTR

b, d Rationale: The normal magnesium level is 1.5-2.5 mEq/L (0.75-1.25 mmol/L). A magnesium level of 1.0 mEq/L(0.5 mmol/L) reflects hypomagnesemia. Assessment signs/symptoms include hypertension; gastrointestinal manifestations such as anorexia, nausea, abdominal distention, and decreased bowel sounds; shallow respirations; neuromuscular manifestations such as twitches, paresthesias, hyperreflexia, and the Trousseau and Chvostek signs; and irritability and confusion.

A nurse enters a client's room and finds the client unconscious. The nurse quickly performs an assessment and determines that the client is not breathing. Which action does the nurse take first 1) Counting the client's carotid pulse for 15 seconds 2) Beginning chest compressions 3) Placing an oxygen mask on the client 4) Checking the client's pulse oximetry reading

begin chest compressions Rationale: According to the American Heart Association, detecting a pulse may be difficult. The primary health care provider should take not more than 10 seconds to check for a pulse; if the rescuer does not definitely feel a pulse within that period, he/she should start chest compressions. The acronym CAB (circulation, airway, and breathing) is used to prioritize the steps of cardiopulmonary resuscitation (CPR). Effective chest compressions are essential for providing blood flow during CPR. To provide effective chest compressions, the provider must push hard and fast. Current guidelines for CPR call for the initiation of compressions before ventilations. Oxygen may be helpful at some point, but the airway is opened before the administration of oxygen. Checking the client's pulse oximetry reading delays implementation of lifesaving measures.

A nurse is obtaining subjective data from the mother of a child admitted to the hospital with a dx of intussusception. Which occurrence does the nurse expect the mother to report 1) Bloody mucus stools and diarrhea 2) Hard, pale stools 3) Projectile vomiting 4) Scleral jaundice

bloody mucus stools and diarrhea Rationale: In the child with intussusception, bloody mucus stools, commonly described as "currant jelly" stools, and diarrhea may occur. The child classically presents with severe abdominal pain that is crampy and intermittent, causing the child to draw the knees to the chest. This pain progresses to a more severe constant pain. Vomiting may be present, but it is not projectile in nature. Pale, hard stools and scleral jaundice are not manifestations of this disorder.

A nurse provides instructions to the mother of a newborn with hyperbilirubinemia who is being breastfed. The nurse determines that the mother understands the instructions if the mother says that she will 1) Bottle feed only 2) Feed her newborn less frequently until the bilirubin level drops 3) Provide water feedings between breast feedings 4) Breastfeed the newborn every 2 to 3 hours

breastfeed the newborn every 2-3 hours Rationale: Breastfeeding should be initiated within 2 hours of birth and performed every 2 to 3 hours thereafter. Supplementation with water should be avoided because the newborn may take less milk, which is more effective than water in removing bilirubin from the intestines. The infant should not be fed less frequently. It is not necessary to stop breastfeeding and to bottle feed only.

A client with gastroenteritis who has been vomiting and has diarrhea is admitted to the hospital with a dx of dehydration. For which clinical manifestations that correlate with this fluid imbalance would the nurse assess the client SATA a) increased BP b) decreased resp depth c) increased resp rate d) decreased HR e) decreased UOP

c, e Rationale: A client with dehydration has an increased depth and rate of respirations. The diminished fluid volume is perceived by the body as a decreased oxygen level (hypoxia), and increased respiration is an attempt to maintain oxygen delivery. Other assessment findings in insufficient fluid volume are decreased urine volume, increased pulse, weight loss, poor skin turgor, dry mucous membranes, concentrated urine with increased specific gravity, increased hematocrit, and altered level of consciousness. Increased blood pressure, decreased pulse, and increased urine output occur with fluid-volume overload

The wife of a client with angina pectoris calls the HCP's office and reports to the nurse that her husband is experiencing chest pain and has taken 2 SL nitro tabs 5 min apart with no relief. The nurse tells the client's wife to 1) Have her husband rest and, if no relief is obtained, call back 2) Give her husband a third tablet and, if no relief is obtained, call an ambulance to have him transported to the ED 3) Call Emergency Medical Services to take her husband to the emergency department (ED) immediately 4) Discuss the situation with the doctor, who will call her as soon as he gets into the office

call EMS to take her husband to the ED immediately Rationale: Chest pain that is unrelieved by rest and nitroglycerin may be not typical anginal pain but instead a sign of myocardial infarction (MI). Because the risk of sudden cardiac death is greatest in the 24 hours after MI, it is imperative that the client receive emergency cardiac care. If the client needs to go to the ED, the nurse must instruct the client's wife to call an ambulance to transport her husband. The client's wife must not drive the client, because the client should not exert energy and place an increased workload on the heart and the client's wife would not be able to provide care if an emergency arose during transport to the hospital. Telling the wife that she will have to discuss the situation with the primary health care provider, who will call her as soon as he gets to his office, delays necessary interventions. Having her husband rest delays necessary interventions; also, the usual procedure is to have the client take one nitroglycerin tablet and seek medical attention if the pain is unrelieved.

A nurse is preparing a teaching plan for the parents of an infant with a ventricular peritoneal shift. which instruction does the nurse plan to include 1) Expect increased urine output with the shunt. 2) Call the primary health care provider if the anterior fontanel bulges when the infant cries. 3) Call the primary health care provider if the infant is lethargic. 4) Position the infant on the side of the shunt for sleep.

call the HCP if the infant is lethargic Rationale: If the shunt is broken or malfunctioning, the fluid from the ventricle part of the brain will not be diverted to the peritoneal cavity, and cerebrospinal fluid will build up in the cranial area. The result is intracranial pressure, which causes the infant to make a high-pitched cry or induces changes in level of consciousness, such as lethargy. The infant should not be positioned on the side of the shunt, because this will cause pressure on the shunt and skin breakdown. This type of shunt affects the gastrointestinal system, not the genitourinary system, and an increased urine output is not expected. The anterior fontanel normally bulges when the infant cries.

