NCLEX prep

The nurse is reviewing discharge instructions on home management for a client with peripheral arterial disease. Which statements indicate a correct understanding of the instructions? Select all that apply. 1. I will apply moisturizing lotion on my legs every day 2. I will elevate my legs at night when I am sleeping 3. I will keep my legs below heart level when sitting 4. I will start walking outside with my neighbor 5. I will use a heating pad to promote circulation

1, 3, and 4 Home management instruction for PAD include: -lower extremities below the heart when sitting and lying down - improves arterial blood flow -engage in moder exercise -perform daily skin care, including application of lotion -maintian mild warmth - improves blood flow and circulation -stop smoking - prevents vessel spasm and constriction -avoid tight clothing and stress -take prescribed medication (vasodilators / anti platelets) option 2: elevating the legs promotes venous return, but does not promote arterial circulation option 5: heating pads should not be used in clients with altered perfusion or sensation due to the increased risk of burns

What are the 6 Ps of compartment syndrome?

1. Pain: increasing despite elevation, analgesics and ice 2. Pressure: affected extremity or digits are firm and tense; skin is tight appears shiny 3. Paresthesia: Tingingling, numbness or burning sensation 4. Pallor: skin appears pale; capillary refit is >3 seconds 5. Pulselessness: pulse distal to injury or compartment is impalpable 6. Paralysis: loss of function or inability to move extremity or digits

steps of donning on PPE

1. hand hygiene 2. gown 3. mask / respirator 4. goggles or face shielf 5. gloves

The nurse is caring for a client with cirrhosis of the liver. Which blood test values would the nurse typically anticipate to be elevated hen reviewing the client's morning laboratory results? Select all that apply 1. Albumin 2. Ammonia 3. Bilirubin 4. Prothombin time 5. Sodium

2, 3, &4 Elevated bilirubin results from functional derangement of liver cells and compression of bile ducts by nodules. The liver has a decreased ability to conjugate and excrete bilirubin Most coagulation factors are produced in the liver. A cirrhotic liver cannot produce the factors essential for blood clotting. Ammonia from intestinal deamination of amino acids normally goes to the liver and is converted to urea and excreted by the kidney. option 1 and 5: albumin holds water inside the blood vessels. In cirrhosis, the liver is unable to synthesize albumin. This is the primary reason that fluid leaks out of a vascular spaces into interstitial spaces (edema, ascites). The kidneys perceive this as low perfusion and try to reabsorb both sodium and water. The large amount of water int he body results in a dilution effect (low sodium)

The nurse planning teaching for the parents of a child newly diagnosed with hemophilia will include information about which long-term complication? 1. Heart valve injury 2. Intellectual disability 3. Joint destruction 4. Recurrent pneumonia

3 When injured, clients with hemophilia should be monitored closely for external as well as internal bleeding. The most frequent sites of bleeding are the joints, especially the knee. Hemarthrosis (bleeding into the joints) can occur with minimal or no trauma - causing chronic swelling and deformity to occur over time

The nurse is assessing an 8-month-old client during a well-child visit. Which assessment finding should the nurse report to the health care provider? 1. Infant responds to their name when called but has not spoken any words 2. Infant gaming 5 oz per week at age 6 months and is now gaining 3 oz per week 3. Infant's head stays behind the shoulders when raised from a supine to a sitting position 4. Infant's posterior fontanel is not palpable when performing assessment of the head

3 After age 6 months, infants should not exhibit head lag when raised from a supine to a seated position. An infant may not speak first words with meaning until approximately age 9-11 months. Infant weight gain decreases after age 6 months (from 5-7 oz to 3-5 oz per week). The posterior fontanel normally closes by age 2 months

The nurse is caring for a client who reports severe abdominal pain and vaginal spotting. The client had positive urine pregnancy test at home, and her last menstrual period was 8 weeks ago. Which client report tot he nurse is most concerning? 1. Abdominal pain rated as 8 out of 10 2. History of pelvic inflammatory disease 3. Intermittenet nausea and vomiting for the past 7 days 4. Right shoulder pain and dizziness

4 symptoms of ectopic pregnancy may include lower abdominal and pelvic pain; amenorrhea; possibly followed by vaginal spotting or bleeding; and a palpable adnexal mass on pelvic examination. -symptoms indicative of a ruptured ectopic pregnancy include: -hypotension -tachycardia -dizziness -referred shoulder pain

droplet precaution diseases

pertussis, influenza virus, adenovirus, rhinovirus, meningititis, group A streptococcus (for first 24 hours of antimicrobial therapy)

The emergency department triage nurse is assessing 4 pediatric clients. Which client is a priority for further diagnostic workup and definitive care? 1. 1-year-old with ventirculoperitoneal shunt who has "lethargy" and pulse of 78/min 2. 3-year-old with history of meningocele who has unilateral ear pain and urinary incontiennce 3. 6- year-old with muscular dystrophy who has "flu-like symptoms and temp of 100.4 4. 8-year-old with history of cerebral palsy who has foot injury and spastic clonus

-A ventriculoperitoneal shunt is used to treat hydrocephalus and is usually placed at age 3-4 months. Blockage results in signs of increased ICP. The normal pulse range for a 1 year old is 100-160/min. A pulse of 78/min is considered bradycardia, a part of Cushing's triad (bradycardia, slowed respiration, widened pulse pressure) (pulse pressure greater than 40 is unhealthy) -muscular dystrophy is an inherited condition of muscle fiber degeneration and muscle wasting - respiratory and cardiac problems are the leading causes of mortality -clonus is a series of involuntary, rhythmic, muscular contractions and relaxations. Spasticity / clonus is an expected finding in a client with cerebral palsy

A nurse is caring for a child with acute glomerulonephritis. Frequent monitoring of which of the following is a priority? 1. Blood pressure 2. Hematuria 3. Intake and output 4. Peripheral edema

1 AGN is an immune complex disease most commonly induced by a prior A beta-hemolytic streptococcal infection of the skin or throat. A latent period of 2-3 weeks occurs between the streptococcal infection and the symptoms of AGN. Clinical manifestations include perioribital and facial/generalized edema, hypertension, and oliguria which are due to fluid retention (decreased by kidney filtration). The urine is tea-colored and cloudy due to the presence of protein and blood. Although most clients recover spontaneously within days, severe hypertension is an anticipated complication that must be identified early. Monitoring of BP is important as they prevent further progression of kidney injury and development of hypertensive encephalopathy or pulmonary edema. -hematuria is common with AGN -the most important measure of fluid status isa daily weight and it identifies fluid retention and response to treatment

Which clinical finding would the nurse anticipate in a client with chronic venous insufficiency? 1. Brownish, hardened skin on lower extremities 2. Diminished peripheral pulses 3. Nonhealing ulcer on lateral surface of great toe 4. Shiny, hairless lower extremities

1 Brownish skin discoloration; chronic edema and inflammation cause the tissue to harden and appear leathery. Affected skin is high prone to breakdown and ulcerations (venous leg ulcers) commonly on the inside of the ankle option 2, 3, and 4: diminished pulses, non healing ulcers on a toe, and shiny hairless extremities are usually associated with peripheral arterial disease due to hardening the arterial walls, which constricts blood flow and impairs transportation of nutrients to tissues.

A registered nurse is precasting a new graduate nurse on the orthopedic unit. Which action by the graduate nurse require the registered nurse to intervene? 1. elevating a client's residual limb on a pillow 1 day after above-the-knee amputation 2. Placing an abductor pillow between a client's legs after total hip replacement 3. positioning a client with buck traction supine with the foot of the bed raised 4. using pillows to raise a client's extremity following cast replacement

1 Care of the client with above-the-knee amputation includes placement in prone position for 30 minutes 3 or 4 times a day and using a figure eight compression bandage to decrease edema. The client's residual limb should not be elevated as this will promote flexion contractures option 2: following a total hip replacement, hip dislocation is prevented by using an abductor pillow to maintain the hip in a straight and neutral position. The nurse should also teach the client not to bed at the hip more than 90 degrees or cross the legs or ankles. option 3: buck traction immobilizes hip and femur fractures option 4: after a new cast is placed, the nurse should elevate the client's limb above the heart for the first 48 hours to increase venous return and decrease edema in the affected extremity. However, the extremity should not be elevated if compartment syndrome develops

A student nurse assesses and obtains a urine specimen from a client with MRSA who is on contact precautions. The registered nurse intervenes when the student performs which action? 1. Cleans the disposable stethoscope with chlorhexidine solution before reuse with a different client 2. Removes the urine specimen cup from the room in a sealed biohazard bag 3. Scrubs the foley catheter collection port with alcohol for 15 seconds before withdrawing a urine specimen 4. Uses an alcohol-based hand antiseptic solutions after removing gloves

1 Disposable or single-client-use equipment must not be shared between clients or transferred to other care areas. Dedicated equipment should be kept in the room for client care, and then disinfected or discarded when no longer needed Option 3: to prevent specimen contamination and the introduction of bacteria into the client's urinary tract, the nurse should curb the foley collection port with alcohol or chlorhexidine for 15 seconds before withdrawing a specimen option4: hand hygiene with an alcohol-based hand rub is recommended, unless there is visible spoiling of the hands with body fluids, or after contact with C. diff. In both situations, hand hygiene must be performed with soap and water.

