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A 10-year-old has just spilled hot liquid on his arm, and a 4-inch (10.2-cm) area on his forearm is severely burned. His mother calls the emergency department. What should the nurse advise the mother to do? a) Keep the child warm. b) Call 911 to transport the child to the hospital. c) Cover the burned area with an antibiotic cream. d) Apply cool water to the burned area.

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

A parent brings a toddler, age 19 months, to the clinic for a regular checkup. When palpating the toddler's fontanels, what should the nurse expect to find? a) Open anterior and posterior fontanels b) Closed anterior fontanel and open posterior fontanel c) Closed anterior and posterior fontanels d) Open anterior fontanel and closed posterior fontanel

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

The nurse is caring for an elderly nursing home client who is anxious and fearful after being admitted to the hospital. Which of the following interventions is the nursing priority? a) Have the client contact the family to come down to visit. b) Explain procedures and unit routines to the client, as well as checking orientation. c) Check on the client frequently to see the adjustment. d) Ask what the fears are and why the client is becoming agitated.

Explain procedures and unit routines to the client, as well as checking orientation. Explanation: Explaining procedures and routines decreases the client's anxiety about the unknown. This is especially important to an elderly client who has been transferred from a familiar en ... (more) Explaining procedures and routines decreases the client's anxiety about the unknown. This is especially important to an elderly client who has been transferred from a familiar environment to a new one. Checking orientation gives feedback as to how the client is coping with the changes. Since there is fear and anxiety, it would be a challenge for the client to contact the family. "Why" questions tend to be judgmental and do not address the main concerns. Checking on the client is not sufficient; explanations will help ease the anxiety.

When a client has a tearing of tissue with irregular wound edges, the nurse should document this as: a) Contusion. b) Colonization. c) Laceration. d) Abrasion.

Laceration. Explanation: The nurse should document a tearing of tissue with irregular wound edges as a laceration. A contusion or a bruise is a closed wound caused by a blunt object resulting in bleeding i ... (more) The nurse should document a tearing of tissue with irregular wound edges as a laceration. A contusion or a bruise is a closed wound caused by a blunt object resulting in bleeding in underlying tissue. An abrasion is a superficial wound from a rubbing or a scraping of the surface of the skin such as from a fall. Colonization is a wound containing microorganisms

A client is diagnosed with human immunodeficiency virus (HIV). After recovering from the initial shock of the diagnosis, the client expresses a desire to learn as much as possible about HIV and acquired immunodeficiency syndrome (AIDS). When teaching the client about the immune system, the nurse states that humoral immunity is provided by which type of white blood cell? a) Lymphocyte b) Monocyte c) Neutrophil d) Basophil

Lymphocyte Explanation: The lymphocyte provides humoral immunity — recognition of a foreign antigen and formation of memory cells against the antigen. Humoral immunity is mediated by B and T lymphocytes ... (more) The lymphocyte provides humoral immunity — recognition of a foreign antigen and formation of memory cells against the antigen. Humoral immunity is mediated by B and T lymphocytes and can be acquired actively or passively. The neutrophil is crucial to phagocytosis. The basophil plays an important role in the release of inflammatory mediators. The monocyte functions in phagocytosis and monokine production.

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

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

The client has had hypertension for 20 years. The nurse should assess the client for? a) Peptic ulcer disease. b) Renal insufficiency and failure. c) Valvular heart disease. d) Endocarditis.

Renal insufficiency and failure. Explanation: Renal disease, including renal insufficiency and failure, is a complication of hypertension. Effective treatment of hypertension assists in preventing this complication. Valvular h ... (more) Renal disease, including renal insufficiency and failure, is a complication of hypertension. Effective treatment of hypertension assists in preventing this complication. Valvular heart disease, endocarditis, and peptic ulcer disease are not complications of hypertension.

A school-age child with cystic fibrosis asks the nurse what sports she can become involved in as she becomes older. Which of the following activities would be appropriate for the nurse to suggest? a) Javelin throwing. b) Swimming. c) Baseball. d) Track.

Swimming. Explanation: Swimming would be the most appropriate suggestion because it coordinates breathing and movement of all muscle groups and can be done on an individual basis or as a team sport. Beca ... (more) Swimming would be the most appropriate suggestion because it coordinates breathing and movement of all muscle groups and can be done on an individual basis or as a team sport. Because track events, baseball, and javelin throwing usually are performed outdoors, the child would be breathing in large amounts of dust and dirt, which would be irritating to her mucous membranes and pulmonary system. The strenuous activity and increased energy expenditure associated with track events, in conjunction with the dust and possible heat, would play a role in placing the child at risk for an upper respiratory tract infection and compromising her respiratory function

During the preoperative interview, the nurse obtains information about the client's medication history. Which of the following is not necessary to record about the client? a) Current use of medications, herbs, and vitamins. b) Over-the-counter medication use in the last 6 weeks. c) Steroid use in the last year. d) Use of all drugs taken in the last 18 months.