A nurse is caring for a hospitalized client who is undergoing peritoneal dialysis. The nurse notes that the outflow is less than the inflow on the first exchange. What should the nurse do first 1) Hang the second exchange and continue to monitor the outflow 2) Check the system for kinks 3) Reposition the client 4) Irrigate the catheter

check the system for kinks Rationale: If outflow drainage is inadequate, the nurse must first check the system for kinks. If there are no kinks in the system, the nurse should change the client's position to shift abdominal fluid. The catheter should not be irrigated. Hanging the next exchange and continuing to monitor outflow will not alleviate the problem.

Buck extension traction is applied to the right leg of a client who sustained a right hip fx. Which intervention should the nurse include in the plan of care 1) Removing the traction weights to provide skin care 2) Assessing the pin sites at least every 8 hours 3) Applying lanolin to the skin of the right leg once per shift 4) Checking the skin integrity of the right leg at least every 8 hours

checking the skin integrity of the right leg at least q8h Rationale: Buck extension traction is a type of skin traction. It is important with skin traction to inspect the skin underneath at least once every 8 hours for irritation or inflammation. The nurse never releases the weights of traction unless specifically asked to do so by the primary health care provider. Applying lanolin to the skin could leave the skin slippery, making it difficult to maintain the belt or boot used for the skin traction. There are no pins to care for with skin traction.

A client with a Spinal Cord Injury suddenly complains of a pounding headache. The nurse quickly assesses the client and notes that the client is diaphoretic, that his BP has increased and that his HR has slowed. Suspecting that the client is experiencing autonomic dysreflexia, the nurse elevates the HOB and immediately 1) Notify the primary health care provider 2) Document the event 3) Check to see whether the client has a prescription for an antihypertensive 4) Check the client's bladder for distention

checks the client's bladder for distention Rationale: Autonomic dysreflexia is an emergency that occurs as a result of exaggerated autonomic responses to stimuli that are innocuous in normal individuals. It occurs only after spinal shock has resolved. A variety of stimuli may trigger this response, including a distended bladder (the most common cause); distention or contraction of the visceral organs, especially the bowel (as a result of constipation or impaction); or stimulation of the skin. When autonomic dysreflexia occurs, the client is immediately placed in a sitting position to lower the blood pressure. The nurse then performs a rapid assessment to identify and alleviate the cause. The client's bladder is emptied immediately by way of a urinary catheter, the rectum is checked for the presence of a fecal mass, and the skin is examined for areas of pressure, irritation, or compromise. The primary health care provider is notified, and then the nurse documents the occurrence and the actions taken.

A nurse is monitoring a client after a transurethral resection TURP procedure for benign prostatic hypertrophy (BPH). The clietn has a bladder irrigation infusing and the urine output is a light cherry color. The nurse performs a f/up assessment 1 hour later and notes that the UOP is now bright red in color with clots and that the client's BP has dropped. Which action by the nurse is appropriate 1) Continuing to monitor the client 2) Placing pressure on the bladder to aid expulsion of any additional clots 3) Increasing the flow rate of the intravenous (IV) solution 4) Contacting the primary health care provider

contacting the HCP Rationale: Some hematuria is normal for several days after transurethral resection of the prostate. If bright-red bleeding occurs, the primary health care provider needs to be notified, particularly if the client exhibits a change in vital signs. These findings are a potential sign of excessive blood loss and the need for emergency surgical intervention. Continuing to monitor the client delays necessary interventions. The nurse would not increase the rate of flow of an IV without a primary health care provider's order. Placing pressure on the bladder to aid expulsion of any additional clots is an inappropriate and unsafe action that could worsen the bleeding.

A nurse is monitoring a client who has just undergone radical neck dissection. The nurse notes that the client's BP has dropped from 132/84 to 90/50 and that the HR has increased from 78 to 96bpm. On the basis of these findings, the nurse immediately 1) Contact the primary health care provider 2) Obtain a pulse oximeter 3) Suction the client 4) Increase the rate of the client's intravenous (IV) solution

contacts the HCP Rationale: The client's blood pressure decrease and pulse rate increase indicates the client is experiencing bleeding, which requires health care provider notification. The changes in vital signs do not indicate suctioning is required, nor is there any indication of respiratory depression. Obtaining a pulse oximeter would not be needed. The nurse cannot increase the rate of the client's IV solution without a health care provider prescription.

A home care nurse visits a pregnant client with a dx of mild preeclampsia. During the assessment, the client tells the nurse taht she has had an upset stomach and pain in the epigastric area. The nurse most appropraitely 1) Administers an antacid to the client and tell her to take a dose every 6 hours 2) Contact the primary client's health care provider 3) Instruct the client to eat a small portion of food every 2 to 3 hours 4) Tell the client to avoid lying flat

contacts the client's HCP Rationale: Preeclampsia is dangerous to the woman and fetus because it can progress rapidly, and the earliest manifestations may go unnoticed by the woman. Some signs/symptoms, such as epigastric pain and upset stomach, are particularly ominous because they indicate distention of the hepatic capsule and often mean that a seizure is imminent. Therefore telling the client to avoid lying flat position, instructing the client to eat a small portion of food every 2 to 3 hours, and administering an antacid and telling the client to take a dose every 6 hours are all incorrect. Additionally, the nurse would not administer an antacid to the pregnant client without a prescription to do so.