The nurse is assessing a 4-day-old, term neonate who is breastfed exclusively. Which assessment finding should the nurse report to the health care provider for further assessment regarding possible formula supplementation? 1. 10% weight loss since birth 2. Cracked, peeling skin 3. Feeds every 2-3 hours 4. Runny, seedy, yellow stools

1 During the first 3-4 days of life, a weight loss of approximately 5-6% of birth weight is expected due to fluid excretion. Weight loss usually ceases around 5 days who return to their birth weight by 7-14 days of life. A weight loss of >7% of birth weight warrants further evaluation. option 2: peeling of the term newborn's skin is a sign of physical maturity and is expected around the third day of life. Cracked peeling skin may be present at birth in post-term newborns option 4: after passing meconium, newborns produce transitional stools that are thin and yellow/brown or yellow/green. Stools of breastfed newborns progress to a seedy, yellow paste. Bottle-fed newborns have firmer light brown stools

The nurse has assessed 4 children. Which finding requires immediate follow-up with the health care provider? 1. Child who had a surgical repair of hypospadias earlier today with no urinary output in the past two hours 2. Child who is awaiting a neurological consult for suspected absence seizures and is sleeping soundly 3. Child who returned from a bronchoscopy an hour ago and coughed up a scant amount of blood-tinged sputum 4. Child with gastroenteritis, serum sodium of 131 mEq/L and temp of 100 F

1 Hypospadias is a congenital defect in which the urethral opening is on the underside of the penis. Postoperatively, the client will have a catheter or stent to maintain latency while the new meatus heals. Urinary output is an important indication of urethral patency. Absence of urinary output for over an hour indicates that kink or obstruction may have occurred and requires immediate follow up -small amounts of blood-tinged sputum are normal after bronchoscopy; however, frank bleeding or clots should be reported

The nurse assesses a child with intussusception. Which assessment findings require priority intervention? 1. Abdominal rigidity with guarding 2. Absence of tears in crying child with IV start 3. Blood-streaked mucous stool in diaper 4. Sausage-shaped right sided mass on palpation

1 Intussusception occurs when part of the intestine telescopes into another adjacent part and causes a blockage. Can lead to peritonitis which can lead to sepsis. Peritonitis is characterized by fever, abdominal rigidity, guarding and rebound tenderness. -a classic sigh on intussusception is blood-streaked mucous stool, sometimes referred to as current jelly-like stool -a savaged shaped right sided mass is commonly felt on palpation.

A mother reports to the pediatric nurse that her 3-year-old child coughs at night and at times until he vomits. The symptoms have not improved over the past 2 months despite multiple over-the-counter cough medications. What should nurse explore related to a possible etiology? 1. aSK ABOUT EXPOSURE to triggers such as pet dander 2. Assess for the presence of a butterfly rash 3. History of intolerance to wheat food products 4. Palpate for an abdominal mass from pyloric stenosis

1 Option 2: a red or pink butterfly rash across the cheeks and bridge of the nose is classes for systemic lupus erythematosus (SLE), an autoimmune disease that affects connective tissue. The child has no symptoms of SLE. Manifestations are acute (nephritis, arthritis, vasculitis) or involve a gradual onset of nonspecific symptoms Option 4: pyloric stenosis is a hypertrophy of the pylorus that results in stenosis of the passage between the stomach and the duodenum. It starts with occasional vomiting that eventually becomes forceful/projectile vomiting as the obstruction becomes complete.

The nurse caring for multiple clients who underwent renal system diagnostic testing should report which post-procedure finding to the health care provider? 1. 150 mL residual urine on bladder scan 2. Burning sensation when voiding after cystoscopy 3. Increased urinary output after arteriogram 4. Less than 10,000 organisms/mL on urine culture

1 Portable ultrasonic bladder scanners are used at the bedside to determine the amount of residual urine in the bladder. Amounts >100 mL should be reported as the client may be experiencing urinary retention option 2: a cystoscope is inserted through the urethra to directly visualize the bladder wall and urethra. Irritation of the urethral and bladder lining from the insertion and manipulation of the cystoscope may cause a slight during sensation with voiding for a day or two. Option 3: renal arteriogram is a radiologic test performed to visualized renal blood vessels to detect abnormalities (renal artery stenosis or aneurysm). A contrast medium is injected into the femoral artery; therefore, the client should be taught to increase fluid intake after the procedure to flush the dye from the body. Increased output is an expected finding option 4: less than 10,000 organisms is a normal value for urine culture

A nurse is admitting a client at 42 weeks gestation to the labor and delivery unit for induction of labor. What is a predictor of a successful induction? 1. Bishop score of 10 2. Firm and posterior cervix 3. History of precipitous labor 4. Reactive non stress test

1 The bishop score is a system for the assessment and rating of cervical favorability and readiness for induction of labor. The cervix is sacred on consistency, position, dilation, effacement, and station of the fetal presenting part. A higher bishop score indicates an increased likelihood of successful induction that results in vaginal birth. option 2: a cervix that is from and posterior is associated with a low Bishop score, which reflects a low likelihood of successful labor induction. option 3: a history of precipitous labor (<3 hours from onset of contractions to birth) may indicate that the client will again experience precipitous labor once labor is established. It is not an independent predictor of successful induction option 4: a reactive non stress test indicates that the fetus is well oxygenated and established fetal well-being. It does not provide information about the likely success or failure of labor induction.

A child is brought to the school nurse after having permanent tooth knocked out during gym class. Which action by the nurse is appropriate? 1. Gently rinse the tooth with sterile saline and reinsert it into the gingival cavity 2. Gently scrub the root of the tooth to remove any debris and wrap it in sterile gauze 3. place the tooth int after and transport the client to the nearest emergency department 4. wrap the tooth in sterile gauze and advise the parent to arrange for a dental appointment

1 dental avulsion (tooth separated from the mouth) of a permanent tooth is a dental emergency. The nurse should rinse and reinsert the tooth into the gingival socket and hold it in place until stabilized by a dentist. Reimplantation within 15 minute of injury re-established blood supply, increasing the probability of tooth survival if the tooth cannot be reinserted it should be kept moist by submerging it in commercially prepared solution (balanced salt solution, cold milk, sterile saline or as a last resort bacteria.

The nurse is changing the dressing, injection caps, and IV tubing of a client who is receiving total parenteral nutrition through a right peripherally inserted central venous catheter. The nurse should implement what actions to prevent complications during this procedure? Select all that apply 1. Instruct the client to hold the breath when changing the injection caps and tubing 2. Instruct the client to keep the head to the right side during the dressing change 3. Perform hand hygiene before and after the procedure 4. Place the client in the Trendelenburg position before the procedure 5. Wear sterile gloves and a surgical mask when changing the dressing

1, 2, & 5 During injection cap and tubing changes, the client is instructed to hold the breath (or perform the valsava maneuver) to prevent air from entering the line, traveling to the heart, and forming an air embolism option 2: when performing the dressing change, the client should be instructed to turn the head away from the PICC site to prevent potential contamination of the insertion site option 4: During dressing change, the client is places in the supine position. if an air embolism is suspected, the client should be placed in the trendelenburg position (head down) on the left side, causing any existing air to rise and become trapped in the right atrium.

The nurse plans care for a pediatric client who has just undergone a cleft palate repair. Which of the following interventions should the nurse include in the plan of care? Select all that apply. 1. Assist and encourage caregivers to hold and comfort the child 2. Offer a pacifier in between feedings to promote the child's comfort 3. Position the child supine with an elevated head of bed after feedigns 4. Remove elbow restraints per policy for skin and circulatory assessment 5. Use tongue blade and penlight to assess surgical site every 4 hours

1, 3, & 4 Patients with cleft palate typically undergo surgical repair between age 6-24 months. Postoeprative nursing interventions include: -implementing pain management (encouraging caregiver soothing) measurements -position the child in an upright, supine position especially after feedings to prevent airway compromise -utilizing elbow restraints to prevent the child from disrupting the surgical site and monitor skin by removing elbow restraints hard objects (utensils, tongue depressors, pacifiers, straws) should not be placed into the mouth as they may damage the surgical site

The nurse is monitoring a neonate 1 hour after spontaneous vaginal delivery. Which of the following are expected findings/ Select all hat apply 1. Capillary glucose of 60 2. Holosytolic murmur auscultated at fourth intercostal space 3. Respirations of 56 breaths per minute 4. Single transverse crease across palm of the hand 5. White papules on bridge of the nose

1, 3, and 5 Expected findings for a neonate at 1-3 hours postpartum include respirations between 30-60 breaths per minute, milia, and glucose levels <70-100 but >40. Option 2: a holosytolic murmur at the left lower sternal border is a classic sign of a ventricular septal defect Option 4: A single transverse crease extending across the palm of the hand is a classic sign of Down syndrome. Other signs include small and low-set ears, flat nose bridge, protruding tongue, and hypotonia

One unit of packed RBCs is prescribed for a client experiencing complications of sickle cell anemia. Which of the following actions by the nurse are appropriate? Select all that apply Blood type: AB negative 1. administer type A-negative blood 2. Delegates all vital sign measurements to the unlicensed assistive personnel 3. transfuses PRBCs over 6 hours 4. Uses filtered Y-type tubing with 0.9% sodium chloride 5. Verifies client identifiers and blood products with another nurse before administration

1, 4, &5 Clients with AB blood can receive A, B, AB or O blood (universal recipient). While Rh-negative recipients can only receive Rh-negative blood, Rh-positive clients can safely receive Rh-positive and Rh-negative blood. -using Y-type blood administration tubing that has a micron filter to remove clots. Blood products should be administered with 0.9 sodium chloride. -blood products should be administered within 4 hours to reduce the risk of bacterial contamination

The nurse receives 4 prescriptions for a child diagnosed with hemophilia A who was brought to the emergency department following an injury on the school playground. The child has vomited once and has a headache. Which prescription should the nurse carry out first? 1. Administer IV factor VIII 2. Administer IV ondansetron 3. Blood draw for hemoglobin 4. CT scan of the head

1. Hemophilia is a bleeding disorder caused by a deficiency in coagulation proteins. Treatment consists of replacing the missing clotting factor and teaching the patient about injury prevention. An intracranial bleed is lethal if unchecked, so administration of factor VIII to a client with hemophilia A is the first order of action, followed by a CT scan -Ondansetron (Zofran) is used to treat nausea / vomiting

The nurse is gathering data on a 5-week old admitted with a suspected diagnosis of pyloric stenosis. The nurse should expect to find which laboratory value? 1. Blood pH of 7.1 2. Hematocrit of 57% 3. Potassium of 5.2 4. White blood cells of 28,500

2 In pyloric stenosis, a hypertrophied pyloric muscle causes postprandial projectile vomiting secondary to an obstruction at the gastric outlet. Emesis is nonbilious and leads to progressive dehydration. Hematocrit of 57% is elevated and indicative of hemoconcentration caused by dehydration. Elevated blood urea nitrogen is also a sign of dehydration. option 1: the stomach contains acid, which becomes depleted with excess vomiting leading to metabolic alkalosis (ph>7.45) Option 3: Vomiting or prolonged NG suctioning would cause hypokalemia, not hyperkalemia

The nurse is providing teaching for parents of a child diagnosed with fifth disease. Which statement by a parent indicate a need for further teaching? 1. Our child should be feeling much better in 7-10 days. 2. Our child's condition is communicable until the rash disappears. 3. We will ensure our child covers the mouth nd nose when coughing or sneezing 4. We will give our child ibuprofen to treat the joint pain.