Use of all drugs taken in the last 18 months. Explanation: The nurse does not need to ask about all drugs used in the last 18 months unless the client is still taking them. The nurse does need to know all drugs the client is currently taki ... (more) The nurse does not need to ask about all drugs used in the last 18 months unless the client is still taking them. The nurse does need to know all drugs the client is currently taking, including herbs and vitamins, over-the-counter medications such as aspirin taken in the past 6 weeks, the amount of alcohol consumed, and use of illegal drugs, because these can interfere with the anesthetic and analgesic agents. Steroid use is of concern because it can suppress the adrenal cortex for up to 1 year, and supplemental steroids may need to be administered in times of stress such as surgery.

One day after cataract surgery the client is having discomfort from bright light. The nurse should advise the client to: a) Attach sun shields to existing eyeglasses when in direct sunlight. b) Use sunglasses that wrap around the side of the face when in bright light. c) Dim lights in the house and stay inside for one week. d) Patch the affected eye when in bright light.

Use sunglasses that wrap around the side of the face when in bright light. Explanation: To prevent discomfort from bright light the client should wear sunglasses that cover the front and side of the face, thus minimizing light that comes into the eye from any directio ... (more) To prevent discomfort from bright light the client should wear sunglasses that cover the front and side of the face, thus minimizing light that comes into the eye from any direction. It is not necessary to remain in dim light or inside. Attaching sun shields or sunglasses to existing glasses will not cover the eye sufficiently and bright light will come in on the side of the face. It is not necessary to patch the affected eye

A nurse receives a lithium level report of l.0 mEq/L (1 mmol/L) for a client who has been taking lithium for 2 months. The nurse should interpret this level to indicate which of the following? a) An error in reporting. b) Within the therapeutic range. c) Too high, indicating toxicity. d) Too low to be therapeutic.

Within the therapeutic range. Explanation: For the client who has been receiving lithium therapy for the past 2 months, a maintenance serum lithium level of 0.6 to 1.2 mEq/L (0.6 to 1.2 mmol/L) is considered therapeutic. A li ... (more) For the client who has been receiving lithium therapy for the past 2 months, a maintenance serum lithium level of 0.6 to 1.2 mEq/L (0.6 to 1.2 mmol/L) is considered therapeutic. A lithium level greater than 1.2 mEq/L (1.2 mmol/L) suggests toxicity

Choice Multiple question - Select all answer choices that apply. A client with peripheral vascular disease has poor circulation. The nurse should assess the client for which of the following? Select all that apply. a) Pain in extremity. b) Skin temperature. c) Nausea. d) Nail bed color. e) Fluid intake.

• Nail bed color. • Skin temperature. • Pain in extremity. Explanation: Maintaining circulation is critical in individuals with peripheral vascular disease. Skin and nail bed color and temperature will reveal the degree to which the extremity is recei ... (more) Maintaining circulation is critical in individuals with peripheral vascular disease. Skin and nail bed color and temperature will reveal the degree to which the extremity is receiving blood flow. Clients with peripheral vascular disease also usually have a certain amount of pain, especially when the oxygen demand becomes greater than oxygen supply, such as with walking or exercising. Fluid intake and reports of nausea are unrelated to peripheral circulation

When teaching a parent of a school-age child about signs and symptoms accompanying fever that require immediate notification of the physician, which of the following descriptions should the nurse include? a) History of febrile seizures b) Reports of a stiff neck c) Cough progressing to productive sputum d) Burning or pain with urination

Reports of a stiff neck Explanation: The nurse should discuss reports of a stiff neck because fever and a stiff neck indicate possible meningitis. Burning or pain with urination, a cough that progresses to productive ... (more) The nurse should discuss reports of a stiff neck because fever and a stiff neck indicate possible meningitis. Burning or pain with urination, a cough that progresses to productive sputum, and a history of febrile seizures should be addressed by the physician but can wait until office hours

A nurse must administer a medication to reverse or prevent Parkinson-type symptoms in a client receiving an antipsychotic. The medication the client will likely receive is: a) propranolol. b) haloperidol. c) diphenhydramine. d) benztropine.

benztropine. Explanation: Benztropine, trihexyphenidyl, or amantadine are ordered for treatment of Parkinson-type symptoms. Diphenhydramine provides rapid relief for dystonia. Propranolol relieves akathisia ... (more) Benztropine, trihexyphenidyl, or amantadine are ordered for treatment of Parkinson-type symptoms. Diphenhydramine provides rapid relief for dystonia. Propranolol relieves akathisia. Haloperidol can cause Parkinson-type symptoms

The primary health care provider orders scalp stimulation of the fetal head for a primigravid client in active labor. When explaining to the client about this procedure, which of the following would the nurse include as the purpose? a) Increase in the strength of the contractions. b) Assessment of the fetal hematocrit level. c) Increase in the fetal heart rate and variability. d) Assessment of fetal position.

ncrease in the fetal heart rate and variability. Explanation: Fetal scalp stimulation is commonly ordered when there is decreased fetal heart rate variability. Pressure is applied with the fingers to the fetal scalp through the dilated cervix ... (more) Fetal scalp stimulation is commonly ordered when there is decreased fetal heart rate variability. Pressure is applied with the fingers to the fetal scalp through the dilated cervix. This should cause a tactile response in the fetus and increase the fetal heart rate and variability. However, if the fetus is in distress and becoming acidotic, fetal heart rate acceleration will not occur. The fetal hematocrit level can be measured by fetal blood sampling. Scalp stimulation does not increase the strength of the contractions. However, it can increase fetal heart rate and variability. Fetal position is assessed by identifying skull landmarks (sutures) during a vaginal examination