A nurse is monitoring a client who is in the active phase of labor and has been experiencing contractions that are coordinated but weak. Which assessment finding indicates to the nurse that the client may be experiencing hypotonic contractions 1) Fetal hypoxia 2) Contractions that can be indented easily with fingertip pressure at their peak 3) Increased frequency and longer duration of contractions 4) Discomfort with each contraction

contractions that can be indented easily with fingertip pressure at their peak Rationale: Hypotonic contractions, coordinated but too weak to be effective, usually occur during the active phase of labor, when progress normally quickens. Contractions are infrequent and brief and can easily be indented on the abdomen with fingertip pressure at their peak. These contractions cause minimal discomfort because the contractions are weak. Fetal hypoxia is not usually seen with hypotonic contractions.

A client with cancer of the larynx is receiving extenal radiation therapy of the neck. Which s/e related specifically to the site of irradiation does the nurse tell the client to expect 1) Diarrhea 2) Dyspnea 3) Headache 4) Dysphagia

dysphagia Rationale: In general, skin reactions and fatigue may occur with radiation therapy of any site, whereas other side effects occur only when a specific area lies in the treatment field. A client undergoing radiation therapy of the larynx is most likely to experience dysphagia. Diarrhea may occur with irradiation of the gastrointestinal tract. Dyspnea may occur with lung irradiation. Headache may occur with irradiation of the head.

A client is found to have viral hepatitis and the nurse provides home care instructions to the client. The nurse should tell the client to 1) Maintain strict bed rest 2) Eat small frequent meals that are low in fat and protein and high in carbohydrates 3) Take acetaminophen for discomfort 4) Limit the intake of alcohol

eat small frequent meals that are low in fat and protein and high in carbs Rationale: Fatigue is a normal response to hepatic cellular damage. During the acute stage, rest is an essential intervention to reduce metabolic demand on the liver and increase its blood supply, but strict bed rest is unnecessary. The client should avoid taking medications, including acetaminophen (which is hepatotoxic), unless they are prescribed by the primary health care provider. The client must avoid all alcohol consumption. The client should consume small frequent meals that are low in fat and protein and high in carbohydrates to reduce the workload of the liver.

a HCP writes a rx for the administration of IV KCL to a client with hypokalemia. What does the nurse plan to do when preparing and administering this med? 1) Insert a Foley catheter in the client 2) Administer the medication with the use of a macrodrip IV tubing set 3) Ensure that the medication is diluted in an appropriate amount of normal saline solution 4) Prepare the client for insertion of a central IV line

ensure that the med is diluted in an appropriate amount of NS sltn Rationale: Potassium chloride administered IV must always be diluted in IV fluid. Undiluted potassium chloride given IV can cause cardiac arrest. The intramuscular and subcutaneous routes of administration are not recommended because the medication cannot be adequately diluted for these routes; toxicity could result if the medication is not adequately diluted. Potassium chloride is never administered as a bolus (IV push) injection; an IV push would result in sudden severe hyperkalemia, which could precipitate cardiac arrest. Saline dilution is recommended, but dextrose is avoided because it increases intracellular potassium shifting. Although urine output is monitored carefully during administration, it is not necessary to insert a Foley catheter unless this is specifically prescribed. The primary health care provider is notified if the urinary output is less than 30 mL/hr. Potassium chloride should be administered with the use of a controlled IV infusion device to avoid bolus infusion and increased risk of cardiac arrest. A central IV line is not necessary; potassium chloride may be administered through a peripheral IV line.

A nurse is providing d/c instructions to a client after outpatient surgery for cataract removal. The nurse determines that the client needs additional instructions if the client indicates that he will 1) Leave the eye patch in place until he has been seen by the primary health care provider 2) Expect to experience pain, nausea, and vomiting after the procedure 3) Take acetaminophen for discomfort 4) Limit activity for 24 hours

expect to experience pain, N&V after the procedure Rationale: If the client experiences any pain that is unrelieved, redness around the eye, or nausea or vomiting, the primary health care provider must be notified, because such findings could be an indication of increased intraocular pressure. Usually the client is given a follow-up appointment on the day after the surgery, and the primary health care provider removes the eye patch at this time. The client is instructed to limit activity to sitting in a chair, resting, and walking to the bathroom for 24 hours. Aspirin or medications containing aspirin should not be taken by the client; rather, acetaminophen should be used to alleviate discomfort.

A nurse is providing instructions to a UAP about effective measures for communicating with a hearing-impaired client. The nurse instructs the UAP to 1) Be cordial and smile when talking to the client 2) Raise his/her voice when talking to the client 3) Face the client when talking, keeping the hands away from the mouth 4) Talk directly into the client's impaired ear

face the client when talking, keeping the hands away from the mouth

A client with CKD is undergoing his first hemodialysis tx, and the nurse is monitoring the clients for signs of disequilibrium syndrome. For which signs of this syndrome does the nurse monitor the client 1) Headache and confusion 2) Irritability and generalized weakness 3) Bradycardia and hypothermia 4) Fever and tachycardia

h/a and confusion Rationale: Disequilibrium syndrome most often occurs in clients who are new to hemodialysis. It is characterized by headache, confusion, decreasing level of consciousness, nausea, vomiting, twitching, and, in some cases, seizure activity. It results from rapid removal of solutes from the body during hemodialysis and a higher residual concentration gradient in the brain, caused by the blood-brain barrier. Water goes into cerebral cells because of the osmotic gradient, causing brain swelling and onset of signs/symptoms. It is prevented with the use of shorter dialysis times or dialysis at a reduced blood flow rate. Irritability and generalized weakness, fever and tachycardia, and bradycardia and hypothermia are not associated with disequilibrium syndrome.