2 Fifth disease (slapped face or erythema infectiosum) is a viral illness that affects mainly school-age children. The virus spreads via respiratory secretions, and the period of communicability occurs before onset of symptoms. The child will have a distinctive red rash on the cheeks and the rash spreads to the extremities a maculopaular rash develops, which then progresses form the proximal to distal surfaces. The child may have general malaise and joint pain that are typically well controlled with NSAIDS. Once these children develop symptoms, they are no longer infectious. Isolation is not required

The nurse is performing an initial assessment on a client in hypertensive crisis/ What is the nurse's priority assessment? BP: 210/120 HR: 109/min respirations: 20/min O2: 96 1. Heart sounds 2. LOC 3. lung sounds 4. visual fields and acuity

2 Hypertensive crisis is a life-threatening medical emergency characterized by severely elevated blood pressure (>180 systolic or > 120 diastolic) The client may have symptoms of hypertensive encephalopathy, including severe headache, confusion, nausea/vomiting, and seizure Hypertensive crisis poses a high risk for end-organ damage (hemorrhagic stroke, kidney injury, heart failure, papilledema The nurse should prioritize neurological assessment (LOC/CRANIAL NERVES) as decreased LOC may indicate onset of hemorrhagic stroke, which requires immediate surgical intervention Treatment for hypertensive crisis typically includes IV nitrates or antihypertensives (nitroprusside, labetalol, nicardipine) and continuous monitoring (blood pressure, telemetry, urine output) in a critical care setting option 1 and 3: assessing heart and lung sounds allows the nurse to identify nd monitor for other complications of hypertensive crisis. However, the client's vital signs do not indicate respiratory distress; therefore, neurological assessment is the priority because a change in LOC may indicate a life-threatening hemorrhagic stroke

A parent brings a 6-month old child to the primary health care provider after the child abruptly starting crying and grabbing intermittently at the abdomen. The client's stool has a red, currant jelly appearance. What intervention does the nurse anticipate? 1. Administer epoiten alfa (erythropoietin) 2. Give air (pneumatic) enema 3. Have the parent give 2 ounces of extra juice a day for constipation 4. Perform hemoccult test on stool

2 Intussusception is when one part of the intestine prolapses and then telescopes into another part. A conrast enema is used for diagnostic purposed and is often treated with an air enema human recombinant erythropoietin stimulates bone marrow to form red blood cells and is used to combat the effects of chemotherapy and/or kidney disease (as erythropoietin is secreted by the kidneys) -constipation during infancy usually can be corrected by increasing fluids or adding 2 oz of pear or applee nice to daily diet. This pt. has no evidence of constipation - a hemoccult test is performed when occult (hidden) blood is suspected due to a dark and tarry stool

The nurse is assessing a 4-week-old infant during a routine office visit. Which assessment is most likely to alert the nurse to the presence of right hip developmental dysplasia? 1. Decreased right hip adduction 2. Presence of extra gluteal folds on right side 3. Right leg longer than the left leg 4. Right pelvic tilt with lordosis

2 Manifestations in infants age <2-3 months include the presence of extra inguinal or thigh folds and laxity of the hip join on the affected side. -after age 3 months, limited hip abduction and limb shortening on the affected side are evident. A pelvic tilt ((a positive Trendelenburg sign) is noted once the child learns to walk)

A newborn has a large myelomeningocele. What nursing intervention is priority? 1. Assess the anus for muscle tone 2. Cover the area with a sterile, moist dressing 3. Measure the occipital frontal circumference 4. Place the newborn supine with the head of the bed elevated

2 Myelomeningocele occurs when the neural tube fails too use properly during fetal development. An outputting of spinal fluid, spinal cord, and nerves covered by only a thin membrane occurs, typically in the lumbar area. A priority nursing intervention is to cover the area with a sterile moist dressing -assessing for an anal wink will assist in the assessment of the level of neurologic deficit but is not a priority intervention -myelomeningocele may decrease the absorption of cerebrospinal fluid which would place the newborn at risk for hydrocephalus from the excess of cerebrospinal fluid. An occipital frontal circumference is needed as a baseline measurement but is not a priority -the newborn would be placed in the prone position with face turned to the side

The nurse is caring for a 7-year-old client diagnosed with nephrotic syndrome who will be discharged soon. Which statement by the parent indicates the need for further teaching? 1. I'll provide a healthy diety without added salt for my child 2. I'll organized playdates to keep my child's spirits up during relapses 3. I'll restrict my child's fluids if I notice swelling or rapid weight gain 4. I'll test for protein in my child's urine every day

2 Patients with nephrotic syndrome experience generalized edema, weight gain, loss of appetite, and decreased urine output. The loss of immunoglobulins causes increased susceptibility to infection. Caregivers should minimize the risk of infection during relapses. -treatment includes: corticosteroids and other immunosuppressants, loss of appetite management, infection preventions

The charge nurse is notified that a client is being admitted with a diagnosis of active shingles with a disseminated rash. Which room assignment is most appropriate for this client? 1. A private room with contact and droplet precautions 2. A private room with negative airflow and contact and airborne precautions 3. private room with positive airflow and airborne precautions 4. A semi-private 2-bed room with standard precautions

2 Shingles lesions that are open may transmit the infection by both air and contact. The client with disseminated shingles that are not crusted over will require contact precautions, airborne precautions, and a negative airflow room to prevent transmission of the infection to others in the hospital. -localized shingles require only standard precautions for clients with intact immune systems and contained/covered lesions option 3: positive airflow would pull fresh air from outside into the hospital room, and then the air from the room would circulate throughout the rest of the hospital. It is not appropriate for this type of infection. Instead, positive airflow would be used for protective isolation in a client who is immunocompromised. option 4: a semi-private room is not appropriate for this client with a communicable illness. Standard precautions are used for localized shingles in clients with intact immune systems and contained/covered lesions

The clinic nurse supervises a student nurse who is preparing to administer routine vaccinations to a child diagnosed with hemophilia. Which instructions should the clinic nurse provide tot he student? Select all that apply 1.Administer ibuprofen for pain relief 2. Administer vaccines via the subcutaneous route 3. Apply a warm compress to the injection stie 4. Hold firm pressure on the site for 5 minutes 5. Massage the injection site to disperse the medication

2 & 4 Vaccinations for those with hemophilia are administered subcutaneously whenever possible to prevent intramuscular hematoma. The smallest gauge needle is used, and firm, continue pressure is applied at this site for 5 minutes. -children with hemophilia should avoid aspirin and NSAIDS due to the risk of bleeding. Acetaminophen is recommended for pain relief

The nurse is assessing an infant with intussusception. Which of the following clinical findings should the nurse expect? Select all that apply 1. Palpable olive-shaped mass in epigastrium 2. Palpable sausage-shaped abdominal mass 3. Projectile vomiting without visualized blood 4. Screaming and drawing of the knees up to the chest 5. Stool mixed with blood and mucous

2, 4, & 5 Classical clinical manifestations of intussusception include episodes of sudden, crampy abdominal pain, a palpable sausage-shaped abdominal mass, and red currant jelly. Other symptoms include inconsolable caring with the knees drawn up to the chest and vomiting. The child may appear normal and calm between painful episodes. -a palpable epigastric, olive-shaped mass and non bloody projectile vomiting are clinical manifestations often seen with pyloric stenosis.

The nurse is providing postoperative care for a newborn with Hirschsprung disease who underwent bowel resection with a temporary colostomy. Which of the following assessment findings are to be expected during the immediate postoperative period? Select all that apply 1. Flattening of the stoma along the abdominal wall 2. Moderate blood-tinged mucus in the colostomy bag 3. Pink and moist stoma with gray tinged edges 4. Small amounts of blood on the stoma during bag changes 5. Surrounding skin is tender to palpation

2, 4, & 5 During the immediate postoperative period, the nurse should recognize the following as expected assessment findings: -beefy red and slightly edematous stoma; a pink and moist stoma is normal thereafter because it indicates adequate intestinal blood flow -blood-tinged mucus coming from the stoma due to irritation of the intestinal mucosa during surgery -a small amount of blood when handling the stoma during bag changes -intact skin surround the stoma, without signs of breakdown or excoriation; the skin may be tender immediately after surgery due to manipulation option 1: a stoma should protrude approximately 3/4 inch from the abdominal wall - a flattened or sunken stoma indicates prolapse and should be reported immediately option 3: paleness or graying of the stoma indicates decreased blood supply

A nurse is caring for a 2 year old child diagnosed with nephrotic syndrome who is in diapers and had red edematous genitals. Which collection technique is appropriate for the nurse to obtain daily urien specimens for proteinuria testing with a urine dipstick? 1. Apply adhesive urine collection bag around the genital area and wait for the child to void 2. Intermittently catheterize the child every morning to a void contaminating the speciment 3. Place cotton balls in a dry diaper; when wet, squeeze urine onto dipstick 4. Place urine dipstick in the child's diaper overnight and check result in the morning

3 Daily dipstick urinalysis determines the presence and pattern of urine protein loss to monitor for exacerbations. To collect a non sterile urine specimen from a child who is not toilet trained, the nurse can place several cotton balls in a dry diaper and later squeeze urine onto a dipstick.