A physician orders prednisone to control inflammation in a client with interstitial lung disease. During client teaching, the nurse stresses the importance of taking prednisone exactly as ordered and cautions against discontinuing the drug abruptly. A client who discontinues prednisone abruptly may experience: a) acute adrenocortical insufficiency. b) GI bleeding. c) hyperglycemia and glycosuria. d) restlessness and seizures.

acute adrenocortical insufficiency. Explanation: Administration of a corticosteroid such as prednisone suppresses the body's natural cortisol secretion, which may take weeks or months to normalize after drug discontinuation. Abru ... (more) Administration of a corticosteroid such as prednisone suppresses the body's natural cortisol secretion, which may take weeks or months to normalize after drug discontinuation. Abruptly discontinuing such therapy may cause the serum cortisol level to drop low enough to trigger acute adrenocortical insufficiency. Hyperglycemia, glycosuria, GI bleeding, restlessness, and seizures are common adverse effects of corticosteroid therapy, not its sudden cessation

The family of a client who is unconscious following a stroke tells the nurse they feel "pressured" by the resident physician to insert a feeding tube. They are reluctant to agree to the procedure because they believe this action is not something the client would want. Which of the following responses by the nurse illustrates ethical practice? a) "Without a living will or power of attorney, you will not be able to prevent this intervention." b) "You don't have to do what the resident says. You should talk with the attending physician." c) "The medical team cannot force you to do anything you don't believe is right." d) "I can arrange for you to talk with the healthcare team about your loved one's situation."

"I can arrange for you to talk with the healthcare team about your loved one's situation." Explanation: The nurse demonstrates ethical behavior when offering to find resources, answer questions, and provide support to the client's family. Unethical behavior would include providing in ... (more) The nurse demonstrates ethical behavior when offering to find resources, answer questions, and provide support to the client's family. Unethical behavior would include providing inaccurate information, giving advice, discussing personal information, or implying that the medical resident is not competent.

A client has a throbbing headache when nitroglycerin is taken for angina. The nurse should instruct the client that: a) Acetaminophen or ibuprofen can be taken for this common side effect. b) Taking the nitroglycerin with a few glasses of water will reduce the problem. c) The client should lie in a supine position to alleviate the headache. d) Nitroglycerin should be avoided if the client is experiencing this serious side effect.

Acetaminophen or ibuprofen can be taken for this common side effect. Explanation: Headache is a common side effect of nitroglycerin that can be alleviated with aspirin, acetaminophen, or ibuprofen. The sublingual nitroglycerin needs to be absorbed in the mouth, ... (more) Headache is a common side effect of nitroglycerin that can be alleviated with aspirin, acetaminophen, or ibuprofen. The sublingual nitroglycerin needs to be absorbed in the mouth, which will be disrupted with drinking. Lying flat will increase blood flow to the head and may increase pain and exacerbate other symptoms, such as shortness of breath

A nurse is caring for a client diagnosed with ovarian cancer. Diagnostic testing reveals that the cancer has spread outside the pelvis. The client has previously undergone a right oophorectomy and received chemotherapy. The client now wants palliative care instead of aggressive therapy. The nurse determines that the care plan's priority nursing diagnosis should be: a) Noncompliance. b) Acute pain. c) Impaired home maintenance. d) Knowledge deficit: Chemotherapy.

Acute pain. Explanation: Palliative care for the client with advanced cancer includes pain management, emotional support, and comfort measures. The client is in the hospital, so home maintenance doesn't ap ... (more) Palliative care for the client with advanced cancer includes pain management, emotional support, and comfort measures. The client is in the hospital, so home maintenance doesn't apply at this time. The client has chosen palliative care, so she isn't noncompliant. The client's decision is not based on a knowledge deficit about chemotherapy because she has previously had treatments with chemotherapy

A registered nurse is staff-shared to the maternal-neonatal unit where she has never worked before. How can this nurse be best employed? a) Assign her to the nursery. b) Assign her a client care assignment in the postpartum unit. c) Assign her to the labor and delivery area. d) Use her as a nursing assistant in the postpartum unit.

Assign her a client care assignment in the postpartum unit. Explanation: The staff-shared nurse can be best employed in client care in the postpartum unit because such an assignment requires medical-surgical knowledge. In this setting, the nurse can saf ... (more) The staff-shared nurse can be best employed in client care in the postpartum unit because such an assignment requires medical-surgical knowledge. In this setting, the nurse can safely use her nursing skills and doesn't need to assume the role of a nursing assistant. The staff-shared nurse isn't qualified to work in the labor and delivery area or the nursery because both require specialized training to safely administer care

Which of the following structures should be closed by the time the child is 2 months old? a) C b) D c) A d) B

C Explanation: The posterior fontanel should be closed by age 2 months. The anterior fontanel and sagittal and frontal sutures should be closed by age 18 months.

A nursing assistant recorded a client's 6 a.m. (0600) blood glucose level as 126 (7 mmol/l) instead of 216 (12 mmol/l). The nursing assistant did not recognize the error until 9 a.m. (0900) but reported it to the nurse right away. The nurse should next: a) Reprimand the nursing assistant for the error. b) Reassign the nursing assistant to another client. c) Call the physician and completing an incident report. d) Wait and observing the client for symptoms of hyperglycemia.