A nurse is conducting the initial assessment of a child with rheumatic fever. Which question does the nurse ask the parents to elicit information specific to the development of the disease 1) "Has he had a sore throat in the last few months?" 2) "Has he complained of a backache recently?" 3) "Has he had any loss of appetite?" 4) "Has he been excessively tired or lethargic?"

has he had a sore throat in the last few months Rationale: Rheumatic fever characteristically presents 2 to 6 weeks after an untreated or partially treated group A beta-hemolytic streptococcal infection of the upper respiratory tract. The nurse first determines whether the child had a sore throat or an unexplained fever within the past 2 months. Asking the parents whether the child has had any loss of appetite, complained of backache recently, or been excessively tired or lethargic will elicit information unrelated to rheumatic fever.

An ambulatory care nurse is providing home care instructions to the mother of a child who had a tonsillectomy. The nurse determines that the mother needs further instruction is she indicates that she will 1) Give acetaminophen to her child for discomfort 2) Have her child use a straw to make drinking easier 3) Avoid giving citrus juices to her child 4) Give her child extra fluids to relieve a foul odor from the mouth

have her child use a straw to make drinking easier Rationale: Introduction of a straw, fork, or any other pointed object into the mouth could result in accidental contact with the surgical site and disrupt its integrity. Citrus fruits are avoided because they could irritate the throat. Acetaminophen is used for pain relief. A foul mouth odor is normal and can be relieved by drinking fluids.

A nurse is reviewing the assessment findings and lab results of a child with a dx of new onset of glomerulonepritis. which finding would the nurse expect to note 1) Hypertension 2) Low serum potassium 3) Cloudy yellow urine 4) Increased creatinine level

hypertension Rationale: Hypertension is a common finding in glomerulonephritis. Gross hematuria resulting in dark-brown or smoky tea-colored urine is also a classic symptom of glomerulonephritis. The blood urea nitrogen and creatinine levels are increased only when there is an 80% decrease in glomerular filtration rate and renal insufficiency is severe. A high potassium level results from inadequate glomerular filtration.

A nurse is assessing a child with increased ICP who has been exhibiting decorticate posturing. The nurse notes extension of the upper and lower extremities, with internal rotation of the upper arms and wrists and the knees and feet. The nurse determines that the child's condition 1) Indicates deterioration in neurological function 2) Is unchanged from the previous neurological assessment 3) Indicates decreased intracranial pressure 4) Indicates improved neurological status

indicates deterioration in neuro fxn

A client is found to have AIDS. What is the nurse's highest priority in providing care to this client 1) Identifying risk factors related to contracting AIDS with the client 2) Providing emotional support to the client 3) Discussing the cause of AIDS with the client 4) Instituting measures to prevent infection in the client

instituting measures to prevent infection in the client Rationale: The client with AIDS has inadequate immune bodies and is at risk for infection. The highest priority nursing intervention is protecting the client from infection. The nurse would also provide emotional support to the client. Discussing the cause of AIDS and the ways in which AIDS is contracted are not priority interventions.

a nurse is assessing a 12 month old child with iron-deficiency anemia. Which finding does the nurse expect to note in this child 1) Hyperactivity 2) Reddened cheeks 3) Bradycardia 4) Lethargy

lethargy Rationale: Clinical manifestations of iron-deficiency anemia vary with the degree of anemia but usually include extreme pallor with porcelainlike skin, tachycardia, lethargy, and irritability.

A nurse provides home care instructions to a client with Meniere disease about measures to control and treat vertigo. The nurse should tell the client to 1) Increase fluid intake to at least 3000 mL/day 2) Limit sodium in the diet 3) Lie down when vertigo occurs and keep a light on in the room 4) Move the head from the right to the left when vertigo occurs to determine the extent of its effects

limit sodium in the diet Rationale: Limiting sodium and fluids in the diet will help reduce the amount of endolymphatic fluid, which is excessive in Ménière disease. The client's room should be darkened to reduce the acute signs/symptoms of vertigo. The client should limit head movement to prevent worsening of the signs/symptoms of vertigo.

A nurse is caring for a client who has undergone resection of an abdominal aortic aneurysm (AAA). Which action should the nurse implement to prevent graft occlusion 1) Limiting elevation of the head of the bed to 45 degrees 2) Monitoring urine output 3) Checking pedal pulses distal to the graft site 4) Monitoring bowel sounds

limiting elevation of the HOB to 45 degrees Rationale: To prevent graft occlusion, the nurse limits elevation of the head of the bed to 45 degrees. The nurse does assess the client for signs/symptoms of graft occlusion, but assessment will not prevent occlusion. The signs/symptoms of graft occlusion include changes in peripheral pulses, cool-to-cold extremities distal to the graft, white or blue extremities or flanks, severe pain, and abdominal distention. Bowel sounds and urine output are also assessed, but these parameters are unrelated to graft occlusion.

A ventilator's low exhaled volume (low-pressure) alarm sounds, and the nurse rushes to the client's room and quickly assesses the client. The client appears to be having respiratory difficulty. The nurse should first: 1) Call the anesthesiologist 2) Suction the client 3) Manually ventilate the client, using a resuscitation bag 4) Call a code

manually ventilate the client, using a resuscitation bag

Mastitis is diagnosed in a client who recently gave birth. The nurse tells the woman that: 1) Moist heat will increase circulation and may be used before the breasts are emptied 2) Antibiotics are not usually used to treat this disorder 3) Wearing a bra will increase the discomfort 4) Breastfeeding must be discontinued until the condition resolves

moist heat will increase circulation and may be used before the breasts are emptied

A nurse is assessing a client with AIDS for signs of Pneumocystitis jiroveci infection. Which sign of infection is the earliest manifestation 1) Dyspnea at rest 2) Fever 3) Nonproductive cough 4) Dyspnea on exertion

nonproductive cough Rationale: The client with P. jiroveci infection usually has a cough as the earliest sign/symptom, which begins as nonproductive then progresses to productive. Later signs/symptoms include fever, dyspnea on exertion, and finally dyspnea at rest.