The nurse is caring for an infant diagnosed with Hirschsprung disease who is awaiting surgery. Which assessment finding requires the nurse's immediate action? 1. Abdominal dissension with no change in girth for 8 hours 2. Did not pass meconium or stool within 48 hours after birth 3. Episode of foul-smelling diarrhea and fever 4. Excessive crying and greenish vomiting

3 Hirschsprung disease occurs when a child is born with some sections of the distal large intestine missing nerve cells, rendering the internal anal sphincter unable to relax. As a result, there is no peristalsis and stool is not passed. These newborns exhibit symptoms of distal intestinal obstruction. -they have distended abdomen and will not pass meconium within the expected 24-48 hours -they also have difficulty feeding and often vomit green bile -surgical removal of the defective section of bowel is necessary and colostomy may be required -a potentially fatal complication is hIRSCHSPRUNG enterocolitis, an inflammation of the colon, which can lead to sepsis and death. Enterocolitis will present with: -fever -lethargy -explosive foul-smelling diarrhea -rapidly worsening abdominal dissension

The clinic nurse is caring for several clients during well-child visits. The nurse should recognize which client as being the most at risk for anemia? 1. 1-month-old infant born at term gestation who exclusively breastfeeds 2. 2-month-old infant born at preterm gestation who exclusively receives iron-fortified formula 3. 3-month-old infant born at preterm gestation who is exclusively bottle-fed with breastmilk 4. 6-month-old infant born at term gestation who breastfeeds and eats iron-fortified infant cereal

3 Infants born at preterm gestation have less time in utero to accumulate iron. Preterm infants typically depelee iron stores by age 2-3 months and require additional iron supplementation option 1 and 4: infants born at term gestation have sufficient iron stores for the first 4-6 months of life. However, infants receiving exclusively breastmilk require iron supplementation around age 4 months until food sources of iron are adequate around age 6 months

The nurse is performing assessments of several clients during routine prenatal visits. Which client should the nurse discuss with the health care provider first? 1. Client at 30 weeks gestation with darkened patches of skin on the face 2. Client at 32 weeks gestations with painless, flesh-colored bumps on the perianal area 3. Client at 34 weeks gestation with intense itching on the hands and feet that worsens at night but no rash 4. Client at 38 weeks gestation with stretch marks on the abdomen that have become reddened and pruritic

3 Intrahepatic cholestasis of pregnancy is a liver disorder exclusive to pregnancy that manifests with intense, generalized itching but no rash. Itching usually worsens at night. This condition increases the risk of intrauterine fetal demise Management: -patients receive ursodeoxycholic acid -laboratory testing (elevated bile acids) -fetal surveillance (non stress test) -labor induction option 1: chloasma is a hormonally stimulated increase in pigmentation over the bridge of the nose that usually appears in the second trimester. It fades postpartum Option 2: fleshy, contender bumps on the genital/anal areas are characteristic of condylomata acuminate (anogenital warts) caused by human paillomavirus. Treatments are available for removal of warts in pregnancy, but it is not a priority. Option 4: a dermatologic complication that causes discomfort but is not harmful

A 12-month-old is found to have a moderately elevated blood lead level. Which of the following is the most serious concern for this child? 1. Gastrointestinal bleeding 2. Growth retardation 3. Neurocognitive impairment 4. Severe liver injury

3 Lead poising is most threatening to the kidneys and neurological system. Severe liver damage is closely associated with acetaminophen oversee or Reye syndrome

The mother of a 6-year-old with cystic fibrosis has received instruction on the use of pancreatic enzymes. Which statement made by the mother indicates a need for further teaching? 1. I need to monitor the total amount of this medication that I give to my child every day 2. I should give this medication with or just before my child has a meal or snack 3. It is okay for my child to chew this medication 4. It is okay to open the capsule and sprinkle the medicine on a tablespoon of applesauce

3 Nutritional therapy includes the administration of pancreatic enzyme supplements with or just before every meal or snack. These enzymes are enteric coated beads designed to dissolve only in an alkaline environment similar to that of the small intestine. Capsule contents may be sprinkled on applesauce, yogurt or acidic soft room temperature foods with pH <4.5. -Capsules should be swallowed whole and not crushed or chewed; chewing the capsules could cause irritation of the oral mucosa

A client with a permanent pacemaker with continuous telemetry calls the nurse and reports feeling lightheaded and dizzy. The client's blood pressure is 75/55. What is the nurse's priority action? 1. administer atropine 0.5 mg IV 2. Administer dopamine 5 mcg/kg/min 3. initiate transcutaneous pacing 4. notify the health care provider

3 The client is experiencing failure to capture from the permanent pacemaker with subsequent bradycardia and hypotension. Failure to capture appears on the cardiac monitor as pacemaker spikes that are not followed by QRS complexes This client is symptomatic from insufficient perfusion. The nurse's priority is to use transcutaneous pacemaker pads t normalize the heart rate, stabilize blood pressure, and adequately perfuse organs until the permanent pacemaker is repaired or replaced. Administer analgesia or sedation as transcutaneous pacing is very uncomfortable. option 1: atropine is administered to clients with symptomatic bradycardia, however this client's symptoms are caused by failure to capture option 2: dopamine isa n inotrope used to treat hypotension due to bradycardia. thIS CLIENT IS BRADYCARDIC AND HYPOTENSIVE DUE TO FAILRUE TO CAPTURE.

The nurse employed in a woman's health care clinic would be most concerned about which client statement? 1. I recently noticed a small, round, painless, mobile lump in my left breast while showering 2. Last night while breastfeeding, my nipples were cracked and my breasts were painful. 3. My right breast is red and warm with little tiny indented areas on the surface of the skin 4. Sometimes during my cycle, I notice breast nodules that are movable and feel soft to touch

3 The nurse would be most concerned about the client who describes symptoms of inflammatory breast cancer. In the aggressive form of cancer, breast lymph channels are blocked by cancer cells, creating breast tissue that becomes red, warm, and has an orange peel pitting appearance on the skin surface option 1: clients usually describe lumps related to fibroadenoma, a benign breast disorder, as small, round, painless, mobile lumps with no breast tissue retraction or discharge

An 8-month-old infant is scheduled for a femoral inserted balloon angioplasty of a congenital pulmonic stenosis in the cardiac catheterization lab. Which finding should the nurse report to the health care provider that could possibly delay the procedure? 1. Auscultation of a loud heart murmur 2. Infant has been NPO for 4 hours 3. Infant has severe diaper rash 4. Slight cyanosis of the nail beds

3 The presence of severe diaper rash should be reported, especially if its in the groin area where access is planned fora femoral inserted arterial cannula. Yeast or bacteria may be present on the rash and could be introduced into the bloodstream with the arterial stick. -a loud heart murmur can be expected in a child with pulmonic stenosis -Children are NPO for 4-6 hours or longer before the procedure. Younger children and infants may have a shorter period of NPO status and should be fed right up to the time recommended by the HCP. -Cyanosis indicates severe pulmonic stenosis with right-to-left shunt and the need for interventional cauterization or surgery without delay

The clinic nurse is planning to assess the visual acuity of a 6-year-old.. Which method is the best way to assess visual acuity in this child? 1. Have the child identify different objects using Allen figure testing cards 2. Have the child point in the direction each letter is facing on a tumbling E chart 3. Have the child read letters on a Snellen chart while standing 10 ft away 4. Have the child view a set of Ishihara colored cards one at a time

3 Visual acuity measurement for children age 6 years and older is best performed by using the Snellen letter chart. If the child wear glasses, they should be worn during testing. Four to six LETTERS MUST BE IDENTIFIED IN EACH ROW BEFORE PROCEEDING TO THE NEXT. -allen figure testing cards and a tumbling E chart are for 3-5 year olds -ishihara cards one at a time is a test of color vision, not visual acuity

The nurse assesses 4 infants. Which assessment finding would require follow-up by the health care provider? 1. 3 week old whose anterior fontanelle bulges with crying 2. 4 week old whose posterior fontanelle is soft 3. 6-month-old with birth weight of 7 lb 3 oz who now weighs 12 lb 4. 12-month-old with birth weight of 6 lb 4 oz who now weighs 20 lb

3 birth weight should double by age 6 months and triple by age 12 months -option 1:anterior fontanelle closes at 18 months

The nurse is obtaining orthostatic vital signs on a client admitted for dehydration. The nurse measures the client's blood pressure and pulse using the left brachial site with the client lying supine and then sitting. Which action by the nurse is appropriate? BP supine: 153/83 BP sitting: 119/70 1. Assist the client to a standing position and measure a third set of vital signs 2. Place the client in reverse Trendelenburg position and take an apical pulse 3. Reassess the client's blood pressure in the supine position using the popliteal site 4. Return the client to a recumbent position and notify the health care provider

4 Clients with impaired compensatory mechanism (hypovolemia, sepsis) may exhibit orthostatic hypotension, in which hypotension and/or neurologic impairment (syncope) occur with position change. This increases the client's risk for falls Orthostatic vital signs involve measuring the client's BP and heart rate in the supine, sitting, and standing positions. Each measurement should be obtained after maintaining each position for 2 minutes. If any position change produces decreased systolic BP >20, decreased diastolic BP > 10, and or increased pulse 20 from supine values, the nurse should discontinue assessment, place the client in a recumbent position, and notify the health care provider

The nurse assesses a client who had a thyroidectomy 8 hours ago. The nurse finds the client anxious, with tingling around the mouth and muscle twitching in the right arm. Which action is most important for the nurse to implement first? 1. Change the surgical dressing to assess for bleeding 2. Document the findings in the electronic medical record 3. Draw arterial blood gases 4. Obtain a serum calcium level

4 Normal serum calcium is 8.6-10.2 Hypocalcemia is a potential complication of thyroidectomy because the parathyroids that regulate calcium levels in the blood are accidentally removed during this surgical procedure. The nurse should monitor the client closely for signs of hypocalcemia, which include tetany (overactive neurological responses such as tingling in the hands, feet, and around he mouth; spasms or cramps that can occur even in the larynx; positive Trousseau (carpopedal spasm of the hand after wearing BP cuff for 2-3 minutes) or Chvostek sign (twitching of the ipsilateral facial muscle when percussion of facial nerve is taking place) -a serum calcium level should be drawn and the nurse should ensure that calcium gluconate is readily available option 1: monitoring for bleeding is an important assessment - however in post thyroidectomy, blood typically trickles and pools behind the client's neck

A nurse is caring for a 2-year-old with a new diagnosis of strabismus. Which intervention should the nurse anticipate? 1. Correction with laser surgery 2. Eye drops in the affected eye 3. Measurement of intraocular pressure 4/ Patching of the unaffected eye