Call the physician and completing an incident report. Explanation: The error should be reported to the physician promptly for orders. The nurse should complete an incident report because an unusual occurrence happened during the client's care. The ... (more) The error should be reported to the physician promptly for orders. The nurse should complete an incident report because an unusual occurrence happened during the client's care. The nurse should observe the client for symptoms of hyperglycemia but first must call the physician and complete an incident report. The nursing assistant does not need to be reassigned for this error. The nurse does not need to reprimand the nursing assistant for the error because the nursing assistant already knows an error was made

For a hospitalized client, the physician orders morphine, 4 mg I.V., every 2 hours as needed for pain. However, the client refuses to take injections. Which nursing action is most appropriate? a) Withholding the medication until the client understands its importance b) Administering the medication as ordered c) Explaining that no other medication can be given until the client receives the pain medication d) Calling the physician to request an oral pain medication

Calling the physician to request an oral pain medication Explanation: The most appropriate action is to call the physician to request an oral pain medication. By doing so, the nurse is adhering to the client's wishes. Administering an I.V. injection ... (more) The most appropriate action is to call the physician to request an oral pain medication. By doing so, the nurse is adhering to the client's wishes. Administering an I.V. injection without client consent is considered battery and may result in a lawsuit. Withholding medication without providing an alternative and attempting to manipulate the client into taking the medication would violate the standards of care

The nurse is planning care for a client in restraints. Which nursing intervention is most important when restraining a this client? a) Checking that the restraints have been applied correctly b) Asking if the client needs to use the bathroom or is thirsty c) Reviewing facility policy regarding how long the client may be restrained d) Preparing an as-needed dose of the client's psychotropic medication

Checking that the restraints have been applied correctly Explanation: A nurse must determine whether the restraints have been applied correctly to make sure that the client's circulation and respiration are not restricted, and that adequate padding h ... (more) A nurse must determine whether the restraints have been applied correctly to make sure that the client's circulation and respiration are not restricted, and that adequate padding has been used. The nurse should document the client's response and status carefully after the restraints are applied. All staff members involved in restraining clients should be aware of facility policy before using restraints. If an as-needed medication is ordered, it should be administered before the restraints are in place and with the assistance of other team members. The nurse should attend to the client's elimination and hydration needs after the client is properly restrained.

The fire alarm sounds on the maternal-neonatal unit at 0200. How can a nurse best care for her clients during a fire alarm? a) Do nothing because it's most likely a fire drill. b) Immediately evacuate the unit. c) Permit the mothers and their neonates to continue sleeping. d) Close all of the doors on the unit.

Close all of the doors on the unit. Explanation: The nurse should respond quickly by closing all of the doors on the unit. This action prevents the spread of smoke in case of a fire. The nurse shouldn't begin evacuating the unit ... (more) The nurse should respond quickly by closing all of the doors on the unit. This action prevents the spread of smoke in case of a fire. The nurse shouldn't begin evacuating the unit until given notification to do so. The nurse shouldn't ignore the alarm because fire drills are necessary to prepare the staff for a fire. The mothers should be awakened in case evacuation is necessary.

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

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

A client who is recovering from chest trauma is to be discharged home with a chest tube drainage system intact. The nurse should instruct the client to call the physician for which of the following? a) Fluid in the chest tube. b) Fluctuation of fluid in the water-seal chamber. c) Respiratory rate greater than 16 breaths/minute. d) Continuous bubbling in the water-seal chamber.

Continuous bubbling in the water-seal chamber. Explanation: Continuous bubbling in the water-seal chamber indicates a leak in the system, and the client needs to be instructed to notify the physician if continuous bubbling occurs. A respira ... (more) Continuous bubbling in the water-seal chamber indicates a leak in the system, and the client needs to be instructed to notify the physician if continuous bubbling occurs. A respiratory rate of more than 16 breaths/minute may not be unusual and does not necessarily mean that the client should notify the physician. Fluid in the chest tube is expected, as is fluctuation of the fluid in the water-seal chamber.

A nurse is preparing for the discharge of a neonate born 7 weeks premature. The neonate has had several apneic episodes and will need a home apnea monitor but will require no other specialized care. Which nursing diagnosis is most appropriate for the neonate's parents? a) Risk for aspiration related to nil orally status. b) Deficient knowledge related to ventilatory support. c) Deficient knowledge related to lack of exposure to apnea monitor. d) Deficient knowledge related to inability to cope.

Deficient knowledge related to lack of exposure to apnea monitor. Explanation: For the parents of a neonate who needs a home apnea monitor, the nursing diagnosis of Deficient knowledge related to lack of exposure to apnea monitor is most appropriate. Although ... (more) For the parents of a neonate who needs a home apnea monitor, the nursing diagnosis of Deficient knowledge related to lack of exposure to apnea monitor is most appropriate. Although the premature neonate may be at risk for aspiration, the question asks about the most appropriate nursing diagnosis for the parents, not the neonate. No ventilatory support is being used, so a diagnosis of Deficient knowledge related to ventilatory support isn't warranted. A diagnosis of Deficient knowledge related to prematurity would be appropriate just after birth but would probably be resolved by the time the neonate is ready for discharge.