A client has an AV fistula in place for hemodialysis. What should the nurse do to assess the patency of the fistula 1) Palpate for a vibrating sensation at the fistula site 2) Flush the fistula with 1 mL of heparin solution once per shift 3) Irrigate the fistula with 3 mL of normal saline solution 4) Infuse 50 mL of normal saline once per 24 hours

palpate for a vibrating sensation at the fistula site

A nurse in the labor room is performing a vaginal assessment of a pregnant client who is in active labor. The nurse notes that the umbilical cord is protruding from the vagina and immediately 1) Prepare to administer a tocolytic medication 2) Prepare the client for cesarean delivery 3) Push the cord gently back into the vagina 4) Place the client in the knee-chest position

places the client in the knee-chest position Rationale: When cord prolapse occurs, prompt action is taken to relieve cord compression and increase fetal oxygenation. The mother should be positioned with the hips higher than the head to shift the fetal presenting part toward the diaphragm. Such positions include knee-chest, Trendelenburg, and the hips elevated on pillows with the client in a side-lying position. The nurse should push the call light to summon help, and other staff members should call the primary health care provider and notify the delivery room. If the cord is protruding from the vagina, no attempt should be made to replace it, because to do so could traumatize it and further reduce blood flow. Oxygen at 8 to 10 L/min by way of facemask is administered to the mother to increase fetal oxygenation. A tocolytic medication is administered to inhibit contractions on the order of the primary health care provider, and the client is quickly prepared for delivery, but these are not the actions that would be taken immediately.

A nurse has been assigned to care for an infant with tetralogy of Fallot. The infant suddenly exhibits rapid, deep resp; irritability and cyanosis. The nurse determines that the infant is experiencing a hypercyanotic episode and immediately 1) Call a code 2) Hold the infant in an upright position 3) Contact the respiratory therapy department 4) Place the infant in the knee-chest position

places the infant in the knee-chest position Rationale: If a hypercyanotic episode occurs, the infant is calmed and placed in the knee-chest position, and the primary health care provider is notified. The knee-chest position is thought to increase pulmonary blood flow by increasing systemic vascular resistance. This position also improves systemic arterial oxygen saturation by decreasing venous return so that smaller amounts of highly saturated blood reach the heart. Toddlers and children squat to achieve this position and relieve chronic hypoxia. Oxygen is also administered to the infant.

A nurse is monitoring a client with DVT for signs of pulmonary embolism. For which most common sign of DVT, does the nurse assess the client 1) Diaphoresis 2) Pleuritic chest pain 3) Cough 4) Hemoptysis

pleuritic chest pain Rationale: Pulmonary embolism is a life-threatening complication of thrombophlebitis or DVT. Pleuritic chest pain, the most common clinical manifestation, occurs suddenly and is worsened by breathing. Other signs/ symptoms include shortness of breath and dyspnea, diaphoresis, and apprehension. Cough is also a manifestation but is not a common sign/symptom.

A nurse has admitted a client with a dx of TB to the nursing unit. Which finding that confirms the dx does the nurse expect to see documented in the client's record 1) Positive result on an acid-fast bacillus smear 2) Cough and expectoration of mucopurulent sputum 3) Night sweats and a low-grade fever 4) A tuberculin skin test result that indicates 5 mm of redness

positive result on an acid-fast bacillus smear Rationale: A definitive diagnosis of TB is confirmed through culture and isolation of Mycobacterium tuberculosis (acid-fast bacillus), which is the organism responsible for the disease. The initial testing involves microscopic examination of stained sputum smears for acid-fast bacilli (a.k.a. the ABF test). In the tuberculin skin test, 0.1 mL of purified protein derivative (PPD) is injected intradermally on the dorsal surface of the forearm. The injection site is then assessed in 48 to 72 hours for the presence of an induration. In low-risk individuals (e.g., those who are not immunocompromised), an area of induration (not redness) measuring 10 mm or more in diameter 48 to 72 hours after injection indicates exposure to and infection with TB. Night sweats, a low-grade fever, cough, and mucopurulent sputum are clinical manifestations of TB but do not confirm the diagnosis.

A nurse is caring for a client in the ICU who is being mechanically ventilated. As the nurse prepares meds, the client suddenly becomes anxious and pulls out the ET tube. The nurse assesses the client for spontaneous breathing and then 1) Calls the rapid response team (RRT) 2) Administers an antianxiety medication to the client 3) Restrains the client's wrists 4) Prepares for reintubation

prepares for reintubation Rationale: If unexpected extubation occurs, the nurse must first assess the client for airway patency and spontaneous breathing. The nurse remains with the client, calls for assistance, and prepares for reintubation. The rapid response team is called when there is a change in the client's status in a hospital area outside the ICU. The nurse would not administer an antianxiety medication, because this could affect the client's breathing. The nurse would not restrain the client, because restraints could increase the client's anxiety.