4 Strabismus (ocular misalignment) occurs when both eyes cannot simultaneously focus on the same image (one eye deviates to look at something else, away from a point of fixation) -treatment involves correcting significant refractive errors (nearsightedness, farsightedness) and promoting use of the affected eye (patching the normal eye) -laser surgery to correct weak eye muscles is indicated if noninvasive methods fail -eye drops (atropine) to blur vision of the normal eye are indicated to strengthen and promote use of the affected eye. Placing eye drops to blur the vision of the affected eye could worsen amblyopia -monitoring intraocular pressure is necessary in a client with glaucoma, not strabismus

A charge nurse is monitoring a newly licensed registered nurse. What action by the new nurse would warrant intervention by the charge nurse? 1. Administers hydromorphone 1 mg to a client who rates pain at 7 on a 1 to 10 scale 2. Notifies physician of occasional premature ventricular beats in a client with myocardial infarction 3. Positions a postoperative pneumonectomy client on the affected side 4. Prepares to administer IVPB potassium chloride via gravity infusion for a client with hypokalemia

4 Treatment of hypokalemia may require an IV infusion of potassium chloride. The infusion rate should not exceed 10 mEq/hr -therefore, IVPB KCL must be given via an infusion pump so the rate can be regulated -IV KCL should be diluted and never given in a concentrated amount option 2: PVCs in the normal heart are not significant. PVCs in the client with coronary artery disease or myocardial infarction indicate ventricular irritability and lead to life-threatening dysrhythmia such as ventricular tachycardia option 3: with the complete removal of the lunch in a pneumonectomy, the client should be positioned on the surgical side to promote adequate expansion and ventilation of the remaining lung

A client comes in for a routine first prenatal examination. According to the last menstrual period, the estimated gestational age is 12 weeks. Where would the nurse expect to palpate the uterine funds in this client? 1. 12 cm above the umbilicus 2. at the level of the umbilicus 3. halfway between the symphysis pubis and th umbilicus 4. just above the symphysis pubis

4 The enlarging pregnant uterus should be just above the symphysis pubis at approximately 12 weeks gestation. At 16 weeks gestation, the funds is roughly halfway between the symphysis pubis and the umbilicus. It reaches the umbilicus at 20-22 weeks and approaches the xiphoid process around 36 weeks -at 38-40 weeks, the fetus engages into the maternal pelvis, and the fundal height drops

Airborne precautions are for what diseases

SARS (Severe Acute Respiratory Syndrome), TB, Measles (rubeola) and Varicella (if lesions not crusted over), variola (smallpox), disseminated shingles

The nurse has provided teaching about home care to the parent of a 10-year-old with cystic fibrosis. Which of the following statements by the parent indicates that teaching has been effective? Select all that apply 1. Chest physiotherapy is administered only if respiratory symptoms worsen 2. I will give my child pancreatic enzymes with meals and snacks 3. I will increase my child's salt and fluid intake when playing outside during hot weather 4. Our child will need a diet high in calories, protein, and fat 5. We will limit our child's participation in sports activities to 15 minutes per day

2, 3, & 4 Patients with cystic fibrosis have a defective protein responsible for transporting sodium and chloride, which causes exocrine gland secretions to be thicker and stickier. Viscous respiratory secretions accumulate, resulting in impaired airway clearance and chronic cough. They eventually develop chronic lung disease. Pancreatic enzyme secretion, needed for digestion and absorption of nutrients, is also impaired because thick secretions block pancreatic ducts. Therefore, clients need supplemental enzymes with meals and snacks. Clients also require supplemental vitamins and a diet high in calories, protein and fat. The parents should encourage physical activity (such as aerobic exercise) as tolerated which helps to thin secretions and remove them from airways and improves muscle strength and lung capacity.

A nurse on a pediatric unit is admitting a school-aged child with suspected Reye syndrome. Which information obtained during the history taking is most consistent with the condition? 1. No history of varicella vaccine administration 2. Recent exposure to bats 3. Recent influenza infection 4. Recent use of acetaminophen for fever

3 Children who develop Reye syndrome often have a recent viral infection, especially varicella or influenza. Clinical manifestations include fever, lethargy, acute encephalopathy, and altered hepatic function. Elevated serum ammonia levels are an expected laboratory finding. The risk of developing Reye syndrome increases if aspirin therapy is used to treat the fever associated with varicella or influenza.

The clinic nurse reviews teaching provided to the parent of a child being considered for growth hormone replacement therapy at home. Which statement by the parent indicates that teaching has been effective? 1. Treatment will be considered a success when my child grows at a rate equal to peers. 2. Treatment will be required throughout my child's life. 3. Treatment will begin when my child becomes an adolescent 4. Treatment will require a daily injection under my child's skin

4 Growth hormone replacement is an option for children who are not growing according to accepted standards. The treatment should begin as soon as delays are noted and continue until bone growth begins to cease despite replacement therapy. Replacement is administered daily via subcutaneous injection.

A nurse is caring for a 3- month-old infant who has bacterial meningitis. Which clinical findings support this diagnosis? Select all that apply 1. depressed anterior fontanelle 2. frequent sezirues 3. High-pitched cry 4. Poor feeding 5. Presence of the Babinski sign 6. Vomiting

2, 3, 4, & 6 Bacterial meningitis is an inflammation of the meninges in the brain and spinal cord that is caused by specific types of bacteria. Clinical manifestations in infants age <2 include: -fever / hypohtermia -irritability, frequent seizures -high pitched cry - poor feeding and vomiting -nuchal rigidity -bulging fontenel but not always present -depressed fontanelles indicate severe dehydration -the Babinski reflex can be present up to 1-2 years and is a normal expected finding

Which prescription should the nurse clarify with the health care provider? 1. 0.45 sodium chloride continuous IV infusion for a client with acute post infectious glomerulonephritis and a sodium level of 147 2. 0.9% sodium chloride IV bolus for a client in diabetic ketoacidosis with a BUN of 28 3. Dextrose 10% in water IV bolus for a client who is unresponsive with a finger stick blood glucose of 50 4. Lactated Ringer solution continuous IV infusion for a client with acute appendicitis who has a WBC count of 15,500

1 APGN leads to decreased renal filtration, causing excessive sodium and water retention. Hypotonic solutions (0.45 sodium chloride) cause fluid to move from the extracellular space to the intracellular space, which worsen edema, and are not appropriate for this client Option 2 and 4: Isotonic solutions (0.9 sodium chloride, LR) have the same osmolality as extracellular fluid and do not cause a fluid shift. They are appropriate for clients with dehydration (diabetic ketoacidosis, appendicitis) Option 3: Hypertonic solutions (dextrose 10% in water) have a higher osmolality than extracellular fluid, which promotes movement of fluid from the intracellular space tot he extracellular intravascular space.

The nurse is assessing a 5-year-old with sickle cell crisis. The client has shortness of breath, nausea with vomiting, and generalized body and joint pain. Which finding requires immediate intervention? 1. Enlarged spleen on palpation 2. Hemoglobin level of 8 3. Pain rated as 10 on the wong-baker faces scale 4. swelling noted in the hands and feet bilaterally

1 Acute splenic sequestration crisis is a complication of SCC that occurs when a large number of sickle-shaped cells get rapped in the spleen, causing splenomegaly. This is a life-threatening emergency as large amounts of pooling blood in the spleen can lead to severe hypovolemia and shock. The classic assessment finding is a rapidly enlarging and hypotension

The nurse cares for a client who gave birth an hour ago to a 9 lb newborn. The client's loch is heavy with large clots, and the fungus remains boggy after fundal massage and an oxytocin bolus. Which prescription from the health care provider should the nurse question? BP is 165/98 1. Administer 0.2 mg methrylergonovine IM 2. aDMINSITER 800 mcg miso-rostol rectally 3. Collect a hemoglobin and hematocrit STAT 4. Initiate second IV line with 19-guage needle

1 Methylergonovine (Methergine) is contraindicated for clients with high blood pressure because the primary mechanism of action is vasoconstriction. If administered for a hypertensive client, it can lead to further blood pressure elevation, seizure, or stroke. option 2: misoprostal combats uterine atony by contracting the uterine muscle. The drug is often given per rectum for PPH to increase absorption

What play behavior would the nurse be most likely to observe in a group of 4-year old children? 1.Children playing and borrowing blocks from each other without directing others 2. Children playing and working together to build a castle out of blocks 3. Children playing next to each other with blocks, but not interacting 4. Children playing with blocks by themselves in separate areas of the room

1 Preeschoolers (3-6) enjoy associative play, in which they engage in similar activities or play with the same or similar items, but without specific goals or rules. tHey often borrow items from each other without directing each other's play. Preschoolers also enjoy play involving motor activities and imaginative, pretend play. -Cooperative play is common in school-age children (6-12). These children play with one another with a specific goal and often have a set of rules. -parallel play is more common in toddlers (1-3). These children play next to each other and are happy to be in the presence of peers, but they do not play directly with one another. -solitary play is common in infants (birth - 1 year)

A 2-year-old is suspected of having retinoblastoma. The nurse recognizes which sign as being most characteristic of this disease? 1. Absence of red reflex 2. Fixed and mid-dilated pupil 3. Ptosis of the eye 4. Purulent eye discharge

1 Retinoblastoma is typically diagnosed in children under age 2 and is usually first recognized when parents report a white glow of the pupil - light reflecting off the tumor will cause the pupil to appear white instead of displaying the usual red reflex -strabismus *misalignment of eyes) is the second most common sign -siblings should undergo regular ocular screenings, as some forms of retinoblastoma are hereditary - a fixed and mid-dilated pupil is seen in acute glaucoma option 3: ptosis is drooping of the upper eyelid often associated with injury of the oculomotor nerve. It is also a characteristic for myasthenia graves option 4: bacterial conjunctivitis causes eyelid swelling, a red conjunctiva, eye discomfort, and purulent eye discharge

A 3-month-old who weighs 8.8 lb (4 kg) has just returned to the intensive care unit after surgical repair of a congenital heart defect. Which finding by the nurse should be reported immediately to the health care care provider? 1. Chest tube output of 50 mL in the past hour 2. Heart rate of 150/min 3. Temperature of 97.5 4. Urine output of 8 mL in the past hour

1 The chest tube and chamber should be assessed every hour for color and quantity of drainage. Drainage >3 mL/kg/hr for 3 consecutive hours or >5-10 mL/kg in 1 hour should be reported immediately to the health care provider. -for infants age 1-12 months, the normal heart rate is 90-160/min -hypothermia is common after surgery -urine output should be 1-2 mL/kg/hr

The nurse is performing the initial assessment of a newborn. Which finding should the nurse report to the health care provider? 1. A sudden jarring of the client's crib does not produce a Moro reflex. 2. The client has swollen labia and a thin, white vaginal discharge. 3. The posterior fontanel is triangular and smaller than the anterior fontanel 4. There are pearly white pinpoint papule on the client's face and nose

1 The moro reflex (startle reflex) present until age 3-6 months, is elicited by quickly lowering the infant's head relative to the body, simulating a falling sensation. It is also a response to sudden loud noises and jarring of the crib. Initially, the newborn extends and raises the arms with fingers fanned out and then curls into the fetal position -absence of the moro reflex may indicate underdeveloped or brain damage option 2: swollen labia and thin white vaginal discharge are normal findings in the first few weeks of life.