A client with a cerebral embolus is receiving streptokinase. The nurse should evaluate the client for which of the following expected outcomes of this drug therapy? a) Improved cerebral perfusion. b) Decreased vascular permeability. c) Prevention of cerebral hemorrhage. d) Dissolved emboli.

Dissolved emboli. Explanation: Thrombolytic agents such as streptokinase are used for clients with a history of thrombus formation, cerebrovascular accidents, and chronic atrial fibrillation. The thrombolytic ag ... (more) Thrombolytic agents such as streptokinase are used for clients with a history of thrombus formation, cerebrovascular accidents, and chronic atrial fibrillation. The thrombolytic agents act by dissolving emboli. Thrombolytic agents do not directly improve perfusion or increase vascular permeability, nor do they prevent cerebral hemorrhage

The American Heart Association (AHA) and Canadian Heart and Stroke Foundation guidelines urge greater availability of automated external defibrillators (AEDs) and people trained to use them. AEDs are used in cardiac arrest situations for: a) Cardioversion in cases of atrial fibrillation. b) Early defibrillation in cases of atrial fibrillation. c) Early defibrillation in cases of ventricular fibrillation. d) Pacemaker placement.

Early defibrillation in cases of ventricular fibrillation. Explanation: AEDs are used for early defibrillation in cases of ventricular fibrillation. The AHA and Canadian Heart and Stroke Foundation places major emphasis on early defibrillation for vent ... (more) AEDs are used for early defibrillation in cases of ventricular fibrillation. The AHA and Canadian Heart and Stroke Foundation places major emphasis on early defibrillation for ventricular fibrillation and use of the AED as a tool to increase sudden cardiac arrest survival rates

A 56-year-old female is currently receiving radiation therapy to the chest wall for recurrent breast cancer. She has pain while swallowing and burning and tightness in her chest. The nurse should further assess the client for indications of: a) Esophagitis. b) Stomatitis. c) Radiation enteritis. d) Hiatal hernia.

Esophagitis. Explanation: Difficulty in swallowing, pain, and tightness in the chest are signs of esophagitis, which is a common complication of radiation therapy of the chest wall. Hiatal hernia is a herni ... (more) Difficulty in swallowing, pain, and tightness in the chest are signs of esophagitis, which is a common complication of radiation therapy of the chest wall. Hiatal hernia is a herniation of a portion of the stomach into the esophagus. The client could experience burning and tightness in the chest secondary to a hiatal hernia, but not pain when swallowing. Also, hiatal hernia is not a complication of radiation therapy. Stomatitis is an inflammation of the oral cavity characterized by pain, burning, and ulcerations. The client with stomatitis may experience pain with swallowing, but not burning and tightness in the chest. Radiation enteritis is a disorder of the large and small bowel that occurs during or after radiation therapy to the abdomen, pelvis, or rectum. Nausea, vomiting, abdominal cramping, the frequent urge to have a bowel movement, and watery diarrhea are the signs and symptoms

A 5-month-old infant is brought to the clinic by his parents because he "cries too much" and "vomits a lot." The infant's birth weight was 6 lb, 10 oz (3,005 g), and his current weight is 7 lb, 4 oz (3,289 g), falling below the 5th percentile on a standard growth chart. Which of the following data should the nurse identify as the priority? a) Pattern of weight gain. b) Family dynamics. c) Feeding pattern. d) Frequency of regular checkups.

Feeding pattern. Explanation: Because the infant falls below the 5th percentile on a standard growth chart, the nurse should consider failure to thrive, a term applied to an infant who is not growing at an acce ... (more) Because the infant falls below the 5th percentile on a standard growth chart, the nurse should consider failure to thrive, a term applied to an infant who is not growing at an acceptable rate. Information about feeding patterns, including types and amounts of food, is needed to determine the cause of failure to thrive. If a child does not receive sufficient calories, growth slows. Whether or not the infant has received regular checkups is important but not the priority because that information alone does not provide evidence or substantiation about the infant's growth patterns. The infant's pattern of weight gain is important but not the priority. Rather, the infant's pattern of weight gain provides valuable and useful information over a period of time. Information about family dynamics is important to provide data about family stresses that may affect or help explain the infant's failure to thrive. However, it is not the priority. This information needs to be viewed in conjunction with the infant's feeding patterns to gain a complete picture.

A client is receiving fluid replacement with lactated Ringer's after 40% of his body was burned 10 hours ago. The assessment reveals: temperature 97.2 (36.2° C); heart rate 122; blood pressure 84/42; CVP 2 mm Hg; and urine output 25 ml for the last 2 hours. The IV rate is currently at 375 ml/hr. Using the SBAR (Situation-Background-Assessment-Recommendation) technique for communication, the nurse calls the healthcare provider with the recommendation for: a) Furosemide. b) IV rate increase. c) Dextrose 5%. d) Fresh frozen plasma.