A nurse is developing a plan of care for a client with a new dx of Graves disease. Which intervention does the nurse include in the plan 1) Keeping the room warm 2) Providing a high-calorie, high-protein diet 3) Placing extra blankets on the client 4) Encouraging frequent ambulation and activities

providing a high calorie, high protein diet Rationale: Graves disease is characterized by a hypermetabolic state. As compensation for the hypermetabolic state, the client needs a diet that is high in calories and high in protein. The client will also benefit most from an environment that is restful both physically and mentally. Therefore the client is encouraged to rest. Individuals with Graves disease experience heat intolerance and diaphoresis and require a cool environment.

A nurse assessing a client in the 4th stage of labor notes that the uterine fundus is firmly contracted and is midline at the level of the umbilicus. On the basis of this finding, the nurse most appropraite 1) Record the findings 2) Massage the fundus 3) Contact the primary health care provider 4) Help the mother void

records the findings Rationale: In the postpartum period, the nurse assesses for uterine atony and checks the consistency and location of the uterine fundus. The uterine fundus should be firmly contracted, at or near the level of the umbilicus, and midline. Therefore the nurse would record the findings. Because the finding is normal, massaging the fundus, contacting the primary health care provider, and assisting the mother to void are not necessary. The nurse would massage the uterine fundus if it were soft and boggy. The primary health care provider would be contacted if the client were to experience excessive bleeding. A full bladder could cause a displaced fundus and one that is above the level of the umbilicus.

A nurse in the newborn nursery is monitoring a neonate born to a mother with diabetes mellitus. For which finding does the nurse monitor the neonate most closely for? 1) Hypobilirubinemia 2) Respiratory distress syndrome 3) Hypercalcemia 4) Hyperglycemia

resp distress syndrome Rationale: The major neonatal complications of preexisting diabetes mellitus in the mother are hypoglycemia, hypocalcemia, hyperbilirubinemia, and respiratory distress syndrome. The infant of a diabetic mother is more likely to have delayed production of pulmonary surfactant, which is needed to keep the alveoli open after birth.

A nurse provides dietary instructions to the mother of a child with celiac disease. Which food does the nurse tell the mother to include in the child's diet 1) Rye crackers 2) Rice 3) Wheat cereal 4) Oatmeal biscuits

rice

a nurse is providing home care instructions to a client with Parkinson Disease about measures to avoid rigidity and to overcome tremor and bradykinesia. The nurse tells the client to 1) Rock back and forth to start movement 2) Perform tasks with only the hand that has the tremor 3) Sit in soft, deep chairs 4) Exercise in the evening to combat fatigue

rock back and forth to start movement Rationale: The client with Parkinson disease should rock back and forth to initiate movement with bradykinesia (slowed movement). The client should avoid sitting in soft, deep chairs to prevent rigidity and because they are difficult to get up from. The client should exercise in the morning, when the energy level at its highest. The client with a tremor is instructed to use both hands to accomplish a task.

A client is transported to the recovery area of the ambulatory care unit after cataract surgery. In which position does the nurse place the client 1) Semi-Fowler 2) Supine 3) Prone on the side that has undergone surgery 4) On the side that has undergone surgery

semi-fowler Rationale: After cataract extraction surgery, the client should be placed in the semi-Fowler position or on the unaffected side to prevent edema at the surgical site. Supine, on the affected side, and prone are all incorrect because they will result in increased edema at the site.

A nurse is assessing a newborn for fetal alcohol syndrome. Which finding would the nurse expect to note in the newborn 1) Greater-than-average length 2) Short palpebral fissures and a flat midface 3) Greater-than-average head circumference 4) Higher-than-normal birth weight

short palpebral fissures and a flat midface

A nurse is caring for a hospitalized child with a dx of Kawasaki disease. During the subacute phase, the nurse monitors the child closely for 1) Failure to thrive 2) Bleeding 3) Signs/symptoms of congestive heart failure (CHF) 4) A high fever

signs of congestive HF Rationale: Kawasaki disease is an acute systemic vasculitis that primarily affects the cardiovascular system. The subacute phase is characterized by continued irritability, anorexia, desquamation of the fingers and toes, arthritis and arthralgia, and cardiovascular manifestations, including CHF. Nursing care is focused on observation of the child for signs/symptoms of CHF. The nurse is alert for an increased respiratory rate, increased heart rate, dyspnea, congestion and crackles, and abdominal distention. Bleeding, a high fever, and failure to thrive are not directly associated with this disorder. In the subacute phase, the fever subsides.

A nurse in a newborn nursery receives a call from the delivery room and is told that a newborn with spina bifida (meningomyelocele type) will be transported to the nursery. Which item does the nurse, preparing for the arrival of the newborn, make a priority of placing at the newborn's bedside 1) Cardiac monitor 2) Sterile dressing 3) Blood pressure cuff 4) Flashlight

sterile dressing

A nurse is teaching a client with DM who requires insulin about methods of preventing DKA when the client is ill. The nurse tells the client to 1) Refrain from eating or drinking during periods of vomiting 2) Contact the primary health care provider when the premeal blood glucose value is greater than 350 mg/dL (19.4 mmol/L) 3) Contact the primary health care provider if a fever over 102° F (38.9°C) occurs 4) Take the prescribed insulin dose even if he/she is unable to eat

take the prescribed insulin dose even if he is unable to eat Rationale: Insulin should never be independently stopped or decreased, and the client is instructed to take prescribed insulin even if he/she is vomiting or unable to eat. Acute illness may cause a counter regulatory hormone response, resulting in hyperglycemia. During times of illness, the client should monitor the blood glucose level and notify the primary health care provider if it exceeds 250 mg/dL (13.9 mmol/L). Adequate fluids and carbohydrates are essential during illness. The client should eat 10 to 15 g of carbohydrate every 1 to 2 hours and drink a small quantity of fluid every 15 to 30 minutes to help prevent dehydration and ketoacidosis. The client should notify the primary health care provider of a fever over 100° F (37.8°C).

