NCLEX 10000 Physiological Adaptation
A child with partial- and full-thickness burns is admitted to the pediatric unit. What should be the priority at this time? a) preventing wound infection b) managing the child's pain c) evaluating vital signs frequently d) maintaining fluid and electrolyte balance
maintaining fluid and electrolyte balance Correct Explanation: Although monitoring vital signs frequently is important, for the first few days the primary concern in burn care is fluid and electrolyte balance, with the goal being to replace fluid and electrolytes lost. With burns, fluid and electrolytes move from the interstitial spaces to the burn injury and are lost. These must be replaced. Once the child's fluid and electrolyte status has been addressed and fluid resuscitation has begun, preventing wound infection is a priority and efforts to control the child's pain can be initiated.
A nurse is providing care for a client who has a sacral pressure ulcer with a wet-to-damp dressing. Which guideline is appropriate for a wet-to-damp dressing? a) The wet-to-damp dressing should be tightly packed into the wound. b) A plastic sheet-type dressing should cover the wet dressing. c) The dressing should be allowed to dry out before removal. d) The dressing should keep the wound moist.
The dressing should keep the wound moist. Correct Explanation: A wet-to-damp saline dressing should always keep the wound moist.
When developing the teaching plan for the mother and a child with insulin-dependent diabetes about sick-day management, which of the following instructions should the nurse include? a) Adjust insulin based on more frequent testing of blood glucose levels. b) Adhere to the same schedule and type and amount of insulin. c) Immediately call the physician for information about what to do. d) Take the child to the emergency department for immediate care.
Adjust insulin based on more frequent testing of blood glucose levels. Correct Explanation: Sick-day management requires more frequent monitoring of the child's blood glucose to evaluate for changes associated with a decreased intake and absorption of food, commonly associated with illness. Based on the child's glucose levels, insulin adjustments may be needed.
A client reports recent onset of chest pain that occurs sporadically with exertion. The client also has fatigue and mild ankle swelling, which is most pronounced at the end of the day. The nurse suspects a cardiovascular disorder. What other client presentation increases the likelihood of a cardiovascular disorder? a) Lower substernal abdominal pain b) Urinary frequency c) Clubbing of fingers d) Irritability
Clubbing of fingers Explanation: Common signs and symptoms of cardiovascular dysfunction include shortness of breath, chest pain, palpitations, fainting, fatigue, and peripheral edema. Clubbing of fingers indicates chronic hypoxemia, possibly as a result of undiagnosed heart disease.
The nurse is caring for an infant diagnosed with a congenital heart disease. Which of the following concerns should be a priority for the nurse to address with the parents when discussing the child's condition? a) Kidney failure b) Nutritional concerns c) Body temperature regulation d) Congestive heart failure
Congestive heart failure Explanation: Parents of children with congenital heart disease need information about congestive heart failure because congestive heart failure is generally the first consequence seen in a child with congenital heart disease. In addition to often being the primary diagnosis, it can also remain an ongoing complication.
The cyanosis that accompanies bacterial pneumonia is primarily caused by which of the following? a) Inadequate peripheral circulation. b) Pleural effusion. c) Decreased oxygenation of the blood. d) Decreased cardiac output.
Decreased oxygenation of the blood. Correct Explanation: A client with pneumonia has less lung surface available for the diffusion of gases because of the inflammatory pulmonary response that creates lung exudate and results in reduced oxygenation of the blood. The client becomes cyanotic because blood is not adequately oxygenated in the lungs before it enters the peripheral circulation.
Which assessment finding is an early sign of heart failure in a toddler? a) Increased urine output b) Increased respiratory rate c) Decreased heart rate d) Decreased weight
Increased respiratory rate Correct Explanation: Increased respiratory and heart rates are the earliest signs of heart failure. Decreased urine output and increased weight are later signs.
A 21-month-old child admitted with the diagnosis of croup now has a respiratory rate of 48 breaths/minute, a heart rate of 120 bpm, and a temperature of 100.8° F (38.2 ° C) rectally. The nurse is having difficulty calming the child. What should the nurse do next? a) Administer acetaminophen. b) Notify the health care provider (HCP) immediately. c) Allow the toddler to continue to cry. d) Offer clear fluids every few minutes.
Notify the health care provider (HCP) immediately. Correct Explanation: The nurse may be having difficulty calming the child because the child is experiencing increasing respiratory distress. The normal respiratory rate for a 21-month-old is 25 to 30 breaths/minute. The child's respiratory rate is 48 breaths/minute. Therefore the HCP needs to be notified immediately.
A client who was diagnosed with type 1 diabetes 14 years ago is admitted to the medical-surgical unit with abdominal pain. On admission, the client's blood glucose level is 470 mg/dl (26.1 mmol/L). Which finding is most likely to accompany this blood glucose level? a) Cool, moist skin b) Rapid, thready pulse c) Arm and leg trembling d) Slow, shallow respirations
Rapid, thready pulse Correct Explanation: This client's abnormally high blood glucose level indicates hyperglycemia, which typically causes polyuria, polyphagia, and polydipsia. Because polyuria leads to fluid loss, the nurse should expect to assess signs of deficient fluid volume, such as a rapid, thready pulse; decreased blood pressure; and rapid respirations.
At 3 a.m., the mother of a 3-year-old child calls the emergency department nurse and reports the child has a temperature of 101° F (38.4° C), a runny nose, and a barky cough that "gets going and won't stop." The mother states that she just gave the child acetaminophen. Which of the following should the nurse recommend next? a) Giving the child an over-the-counter decongestant. b) Running a steam vaporizer near the child's bedside. c) Sitting with the child in a steamy, warm bathroom. d) Administering aspirin in 2 hours.