IV rate increase. Explanation: The decreased urine output, low blood pressure, low CVP, and high heart rate indicate hypovolemia and the need to increase fluid volume replacement. Furosemide is a diuretic that s ... (more) The decreased urine output, low blood pressure, low CVP, and high heart rate indicate hypovolemia and the need to increase fluid volume replacement. Furosemide is a diuretic that should not be given due to the existing fluid volume deficit. Fresh frozen plasma is not indicated. It is given for clients with deficient clotting factors who are bleeding. Fluid replacement used for burns is lactated Ringer's solution, normal saline, or albumin.

For a client with hyperglycemia, which assessment finding best supports a nursing diagnosis of Deficient fluid volume? a) Jugular vein distention b) Cool, clammy skin c) Increased urine osmolarity d) Decreased serum sodium level

Increased urine osmolarity Explanation: In hyperglycemia, urine osmolarity (the measurement of dissolved particles in the urine) increases as glucose particles move into the urine. The client experiences glucosuria and p ... (more) In hyperglycemia, urine osmolarity (the measurement of dissolved particles in the urine) increases as glucose particles move into the urine. The client experiences glucosuria and polyuria, losing body fluids and experiencing deficient fluid volume. Cool, clammy skin; jugular vein distention; and a decreased serum sodium level are signs of fluid volume excess, the opposite imbalance

The multigravid client with a history of rapid labor who is in active labor calls out to the nurse, "The baby is coming!" Which of the following should be the nurse's first action? a) Auscultate the fetal heart rate. b) Time the contractions. c) Inspect the perineum. d) Contact the health care providert.

Inspect the perineum. Explanation: When the client says the baby is coming, the nurse should first inspect the perineum and observe for crowning to validate the client's statement. If the client is not giving birth ... (more) When the client says the baby is coming, the nurse should first inspect the perineum and observe for crowning to validate the client's statement. If the client is not giving birth precipitously, the nurse can calm her and use appropriate breathing techniques. Timing contractions is not the priority action. The nurse needs to determine if what the client says is accurate. Monitoring the fetal heart rate, including auscultation, occurs throughout the labor process. The nurse should try to obtain assistance if birth is imminent, but the nurse should never leave the client. Birth may occur before the health care provider arrives.

An HIV-positive client discovers that his name is published in a report on HIV care prepared by his nurse. He strongly opposes this and files a lawsuit against the nurse. Which of the following offenses has this nurse committed? a) Unintentional tort. b) Negligence of duty. c) Invasion of privacy. d) Defamation.

Invasion of privacy. Explanation: The nurse has committed the tort of invasion of privacy. Personal names and identities are concealed or obliterated in case studies or research work. Invasion of privacy is a type ... (more) The nurse has committed the tort of invasion of privacy. Personal names and identities are concealed or obliterated in case studies or research work. Invasion of privacy is a type of intentional tort. Defamation is an act in which untrue information harms a person's reputation, and is therefore not applicable here. Negligence is the harm that results because a person did not act reasonably.

The nurse is instructing the client with chronic renal failure to maintain adequate nutritional intake. Which of the following diets would be most appropriate? a) High-carbohydrate, high-protein. b) Low-protein, low-sodium, low-potassium. c) Low-protein, high-potassium. d) High-calcium, high-potassium, high-protein.

Low-protein, low-sodium, low-potassium. Explanation: Dietary management for clients with chronic renal failure is usually designed to restrict protein, sodium, and potassium intake. Protein intake is reduced because the kidney can no ... (more) Dietary management for clients with chronic renal failure is usually designed to restrict protein, sodium, and potassium intake. Protein intake is reduced because the kidney can no longer excrete the byproducts of protein metabolism. The degree of dietary restriction depends on the degree of renal impairment. The client should also receive a high-carbohydrate diet along with appropriate vitamin and mineral supplements. Calcium requirements remain 1,000 to 2,000 mg/day.

A client comes to the emergency department complaining of headache, malaise, chills, fever, and a stiff neck. Vital sign assessment reveals a temperature elevation, increased heart and respiratory rates, and normal blood pressure. On physical examination, the nurse notes confusion, a petechial rash, nuchal rigidity, Brudzinski's sign, and Kernig's sign. What do these manifestations indicate? a) Low cerebrospinal fluid (CSF) pressure b) Encephalitis c) Increased intracranial pressure (ICP) d) Meningeal irritation

Meningeal irritation Explanation: Brudzinski's sign indicates meningeal irritation, as in meningitis. Other signs of meningeal irritation include nuchal rigidity and Kernig's sign. Brudzinski's sign and Kernig's si ... (more) Brudzinski's sign indicates meningeal irritation, as in meningitis. Other signs of meningeal irritation include nuchal rigidity and Kernig's sign. Brudzinski's sign and Kernig's sign don't indicate increased ICP, encephalitis, or low CSF pressure

A child has discomfort and swelling in the region where an I.V. needle is inserted. The nurse should first determine if the: a) I.V. site has been used too long. b) Child is allergic to the plastic in the needle. c) Needle has come out of the vein. d) Rate of fluid administration is too rapid for the vein size.

Needle has come out of the vein. Explanation: Pain and swelling in the area of needle insertion most likely indicate that the needle has come out of the vein. Swelling occurs as the fluid infuses into subcutaneous tissues. Oth ... (more) Pain and swelling in the area of needle insertion most likely indicate that the needle has come out of the vein. Swelling occurs as the fluid infuses into subcutaneous tissues. Other typical signs of infiltration include skin pallor and coldness around the insertion site. Signs of inflammation, such as redness and warmth, are likely if the I.V. site is used too long. Because inert plastic is used for manufacturing I.V. needles, the risk of an allergic reaction is remote. If fluid is administered too rapidly for the vein size, the fluid would most probably leak around the needle at the area of connection with the tubing.