A nurse provides home care instructions to a client after a scleral buckling procedure. The nurse should tell the client 1) That vision will be perfectly clear immediately after surgery 2) To expect bloody drainage on the eye dressing 3) That redness and swelling of the eyelids and conjunctiva are expected 4) To maintain strict bedrest for 48 hours

that redness and swelling of the eyelids and conjunctiva are expected Rationale: The scleral buckling procedure is performed to treat retinal detachment. In the preoperative period the nurse places an eye patch over the client's affected eye to reduce eye movement. Some clients may require bilateral patching. Redness and swelling of the eyelids and conjunctiva, the result of surgical manipulation, are expected. Blood loss in retinal detachment surgery is minimal, and only serous drainage is expected on the postoperative dressing. The client should not expect immediate return of vision. Postoperative inflammation and eye drops interfere with vision. Because healing takes place over weeks to months, vision will improve gradually. Strict bedrest for 48 hours is not required; however, depending on the location and size of the retinal break, activity restrictions may be needed to prevent further tearing or detachment and to promote drainage of any subretinal fluid.

During a client's yearly eye exam, the nurse checks the intraocular pressure. The nurse notes that the pressure in the right eye is 12mmHg and the left eye is 19mmHg. The nurse tells the client that 1) That he has glaucoma in the left eye 2) That the intraocular pressure in both eyes is normal 3) That he needs to increase his fluid intake, because the pressure in the right eye is low 4) That he has glaucoma in the right eye

the IOP in both eyes is normal Rationale: Normal intraocular pressure ranges from 10 to 21 mm Hg. Therefore this client's intraocular pressure is normal. Increased intake of fluids is unrelated to increasing intraocular pressure.

A client with a leg fx who has been placed in skeletal traction is transported to the ortho unit after surgery. Which finding would indicate the need to contact the ortho specialist 1) The traction weights are hanging freely. 2) The traction knots are intact. 3) The clamps on the traction frame are tight. 4) The traction ropes are unable to move over the pulleys.

the traction ropes are unable to move the pulleys Rationale: After skeletal traction pins are inserted and traction is applied, all ropes, knots, and pulleys are inspected to ensure that they are positioned properly. Traction knots and ropes must be intact and secure. Ropes should move easily over pulleys and weights, and the weights should hang freely at all times. The clamps on the traction frame should be tight.

A mother calls the clinic and tells the nurse that her newborn's umbilical cord site looks red and swollen. The nurse should tell the mother 1) To place an ice pack on the cord for 10 minutes three times a day 2) To bring the newborn to the clinic 3) That this is a normal occurrence 4) To increase the number of cord site cleanings each day

to bring the newborn to the clinic

A client has undergone creation of an Indiana pouch for urine diversion after cystectomy and the nurse provides instructions about reservoir catheterization. The nurse tells the client 1) To plan to drain the reservoir every 2 to 3 hours initially 2) That sometimes force is needed to insert the catheter into the reservoir 3) That if mucus drains from the reservoir the primary health care provider should be contacted 4) To obtain 26F catheters from the medical supply store for the irrigations

to plan to drain the reservoir every 2-3 hours initially Rationale: An Indiana pouch is a continent internal ileal reservoir, and the nurse instructs the client in the technique of catheterization. Initially the client drains the reservoir every 2 to 3 hours. Each week thereafter, the interval is increased by 1 hour until finally catheterization is completed every 4 to 6 hours during the day. The catheter is never forced into the reservoir. If resistance is met, the client is instructed to pause and apply only gentle pressure while slightly rotating the catheter. A 16F to 20F catheter is used; 26F is too large and could damage the reservoir. Mucus is expected, and the client is instructed to irrigate the reservoir with 50 to 60 mL of normal saline solution to prevent excessive mucus buildup.

A nurse is conducting an assessment of a client with mild preeclampsia. Which sign indicates improvement in the client's condition 1) Blood urea nitrogen (BUN) of 40 mg/dL (14.2 mmol/L) 2) Blood pressure 148/94 mm Hg 3) Complaint of headache 4) Trace protein in the urine

trace protein in the urine Rationale: Preeclampsia is considered mild when the systolic blood pressure is 140 mm Hg or greater but less than 160 mm Hg and the diastolic blood pressure is 90 mm Hg or greater but less than 110 mm Hg, proteinuria is 1+ on a random dipstick, and signs/symptoms such as headache, visual disturbances, and abdominal pain are absent. In addition, signs of kidney or liver involvement are absent. The normal BUN range is 6-20 mg/dL (2.1-7.1 mmol/L). An increased BUN level indicates kidney damage, a result of the preeclampsia.

A nurse is teaching a client who is experiencing homonymous hemianopsia after a brain attack (stroke) about measures to overcome the defecit. The nurse tells the client to 1) Keep all objects in the impaired field of vision 2) Turn the head to scan the lost visual field 3) Wear a patch on the affected eye 4) Wear eyeglasses 24 hours a day

turn the head to scan the lost visual field Rationale: Homonymous hemianopsia is loss of half of the visual field. The nurse instructs the client to scan the environment to overcome the visual deficit. The nurse encourages the use of personal eyeglasses to improve overall vision, but it is not necessary to wear the glasses 24 hours a day. The client should keep objects in the intact field of vision whenever possible. An eye patch is of no use because the client does not have double vision.