Sitting with the child in a steamy, warm bathroom. Correct Explanation: Based on the mother's description, the child most likely is exhibiting signs and symptoms of laryngotracheal bronchitis. The mother should try to decrease the inflammation in the upper airway by exposing her child to a warm, steamy environment. The safest method is to steam up the bathroom and stay with the child.
The nurse evaluates the effectiveness of the client's postoperative plan of care. Which outcome is expected for a client with an ileal conduit? a) The client demonstrates how to catheterize the stoma. b) The client will empty the drainage pouch frequently throughout the day. c) The client will place an aspirin in the drainage pouch to help control odor. d) The client verbalizes the understanding that physical activity must be curtailed.
The client will empty the drainage pouch frequently throughout the day. Correct Explanation: It is important that the client empty the drainage pouch throughout the day to decrease the risk of leakage.
To prevent external rotation of the client's hips while lying on the back, it would be best for the nurse to place: a) A footboard that supports the feet in the normal anatomic position. b) Sandbags alongside the legs from knees to ankles. c) Firm pillows under the length of the legs. d) Trochanter rolls alongside the legs from ilium to midthigh.
Trochanter rolls alongside the legs from ilium to midthigh. Correct Explanation: Trochanter rolls placed alongside the client's legs from the ilium to midthigh are recommended to prevent external rotation of the hips
A client, diagnosed with acute pancreatitis 5 days ago, is experiencing respiratory distress. Which finding should the nurse report to the health care provider (HCP)? a) arterial oxygen level of 46 mm Hg (6.1 kPa) b) respirations of 12 breaths/min c) oxygen saturation of 96% on room air d) lack of adventitious lung sounds
arterial oxygen level of 46 mm Hg (6.1 kPa) Correct Explanation: Manifestations of adult respiratory distress syndrome (ARDS) secondary to acute pancreatitis include respiratory distress, tachypnea, dyspnea, fever, dry cough, fine crackles heard throughout lung fields, possible confusion and agitation, and hypoxemia with arterial oxygen level below 50 mm Hg. The nurse should report the arterial oxygen level of 46 mm Hg (6.1 kPa) to the HCP.
The nurse is assessing a client with anemia. In order to plan nursing care, the nurse should focus the assessment on which sign or symptom? a) nausea b) decreased salivation c) cold intolerance d) bradycardia
cold intolerance Explanation: Cold intolerance may be associated with anemia because of the diminished oxygen supply to the peripheral circulation. Decreased salivation is not associated with anemia. Tachycardia may be expected in severe anemia.
The nurse is assessing a child with suspected juvenile hypothyroidism. Which signs or symptoms should the nurse expect this child to manifest? a) weight loss and flushed skin b) short attention span and weight loss c) rapid pulse and heat intolerance d) dry skin and constipation
dry skin and constipation Correct Explanation: Clinical manifestations of juvenile hypothyroidism include dry skin, constipation, sparse hair, and sleepiness.
A client with multiple sclerosis (MS) is experiencing bowel incontinence and is starting a bowel retraining program. Which strategy is not appropriate? a) eating a diet high in fiber b) setting a regular time for elimination c) using an elevated toilet seat d) limiting fluid intake to 1,000 mL/day
limiting fluid intake to 1,000 mL/day Correct Explanation: Limiting fluid intake is likely to aggravate rather than relieve symptoms when a bowel retraining program is being implemented. Furthermore, water imbalance, as well as electrolyte imbalance, tends to aggravate the signs and symptoms of MS.
Postoperative nursing care for a client after an appendectomy should include: a) noting the first bowel movement after surgery. b) administering sitz baths 4 times a day. c) measuring abdominal girth every 2 hours. d) limiting the client's activity to bathroom privileges.
noting the first bowel movement after surgery. Correct Explanation: Noting the client's first bowel movement after surgery is important because this indicates that normal peristalsis has returned.
When positioning a neonate with an unrepaired myelomeningocele, which position is most appropriate? a) supine with the hips at 90-degree flexion b) supine in semi-Fowler's position with chest and abdomen elevated c) right side-lying position with the knees flexed d) prone with hips in abduction
prone with hips in abduction Correct Explanation: Before surgery, the infant is kept flat in the prone position to decrease tension on the sac. This allows for optimal positioning of the hips, knees, and feet because orthopedic problems are common.
A client with a longstanding diagnosis of generalized anxiety disorder presents to the emergency room. The triage nurse notes upon assessment that the patient is hyperventilating. The triage nurse is aware that hyperventilation is the most common cause of: a) acute CNS disturbances b) metabolic acidosis c) increased PaCO2 d) respiratory alkalosis
respiratory alkalosis Correct Explanation: The most common cause of acute respiratory alkalosis is hyperventilation.
A 32-year-old multigravida returns to the clinic for a routine prenatal visit at 36 weeks' gestation. The assessments during this visit include: blood pressure 140/90 mm Hg; pulse 80 beats/min; respiratory rate 16 breaths/min. What further information should the nurse obtain to determine if this client is becoming preeclamptic? a) proteinuria b) blood glucose level c) headaches d) peripheral edema
proteinuria Explanation: The two major defining characteristics of preeclampsia are blood pressure elevation of 140/90 mm Hg or greater and proteinuria. Because the client's blood pressure meets the gestational hypertension criteria, the next nursing responsibility is to determine if she has protein in her urine. If she does not, then she may be having transient hypertension.