Which of the following instructions would be most appropriate for the nurse to include in the teaching plan for the mother of a 1-year-old child who is to receive iron therapy with ferrous sulfate drops? a) Dilute the drops with water and put them in the child's mouth. b) Put the drops in the child's mouth, then follow with milk. c) Mix the drops with a cup of milk. d) Put the drops in the child's mouth, then follow with juice.

Put the drops in the child's mouth, then follow with juice. Explanation: Absorption of iron is enhanced in an acid environment. Thus, iron drops are better absorbed when mixed with fruit juice or followed by fruit juice. Medications should not be mixed ... (more) Absorption of iron is enhanced in an acid environment. Thus, iron drops are better absorbed when mixed with fruit juice or followed by fruit juice. Medications should not be mixed in a cup or bottle of fluids. If the child does not drink the entire cup or bottle, it is difficult to determine how much of the medication the child actually received. Also, even though the child may be learning to use a cup, it may spill, again making it difficult to determine the amount of medication that the child has received. In addition, milk tends to decrease iron absorption. Putting the drops in the child's mouth is appropriate. However, following administration with milk should be avoided because milk decreases iron absorption. Medications should not be diluted with water. If the child does not swallow the entire dose, it is difficult to determine how much of the medication the child actually received.

Which of the following topics would be most important to include when teaching the parents how to promote overall toddler development? a) Discipline is critical to appropriate development. b) Safety is a priority concern for this age-group. c) Eating habits that follow into adulthood begin now. d) Language is the most important achievement.

Safety is a priority concern for this age-group. Explanation: Because of toddlers' high energy and poor impulse control, safety is a priority concern for this age-group. Language is important in toddler development, but not the most importa ... (more) Because of toddlers' high energy and poor impulse control, safety is a priority concern for this age-group. Language is important in toddler development, but not the most important at this time. While parents should set clear guidelines for behavior, the priority for toddlers is ensuring safety. Diet habits should be developed at this time, but the most important subject to teach parents of toddlers is safety

The charge nurse on the postpartum unit has received report about a client with a fetal demise who will be ready for transfer out of Labor and Birth in about 2 hours. The client has asked her primary nurse if she can stay on the obstetrical unit since she has found support from the nursing staff there. What action should the charge nurse on the postpartum unit take? a) Admit the mother to a private room on the postpartum unit. b) Request a room for this client on a unit without newborns. c) Ask the nurse in labor and birth to discharge the mother as soon as she is physically able to leave. d) Talk to the mother first and decide on a location that is mutually agreeable.

Talk to the mother first and decide on a location that is mutually agreeable. Explanation: The nurse on the postpartum unit should discuss with the client what her wishes are and mutually agree on a location. The charge nurse better understands the current and future nee ... (more) The nurse on the postpartum unit should discuss with the client what her wishes are and mutually agree on a location. The charge nurse better understands the current and future needs of the client experiencing this type of loss as the client may or may not be thinking well or clearly at the moment. The postpartum unit is full of sounds of infants, and although being in a room by herself may support the need for separation, it is often in the best interest of the client to locate her away from the noise of the babies. Placing the client on another unit will remove her from the support she is seeking. On the other hand, she will not be hearing crying infants. This has often been the location for someone experiencing a loss. Discharging the mother home as soon as she is stable physically is also a possibility, but the nurse must also assess the client's emotional stability and preferences for grieving.

Following the formation of an ileal conduit, the nurse notes that the client's urinary drainage appliance contains pale yellow urine with large amounts of mucus. How should the nurse interpret these data? a) These findings are normal for a client with an ileal conduit. b) The mucus is caused by elevated levels of glucose in the urine. c) There is irritation of the stoma. d) The client is developing an infection of the urinary tract.

These findings are normal for a client with an ileal conduit. Explanation: A segment of the terminal ileus is used to form the conduit that collects urine from the ureters. Hence, the client with an ileal conduit can be expected to excrete urine that cont ... (more) A segment of the terminal ileus is used to form the conduit that collects urine from the ureters. Hence, the client with an ileal conduit can be expected to excrete urine that contains mucus from this intestinal mucous membrane. Mucus production is not a result of infection or stomal irritation. Mucus production is not a result of glycosuria. There is no reason to expect to find glucose in the client's urine.

A 34-year-old primigravid client at 39 weeks' gestation admitted to the hospital in active labor has type B Rh-negative blood. The nurse should instruct the client that if the neonate is Rh positive, the client will receive an Rh immune globulin (RHIG) injection for which of the following reasons? a) To destroy fetal Rh-positive cells during the next pregnancy. b) To prevent Rh-positive sensitization with the next pregnancy. c) To provide active antibody protection for this pregnancy. d) To decrease the amount of Rh-negative sensitization for the next pregnancy.