The nurse is caring for an adolescent client with type 1 diabetes mellitus. The client has a pH of 7.27; a serum glucose level of 350 mg/dL; hot, dry skin; and minimal urinary output. Serum electrolyte test results are pending. Cardiac monitoring shows sinus rhythm with peaked T waves. Which of the following actions is a priority for the nurse to implement? 1. Administering an IV bolus of 0.9% sodium chloride 2. Administering an IV infusion of regular insulin 3. Obtaining a urine specimen for urinalysis 4. requesting a prescription for potassium chloride

1 This client has diabetic ketoacidosis (DKA), a life-threatening complication of diabetes mellitus that results form a lack of insulin production. Insulin deficits cause intravascular hyperglycemia. Osmotic diuresis occurs to reduce intravascular glucose levels, which results in dehydration, electrolyte imbalances, and metabolic acidosis. Fluid resuscitation also prevents hypovolemic shock and normalizes electrolyte and glucose levels via hemodilution. The priority intervention for DKA management is rapid fluid resuscitation to restore intravascular volume na organ perfusion option 2: insulin therapy should be started after fluid resuscitation is initiated because serum glucose levels fall rapidly with volume expansion option 3: urinalysis is important to detect the presence of ketones but is not the priority option 4: peaked t waves indicated hyperkalemia. Initially, clients with DKA may have elevated serum potassium levels due to the extracellular shift, despite having total body potassium deficit form urinary losses.

Which assessment findings should the nurse anticipate in a child with suspected acute otitis media (AOM)? 1. Frequent pulling on the affected ear 2. refusal to eat 3. restlessness and irritability 4. Retracted tympanic membranes 5. severe pain with pressure on the tragus

1, 2, & 3 OM typically occurs in infants and children age <2, often following a respiratory tract infection. Clinical manifestations of AOM include high fever, ear pain, irritability, loss of appetite, and pulling on the affected ear. The tympanic membrane will be bulging and very red. -retracted tympanic membranes occur when there is negative pressure in the middle ear which occurs with a blocked eustachian tube or a complication of chronic infection -severe pain with pressure on the trigs or with pulling on the pinna occurs with otitis externa, an infection on the outer ear

The nurse is reviewing anticipatory guidance with the parents of a 6-month old infant with phenylketonuria. Which statements by the nurse are appropriate? Select all that apply 1. A low phenylalanine diet is required 2. Meat and dairy products should not be introduced into the diet 3. Phenylketonuria is self-limiting and usually resolves by adulthood 4. Special infant formula is required 5. Tyrosine should be removed from the diet

1, 2, & 4 A low-phenylalanine diet is essential in the treatment of PKU. Phenylalanine cannot be entirely eliminated from the diet as it is an essential amino acid and necessary for normal development. There is no known age at which the diet can be discontinued safely, and lifetime dietary restrictions are recommended Management: -monitoring serum levels of phenylalanine diet -special formulas -eliminating high phenylalanine foods (meats, egg milk) from diet -encouraging the consumption of natural foods low in phenylalanine (most fruits and vegetables)

The nurse cares for a client who had an abdominal aortic aneurysm repair 6 hours ago. Which assessment findings would indicate possible graft leakage and require a report to the primary care provider? Select all that apply 1. Ecchymosis of the scrotum 2. Increased abdominal girth 3. Increased urinary output 4. Report of groin pain 5 Report of increased thirst and appetite loss

1, 2, & 4 Repair of abdominal aortic aneurysms can be done via femoral percutaneous placement of a stent graft or via an open surgical incision of the aneurysm and placement of a synthetic graft. Manifestations of graft leakage include: -ecchymosis of the groin, penis, scrotum, or perineum -increased abdominal girth -tachycardia -weak or absent peripheral pulses -decreasing hematocrit and hemoglobin -increased pain the pelvis, back, or groin -decreased urinary output option 5: increased thirst and appetite loss are not signs of graft leakage

The most recent laboratory results for a 12-month old who is HIV positive shows a CD4 lymphocyte count of 500 and a CD4 lymphocyte percentage of 10%. The nurse anticipates administering which immunizations? Select all that apply 1. Haemophilus influenza type b (Hib) 2. Hepatitis A (Hep A) 3. Measles mumps, rubella (MMR) 4. Pneumococcal conjugate vaccine (PCV) 5. Varicella

1, 2, & 4 Routine immunization for a 12-month old included His, PCV, MMR, varicella, and Hep A. live vaccine (MMR, VARICELLA, Rotavirus, Influenza) are contraindicated in the presence of marked immunosuppression. An individual with a CD4 lymphocyte percentage <15% is considered to be severely immunocompromised

The health care provider suspects fat embolism syndrome in a client who has a long bone fracture in the right lower extremity. Which of the following assessment findings does the nurse expect to support this diagnosis? Select all that apply 1. Confusion and restlessness 2. Hypoxemia detected by pulse oximetry 3. Increasing pressure in the affected extremity 4. Paresthesia of the affected extremity 5. Petechia over the neck and chest

1, 2, & 5 Fat embolism syndrome is a rare life threatening complication related to bone fractures, typically of the pelvis or long bones. It occurs when fat globules travel through the bloodstream and obstruct small blood vessels, causing impaired circulation and ischemia. The lungs, brain, and skin are most often affected, leading to acute respiratory distress and neurologic impairment. Clinical manifestations of FES include: -neurolgoic changes (altered mental status, confusion restlessness) -respiratory distress (dyspnea, tachypnea, hypoxemia) -petechial rash which appears on the neck, chest, and axilla option 3 and 4: increasing pressure and paresthesia of the affected extremity are assessment findings indicative of compartment syndrome, not FES

A client comes to the clinic indicating that a home pregnancy test was positive. The client's last menstrual period was Septemberr 7. Today is December 7. Which are true statements for this client? Select all that apply 1. According to Naegele's rule, the expected date of delivery is June 14 2. Detection of the fetal heart rate via Doppler is possible 3. Fundal height should be 24 cm above the symphysis pubis 4. The client should be feeling fetal movement 5. Urinary frequency is a common symptom

1, 2, & 5 Naegele's rule, which is the last menstrual period minus 3 months plus 7 days, can be used to calculate a client's expected date of delivery. -detection of a fetal heart rate is possible using a doppler by 10-12 weeks -urinary frequency is common in first trimester (1-12 weeks) option 3: uterine growth is assessed by measuring fundal height using a measuring tape. After 20 weeks gestation, the fundal height measurement in centimeters should correlate closely with number of weeks pregnant (24 cm = 24 weeks). The client should empty the bladder before having fundal height measured, as a full bladder can displace the uterus and affect measurement accuracy option 4: quickening, the awareness of fetal movements, occurs around 18-20 weeks gestation in primigravidas and at 14-16 weeks in multigraviadas

A client is admitted to the labor and delivery unit with a diagnosis of severe preeclampsia. IV magnesium sulfate is prescribed. Which nursing measures should the nurse include in this client's plan of care? Select all that apply 1. Assess deep tendon reflexes hourly 2. Ensure availability of calcium gluconate 3. Ensure bright lightning to prevent falls 4. Have supplemental oxygen at bedside 5. Limit visitors to minimize stimulation

1, 2, 4, & 5 Seizures are a potential complication of worsening preeclampsia. Side rails should be padded and the bed kept in the lowest position to prevent trauma during a seizure. Functioning suction and oxygen should be available at the bedside. Magnesium sulfate is a cns DEPRESSANT PRESCRIBED commonly to prevent seizures. Deep tendon reflexes should be assessed hourly during administration as hyperreflexia or clonus may indicate impending seizure activity whereas hyporefelxia may indicate magnesium toxicity. Calcium glutinate is the reversal agent administered in the event of magnesium toxicity. Environmental stimuli should be minimized to decrease risk of seizures. Option 3: severe preeclampsia is associated with CNS irritability, and excessive stimulation should be avoided. Lights should be lowered.