A nurse is having dinner at a resturant when a man sitting at the next table collapses and falls to the floor. The nurse yells for help and quickly assesses the client, noting that the client is not breathing and does not have a pulse. The nurse inititates CPR immediately and the resturant manager rushes to the scene with and AED. What should the nurse do next 1) Check for a pulse for 30 seconds before continuing CPR 2) Use the AED 3) Perform CPR until emergency medical services arrives 4) Stop the resuscitation efforts

use the AED

A nurse answers the call bell of a client who has been fitted with an internal cervical rad implant, and the client states that she thinks that the implant has fallen out. The nurse checks the client and sees the implant lying in the bed. Which action should the nurse take first 1) Picking up the implant with gloved hands and placing it in sterile water 2) Reinserting the implant into the client's vagina 3) Using long-handled forceps to place the implant in a lead container 4) Calling the primary health care provider

using long-handled forceps to places the implant in a lead container Rationale: A lead container and long-handled forceps should be kept in the client's room at all times during internal radiation therapy. If the implant is dislodged, the nurse should pick it up with long-handled forceps and place it in the lead container. Reinserting the implant into the vagina and picking up the implant with gloved hands and placing it in sterile water are both incorrect nursing actions. The primary health care provider is called after action is taken to maintain the safety of the client.

A nurse is reading the medical record of a pregnant client in the second trimester with a dx of abruptio placentae. Which clinical manifestation of the disorder does the nurse expect to see documented 1) Uterine tenderness 2) Painless vaginal bleeding 3) Lack of uterine activity 4) Constipation

uterine tenderness Rationale: In abruptio placentae, abdominal pain and uterine tenderness are present. Uterine tenderness accompanies placental abruption, especially with a central abruption in which blood becomes trapped behind the placenta. The abdomen will feel hard and boardlike on palpation because the blood penetrates the myometrium, resulting in uterine irritability. Excessive uterine activity with poor relaxation between contractions is present. Fetal monitoring often reveals increased uterine resting tone, caused by failure of the uterus to relax in an attempt to constrict blood vessels and control bleeding. Painless bright-red vaginal bleeding in the second or third trimester of pregnancy is a sign of placenta previa. Constipation is not associated with this disorder.

A nurse develops a nursing care plan for a client with a sealed radiation implant. Which stipulation does the nurse include in the plan 1) Visitors must remain at least 2 feet (61 cm) from the client. 2) The client may be maintained in a semiprivate room as long as the client uses a commode. 3) A dosimeter badge must be placed on the client's bedside stand. 4) Visitors must be limited to one half-hour per day.

visitors must be limited to one half hour per day Rationale: The nurse would limit each visitor to a half-hour per day and be sure that visitors remain at least 6 feet (1.8 metres) from the radiation source. The nurse would wear the dosimeter badge when caring for the client. The dosimeter badge measures an individual's exposure to radiation and should be used by only one individual. The dosimeter badge is not left in the client's room. The client is assigned to a private room with a private bath to keep other clients from being exposed to radiation.

An ED nurse is caring for a client with acute pancreatitis. who will be admitted to the hospital. Into which position that will ease the abdominal pain does the nurse assist the client 1) With the knees drawn up to the chest 2) Side-lying with the head of the bed flat 3) Prone 4) Supine with the legs straight

with the knees drawn up to the chest

A client who experienced a brain attach (stroke) exhibits right-sided unilateral neglect. The nurse caring for this client plans to place the client's personal care items 1) Within the client's reach on the left side 2) Just out of the client's reach on the right side 3) Just out of the client's reach on the left side 4) Within the client's reach on the right side

within the client's reach on the right side Rationale: Unilateral neglect is unawareness of one side of the body. The client behaves as if that part is not there. The client does not look at the paralyzed limb when moving about. Unilateral neglect results in increased risk for injury. It is possible for the client to relearn to look for and to move the affected limb(s). Therefore in this condition the client's personal care items are placed within the client's reach on the right side. Hemiparesis is a weakness of the face, arm, and leg on one side. The client with one-sided hemiparesis benefits from having objects placed on the unaffected side and within reach. This reduces client frustration and aids in ensuring client safety because the client does not have to strain and reach for needed items. The nurse adapts the client's environment to the deficit by focusing on the client's unaffected side and by placing the client's personal care items on the affected side within reach. Placing items out of the client's reach presents a risk of injury.

a nurse is caring for a client who is being treated for congestive HF and has been assigned a nursing dx of excessive fluid vol. Which assessment finding causes the nurse to determine that the client's condition has improved 1) 1+ edema in the legs 20 Moist crackles in the lower lobes of the lungs 3) Dyspnea 4) Weight loss of 4 lb (1.8 kg) in 24 hours

wt loss of 4lbs in 24 hours Rationale: One sign that excessive fluid volume is resolving is loss of body weight. It is important to recall that 1 L of fluid weighs 1 kg, which equals 2.2 lb (1 liter = 2.2 lb = 1 kg). The other options listed indicate that the client is retaining fluid. Assessment findings associated with excessive fluid volume include cough, dyspnea, rales or crackles, tachypnea, tachycardia, increased blood pressure and bounding pulse, increased central venous pressure, weight gain, edema, neck and hand vein distention, altered level of consciousness, and decreased hematocrit. These signs/symptoms must be reversed if the fluid-volume excess is to be resolved.

A female client who has undergone placement of a sealed rad implant asks the nurse whether she can take a walk around the nursing unit. How should the nurse respond to the client's request 1) "Do you think that a walk around the unit will tire you out?" 2) "You need to stay in your room for now." 3) "Short walks are OK." 4) "Yes, it's fine to take a walk around the nursing unit."

you need to stay in your room for now Rationale: The client with a sealed radiation implant must remain in a private room to keep others from being exposed to radiation. The other options are all incorrect.