To prevent Rh-positive sensitization with the next pregnancy. Explanation: The purpose of the RHIG is to provide passive antibody immunity and prevent Rh-positive sensitization with the next pregnancy. It should be given within 72 hours after birth of an ... (more) The purpose of the RHIG is to provide passive antibody immunity and prevent Rh-positive sensitization with the next pregnancy. It should be given within 72 hours after birth of an Rh-positive neonate. Clients who are Rh-negative and conceive an Rh-negative fetus do not need antibody protection. Rh-positive cells contribute to sensitization, not Rh-negative cells. The RHIG does not cross the placenta and destroy fetal Rh-positive cells.

Which intervention is essential when performing dressing changes on a client with a diabetic foot ulcer? a) Cleaning the wound with a povidone-iodine solution b) Applying a heating pad c) Using sterile technique during the dressing change d) Debriding the wound three times per day

Using sterile technique during the dressing change Explanation: The nurse should perform the dressing changes using sterile technique to prevent infection. Applying heat should be avoided in a client with diabetes mellitus because of the risk o ... (more) The nurse should perform the dressing changes using sterile technique to prevent infection. Applying heat should be avoided in a client with diabetes mellitus because of the risk of injury. Cleaning the wound with povidone-iodine solution and debriding the wound with each dressing change prevents the development of granulation tissue, which is essential in the wound healing process

In order to prevent recurrent vasospastic episodes with Raynaud's phenomenon, the nurse should instruct the client to: a) Keep the hands and feet elevated as much as possible. b) Increase coffee intake to 2 cups per day. c) Wear gloves when obtaining food from the refrigerator. d) Use a vibrating massage device on the hands.

Wear gloves when obtaining food from the refrigerator. Explanation: Loose warm clothing should be worn to protect from the cold. Wearing gloves when handling cold objects will help prevent vasospasms. Vibrating equipment and typing contribute to va ... (more) Loose warm clothing should be worn to protect from the cold. Wearing gloves when handling cold objects will help prevent vasospasms. Vibrating equipment and typing contribute to vasospasm. Tobacco and caffeine should be avoided. Elevation will decrease arterial perfusion during vasospasms

A client describes anxiety attacks that usually occur shortly after work when he is preparing his evening meal. Which of the following questions would be most appropriate for the nurse to ask the client first in an effort to learn how he can be helped? a) "Have you tried walking to ease your anxiety?" b) "Do you think taking several slow, deep breaths would help?" c) "What do you do when you're anxious to help yourself feel better?" d) "What are you thinking about before you start to prepare supper?"

What are you thinking about before you start to prepare supper?" Explanation: The nurse initially helps the client to identify a cause or event that precedes the symptoms of anxiety. Nursing care of an anxious client, however, must ultimately take into accou ... (more) The nurse initially helps the client to identify a cause or event that precedes the symptoms of anxiety. Nursing care of an anxious client, however, must ultimately take into account all aspects of the client's anxiety, including what leads to attacks and what happens during an attack. Only then can the nurse help the client understand his anxiety, what personal needs may be unmet, and how to cope with his problem with more satisfactory behavior than having an anxiety attack. The nurse must first assess the possibility of a trigger for the client's anxiety before progressing to assessing the client's coping strategies or educating him regarding adaptive coping

When a nurse attempts to make sure the physician obtained informed consent for a thyroidectomy, she realizes the client doesn't fully understand the surgery. She approaches the physician, who curtly says, "I've told him all about it. Just get the consent." The nurse should: a) tell the physician the client isn't comfortable consenting to surgery at this point. b) explain the procedure more fully to the client and obtain his signature. c) tell the physician he didn't give the client enough information. d) ask the charge nurse to talk with the physician.

tell the physician the client isn't comfortable consenting to surgery at this point. Explanation: The nurse has evaluated the client's knowledge concerning the surgery and determined that he doesn't have enough information to give informed consent. Even though the physician mig ... (more) The nurse has evaluated the client's knowledge concerning the surgery and determined that he doesn't have enough information to give informed consent. Even though the physician might want to move ahead, the nurse should advocate for the client by telling the physician the client isn't ready for the surgery. Telling the physician that he hasn't given the client enough information would be rude. The nurse shouldn't ask the charge nurse to talk with the physician unless the physician refuses to accept the nurse's professional opinion. Explaining surgery for the purpose of obtaining consent is beyond the nurse's scope of practice

When preparing a client for electroconvulsive therapy (ECT), the nurse should make sure that: a) the client has undergone a thorough medical evaluation. b) the client has been on nothing-by-mouth (NPO) status for no more than 2 hours before the procedure. c) the client is scheduled for a brain scan immediately after the procedure. d) the client sees family members immediately before the procedure.

the client has undergone a thorough medical evaluation. Explanation: Before an ECT treatment, the nurse should ensure that the client has had a medical evaluation that includes an electrocardiogram, a chest X-ray, neurologic and laboratory tests, an ... (more) Before an ECT treatment, the nurse should ensure that the client has had a medical evaluation that includes an electrocardiogram, a chest X-ray, neurologic and laboratory tests, and spinal X-rays, if indicated. Although making sure that the client sees family members immediately before the procedure would be appropriate, it's unnecessary (unless the client requests this). A brain scan isn't required after ECT because such a scan can't evaluate the therapeutic effects of this treatment. The client should be NPO for at least 8 hours before the treatment to decrease the risk of aspiration and vomiting