The nurse is assessing a 4-year-old boy in a pediatric clinic. Which behaviors by the client would concern the nurse for possible Duchenne musucular dystrophy? Select all that apply 1. Frequently trips and falls at home 2. Has painful knees and elbows in the morning 3. Places hands on the thighs to push up to stand 4. Suddenly rigidly extends the arms and legs 5. Walks on tiptoes and has disproportionately large calves

1, 3, & 5 Duchenne muscular dystrophy is an X-linked recessive disorder characterized by progressive replacement of muscle tissue with connective tissue. Classic signs include: -Gower sign/maneuver (placing hands on the thighs to push up to stand) -enlarged calves -walking on tiptoes -frequent dropping and falling

A client without prenatal care gives birth to a newborn at term gestation. The client denies opioid or other illicit drug use during pregnancy. When monitoring the newborn, which of the following signs would indicate neonatal abstinence syndrome to the nurse? Select all that apply 1. irritability and restlessness 2. Meconium ileum and floppy muscle tone 3. Microcephaly and cleft palate 4. Nasal congestion and frequent sneezing 5. Poor feeding and loose stools

1, 4, & 5 Clinical manifestations of NAS are: -CNS findings: irritability, restlessnesss, high pitched crying, abnormal sleep pattern, increased muscle tone, hyperactive primitive reflexes -nasal congestion, sweating, frequent yawning, sneezing, tachypnea -poor feeding, vomiting, diarrhea option 2: meconium ileum is a classic findings in clients with cystic fibrosis. Floppy muscle tone is typical of clients with Trisomy 21 (down syndrome) option 3: microcephaly and cleft palate are manifestations of early prenatal exposure to alcohol, cytomegalovirus, and valproic acid

A client who is being evaluated for suspected ectopic pregnancy reports sudden onset severe, right lower abdominal pain and dizziness. Which additional assessment findings will the nurse anticipate if the client is experiencing a ruptured ectopic pregnancy? Select all that apply 1. Blood pressure 82/64 mm Hg 2. Crackles on auscultation 3. Distended jugular veins 4. Pulse 120/min 5. Shoulder pain

1, 4, & 5 Risk factors for ectopic pregnancy: STIs, tubal damage or scarring, intrauterine devices, and previous tubal surgeries Clinical manifestations: lower-quadrant abdominal pain on one side, mild to moderate vaginal bleeding, and missed or delayed menses. Signs of hypovolemic shock from rupture include dizziness, hypotension, and tachycardia. Free intraperitoneal blood pooling under the diaphragm can cause referred shoulder pain. Peritoneal signs (tenderness, rigidity, low-grade fever) may develop.

A pregnant client comes to the labor and delivery unit stating, my water just broke at home. On assessment of the client's perineal area, the nurse visualizes a loop of umbilical cord protruding from the vagina. Which nursing intervention would be appropriate? 1. Apply suprapubic pressure 2. Assist the client to the knee-chest position 3. Perform Leopold maneuvers 4. Perform the mcroberts maneuver

2 -an emergency cesarean birth is usually required unless vaginal birth is considered with an umbilical cord prolaps -postioning the client on the hands and knees with buttocks elevated above the head (knee-chest position) or in the Trendelenburg position relieves pressure on the compressed cord -the nurse may also use a sterile, gloved hand to lift the presenting part off the cord -other actions include administration of oxygen and IV fluids option 3: not used as an emergency intervention option 4 and option 1: mcroberts maneuver consists of sharply flexing the thing onto the maternal abdomen to straighten he sacrum. It is used for shoulder dystocia along with suprapubic pressure

A client at 38 weeks gestation is in latent labor with ruptured membranes and is receiving an oxytocin infusion for labor augmentation. The client is requesting IV pain medication. When administering an IV narcotic during labor, which nursing action is appropriate? 1. Discontinue the oxytocin infusion prior to giving the medication 2. Give the medication slowly during the peak of the next contraction 3. Hold until contractions are occurring at least every 4 minutes for an hour 4. withdraw 5 mL of lactated Ringer from the IV tubing to dilute the medication

2 Administration of IV narcotics (nalbuphine, butorphanol, meperidine) during the peak of contractions can help decrease sedation of the fetus and subsequent newborn respiratory depression at birth. Uteroplacental blood flow is significantly reduced during contraction peaks, and administration of IV medication at this time results in less medication crossing the placental barrier. Option 4: Diluent should never be obtained from IV bag or tubing due to the risk of inadvertently adding medication to IV fluids

The nurse is caring for a child receiving IV immunoglobulin for treatment of Kawasaki disease. Which action by the nurse is the priority? 1. Apply cool compresses to the hands and feet 2. Monitor for gallop heart sounds and decreased urine output 3. Prepare a quiet, non stimulating environment 4.Provide soft foods and clear liquids

2 Kawasaki disease is an inflammatory condition of unknown origin that causes systemic vasculitis (blood vessel inflammation) in children. The coronary arteries are especially vulnerable and life threatening coronary artery aneurysms and heart failure may occur. Clinical manifestations of KD: -high fevers -unresponsive to antibiotics or antipyretics -conjunctivitis -strawberry tongue -swollen and cracked lips - and erythema of the hands and feet with skin peeling -IVIG can reduce inflammation but increases plasma oncotic pressure and can lead to fluid overload --> nurses should look out for signs of heart failure (tachycardia, decreased urine output, gallop heart sounds)

The nurse is caring for a baby born at 30 weeks gestation and diagnosed with necrotizing enterocolitis. Which nursing action should be implemented? 1. Encourage parents to increase skin-to-skin care 2. Measure abdominal girth daily 3. Measure rectal temperature every 3-4 hours 4. Position client on side and check diaper for stool

2 Necrotizing enterocolitis occurs predominantly in preterm infants secondary to gastrointestinal and immunologic immaturity. On initiation of enteral feeding, bacteria can be introduced into the bowel, where they can proliferate excessively due to compromised immune clearance. This results in inflammation and ischemic necrosis of the intestine. As the disease progresses, the bowel becomes congested and gangrenous with gas collections forming inside the bowel wall. -Measuring the client's abdominal girth daily is an important nursing intervention to note any worsening intestinal gas-associated swelling. Clients are made NPO and receive nasogastric suction to decompress the stomach and intestines. option 1: skin to skin care should be avoided in infants who are not stable as it may cause additional stress option 4: to avoid pressure on the abdomen and facilitate observation for a distended abdomen, clients are placed supine and undiapered

The nurse is caring for a newborn with patent ductus arterioles. Which assessment finding should the nurse expect? 1. Harsh systolic murmur 2. Loud machine-like murmur 3. Soft diastolic murmur 4. Systolic ejection murmur

2 Patent ductus arterious is an cyanotic congenital defect more common in premature infants. When fetal circulation changes to pulmonary circulation outside the womb, the ductus arteriosus should close spontaneously. If a PDA is present, blood will shunt from the aorta back to the pulmonary arteries via the opened ductus arteriosus. Many newborns are asymotpmatic except for a loud, machine like systolic and diastolic murmur. The PDA will be treated with surgical ligation or IV indomethacin to stimulate duct closure. -a harsh systolic murmur indicate ventricular septal defect (an opening between the ventricles of the heart) - an acyanotic defect -a diastolic murmur indicates in mitral stenosis and aortic regurgitation -systolic ejection murmur is heard in pulmonic stenosis

The nurse provides care for a client diagnosed with polycythemia vera. Which statement by the client would require immediate follow up? 1. I am trying to find makeup to cover my unattractive, ruddy facial complexion 2. I must have injured my leg in some way. It is a sore, swollen, and red 3. I take a baby aspirin to relieve my occasional headaches 4. My skin itches so severely, and no lotion or cream seems to help

2 Polycythemia vera is a hematological disorder in which too many rbcs are produced, causing increased blood viscosity, venous stasis, and increased risk for thrombus formation -the PV client should wear graduated compression stockings, elevating legs when sitting, maintaining adequate hydration option 1: venous stasis causes the skin on the face, hands, and feet to become ruddy (red). this is an expected finding option 3: occasional headaches or blurred vision can result from sluggish, viscous blood flow in the brain. Aspirin therapy is used for its antiplatelelt analgesic action option 4: pruritic is a common occurrence in clients with PV, often after bathing. Clients should bathe with cool water and pat (not rub) themselves dry with a towel to avoid histamine release and use antihistamine creams fro relief.

A nurse is making initial client rounds at the beginning of the shift. Which client should the nurse see first? 1. 36-year-old client with endocarditis who has a temperature of 100.6, chills, malaise, and a heart murmur 2. 40-year-old client with pericardial effusion who has blood pressure of 84/62 and jugular venous distention. 3. 67 year old client admitted for pneumonia with new-onset atrial fibrillation, who has blood pressure of 130/90 and heart rate of 110/min 4. 70-year-old client with advanced heart failure who is receiving intravenous diuretics, has blood pressure of 80/60 mm Hg, and is watching TV

2 The client with pericardial effusion is exhibiting signs and symptoms (narrowed pulse pressure, hypotension, and jugular venous distention) of developing cardiac tamponade, a life-threatening complication of pericardial effusion in which fluid builds up in the pericardial sac and compresses the heart. The heart is unable to contract effectively against the fluid, and cardiac output can drop drastically. Other important manifestation of tamponade include: -muffled or distant heart tones -pulsus paradoxus -dyspnea -tachypnea -tachycardia option 1 The are symptoms typically seen in the client with endocarditis. The nurse should further assess the murmur to see if it has worsened or changed, but this should be done after the client with pericardial effusion is seen option 3: the new onset of atrial fibrillation should be reported to the health care provider, but the client's vital signs are stable option 4: the client is watching TV, an indication that the client is stable

The graduate nurse (GN) is caring for a client at 20 weeks gestation with secondary syphilis. The client reports an allergic reaction to penicillin as a child but does not know what kind of reaction occurred. When discussing the client's potential treatment plan with the precasting nurse, which statement by the GN indicates an appropriate understanding? 1. Doxycycline is an acceptable alternative to penicillin for treatment of syphilis during pregnancy 2. The client will require penicillin desensitization to receive appropriate treatment 3. The newborn can be treated after birth if antepartum treatment is contrainidcated 4. Treatment is only effective if provided during the primary stage of syphilis

2 The only adequate prenatal treatment is IM PENICILLIN injection. If the client has a penicillin allergy, the nurse should anticipate penicillin desensitization so that adequate treatment can be provided option 1: doxycycline, a tetracycline antibiotic, is a potential treatment alternative for non pregnant clients with syphilis but is contraindicated in pregnancy because it can impair fetal bone mineralization and discolor permanent teeth option 3: syphilis that goes untreated can result in fetal or newborn death. Although some newborns require treatment after birth, complications can be prevented with prenatal treatment option 4: many clients with primary syphilis have nonreactive serologic tests due to a delay in antibody development. However, IM penicillin therapy is appropriate for the treatment of primary secondary and latent syphilis

A client started a 24-hour urine collection test at 6:00AM. The UAP reports discarding a urine specimen of 250 mL at 10:00Am by mistake but adding all specimens to the collection container before and after that time. What action should the nurse take? 1. Add 250 mL to the toal output after the 24-hour urine collection is complete tomorrow morning. 2. Discard the urine and container, and restart the 24-hour urine collection tomorrow morning 3. Discard urine and container, have client void, add urine to new container, and then restart test 4. reliable the same collection container, and change the start time from 6:00AM to 10:00AM

2 Timed urine collection tests require the collection of all urine produced in a specified time period. The collection container must be kept cool to prevent bacterial decomposition of the urine. -not all the clients urine was saved during the collection period. Therefore, the nurse or UAP must discard the urine and container and restart the specimen collection procedure. -it is common practice to start the collection in the morning after the client's first morning voiding and to end it at the same hour the next morning after the morning voiding

A nurse is caring for a 6-year-old client with tonsillitis. Which assessment finding requires immediate intervention? 1. dry mucous membranes 2. presence of trismus 3. pulling at the ears 4. sandpaper-like rash

2 Trismus (inability to open the mouth due to a tonic contraction of the muscles used for chewing) may indicate a more serious complication of tonsillitis, a peritonsillar or retropharygeal abscess -other features include a muffled voice, pooling of saliva, and deviation of the uvula to one side

A nurse in a pediatric clinic is preparing to administer ear drops to a 5-year old. Which is an appropriate action by the nurse? 1. Have the child sit upright with the chin tilted down 2. Pull the pinna upward and back 3. Remove the medication rom the refrigerator just before use 4. touch the dropper to the entrance of the ear canal

2 When administering an otic medication to an adult or child age 3 and older, the pinna is pulled upward and back to straighten the external ear canal. For an infant, the pinna is pulled downward and straight back. option 1: the child should be placed in the prone or supine position with the head turned to the appropriate side

The nurse at the women's clinic is caring for several clients who are pregnant. The nurse should alert the health care provider to see which client first? 1. Client in the first trimester who reports frequent nausea and vomiting 2. Client in the first trimester with malaise, myalgia, and temperature of 100.8 3. Client in the second trimester who reports dysuria and urinary frequency 4. Client in the third trimester with right upper quadrant pain and nausea

4 HELLP (Hemolysis, Elevated Liver enzymes, Lower Platelet count) syndrome is a form of preeclampsia that most often develops during the third trimester of pregnancy. Symptoms may be nonspecific, such as right upper quadrant pain and nausea

A nurse is caring for a pregnant client at 27 weeks gestation after a motor vehicle collision with side airbag deployment. The client's blood type is O negative. Which laboratory test should the nurse anticipate? 1. Group B streptococcal culture 2. Indirect Coombs test 3. Rubella immunity titer 4. Serum alpha-fetoprotein

2 An indirect Coombs test is performed to screen for Rh sensitization at any time hemorrhage secondary to placental abruption is suspected. Rh immune globulin (RhoGAM) is administered to all Rh-negative pregnant clients at 28 weeks gestation and within 72 hours postpartum, as well as after after any maternal trauma. Option 1: Perineal group B streptococcal cultures are obtained 35-37 WEEKS TO DETERMINE THE NEED FOR ANTIBIOITCS DURING LABOR Option 3: Testing for Rubella immunity is performed in the first trimester; non immune mothers receive the MMR vaccine in the postpartum period option 4: serum alpha-fetoprotein is a blood test to screen for fetal neural tube defects

The nurse is caring for a client in the first trimester during an initial prenatal clinic visit. Based on the information provided by the client, which factor places the client at an increased risk for preterm labor? 1. Age 25 2. Periodontal disease 3. Vegetarian diet 4. White ethnicity

2 Preterm birth is defined as birth before 37 weeks and 0 days gestations. Infection (periodontal disease, UTI) is strongly associated with preterm labor, particularly when untreated. Other risk factors: -history of spontaneous preterm birth - previous cervical surgery such as a cone biopsy -tobacco or drug use

What socioeconomic indicators would the nurse identify as risk factors for a 2-month-old infant to develop failure to thrive? Select all that apply 1. Both caregivers work outside the home 2. Infant lives only with mother, who is currently unemployed 3. Infant's primary caregiver has cognitive disabilities 4. Parents are socially and emotionally isolated 5. Parents live together but are not married

2, 3, & 4 Socioeconomic factors of FTT include: -poverty -social or emotional isolation -cognitive disability or mental health disorder -lack of nutritional education Physical risk factors: -preterm birth, -bf difficulties -gastroesophageal reflux -cleft palate

A 2-month old recently diagnosed with developmental dysplasia of the hip is beginning treatment with a Pavlik harness. Which instructions should the nurse provide to the parents? Select all that apply 1. Apply lotion under the straps to protect the skin 2. Dress the child in a shirt and knee socks under the straps 3. Lightly massage the skin under the straps daily 4. Place the diaper under the straps 5. Remove the harness during diaper changes

2, 3, & 4 To care for the infant wearing a pavlik harness: -regularrly assess skin for redness or breakdown under the straps -dress the child in a shirt and knee socks under the harness -avoid lotions and powders to prevent irritation and excess moisture -lightly massage the skin under the straps every day to promote circulation -only apply 1 diaper t a time -apply diapers underneath the straps

A client is admitted to the ICU with diagnoses of a brain tumor complicated by transient diabetes insipidus. Which client data related to this complication should the nurse expect? Select all that apply 1. Dark amber urine with sediment 2. High serum osmolality 3. Low urine specific gravity 4. Recent weight gain 5. Reports of excessive thirst

2, 3, and 5 Diabetes insipidus is a condition in which antidiuretic hormone (ADH) is insufficiently produced or suppressed. Neurogenic DI results from manipulation or interference with ADH release, transport, or synthesis. Neurogenic DI can occur after manipulation of the pituitary or other parts of the brain during surgery, brain tumors, head injury, or central nervous system infections. Neurogenic DI is characterized by: -polydipsia -polyuria (can lead to dehydration resulting in weight loss, hypernatremia, and high serum osmolality) -urine is dilute and copious with a low specific gravity

A 2-year-old child is brought to the emergency department for a severe sore throat and fever of 102.9. The child is drooling and has distressed respirations and inspiratory stridor. What actions should the nurse take first? 1. Assess an acute temperature with a rectal thermometer 2. Directly examine the throat for the presence of exudates 3. Obtain IV access for anticipated steroid administraiton 4. Position the child in the tripod position on the parents lap

4 Epiglottits is inflammation of the tissues surrounding the epiglottis, a long, narrow, structure that closes off the glottis during swallowing. Manifestations include sudden onset high fever, drooling, difficulty swallowing, agitation, lack of spontaneous cough, and acute respiratory distress. The priority here is to protect the airway. The tripod position opens the airways and helps airflow The nurse should not attempt to examine the child's throat because manipulation of the oral cavity can further aggravate the child's condition

The postpartum nurse is assessing a client who gave birth by cesarean section 5 hours ago and is requesting pain medication. The client appears restless, has a heart rate of 110/min, and admits to recent onset of anxiety. Which priority action should the nurse take? 1. Assess for lower extremity warmth and redness 2. Instruct the client in relaxation breathing techniques 3. Obtain oxygen saturation reading by pulse oximeter 4. Offer the client prescribed PRN pain medication

3 Women who give birth by cesarean section are at particularly increased risk for DVT. Additional risk factors include obesity, smoking, and genetic predisposition. If unrecognized, DVT may progress to pulmonary embolism, characterized by: -anxiety restlessness -pleuritic chest pain/tightness -shortness of breath -tachycardia -hypoxemia -hemoptysis The nurse's priority ir rapidly identifying symptoms, assessing respiratory status, administering supplemental oxygen, and notifying the health care provider option 1: any redness, tenderness, or warmth in the lower extremities may indicate DVT, which could be reported to the HCP. However, the nurse's priority is addressing the client's current symptoms indicative of acute PE by assessing oxygenation

When monitoring an infant with a left-to-right sided heart shunt, which findings would the nurse expect during the physical assessment? Select all that apply 1. Clubbing of fignertips 2. Cyanosis when crying 3. Diaphoresis during feedings 4. Heart murmur 5. poor weight gain

3, 4, & 5 Left-to-right-shunting (patent ductus arteriousus, atrial septal defect, ventricular septal defect) results in pulmonary congestion, causing increased work of breathing and decreased lung compliance. Compensatory mechanisms (tachycardia, diaphoresis) result from sympathetic stimulation. Clinical manifestations of acyanotic defects may include: -tachypnea -tachycardia -diaphoresis during feeding or exertion -heart murmur or extra heart sounds -signs of congestive heart failure -increased metabolic rate with poor weight gain

A laboring client, gravida 3 para 2, is admitted to the labor unit reporting severe perineal pressure and urgently requesting pain relief. The client's cervix is 10 cm dilated and 100% effaced, with the fetal head at 0 station. Which pain management technique is most appropriate for this client's report of perineal pressure? 1. Epidural anesthesia 2. Hydrotherapy 3. IV narcotics 4. Pudendal nerve block

4 A pundendal nerve block can provide pain relief for clients experiencing perineal pressure in the late second stage of labor. It may also be used in preparation for forceps-assisted birth or laceration repair in clients without an epidural. It does not provide relief of contraction pain Option 1: an epidural can be administered in the first (beginning of labor and ends with full dilation) or early second stage of labor but may not be feasible option in late second stage when birth is imminent. option 3: IV narcotics cross the placenta and can cause neonatal respiratory depression when administered close to birth. These are not generally administered in the second stage of labor

The nurse prepares to assess a newly admitted client diagnosed with chronic alcohol abuse whose laboratory reports shows a magnesium level of 1.0. Which assessment finding does the nurse anticipate? 1. Constipation and polyuria 2. Increased thirst and dry mucous membranes 3. Leg weakness and soft, flabby muscles 4. Tremors and brisk deep tendon reflexes

4 Hypomagnesemia, a low blood magnesium level is associated with alcohol abuse due to poor absorption, inadequate nutritional intake, and increased losses via the gastrointestinal and renal systems. It is associated with 2 major issues: 1. ventricular arrhytmias (very serious / priority) 2. neuromuscular excitability option 1: constipation and polyuria indicate hypercalcemia. Calcium has a diuretic effect. option 2: increased thirst with dry mucous membranes indicates hypernatremia option 3: hypokalemia results in muscle weakness/paralysis and soft, flabby muscles. Parallytic ileum (abdominal distension, decreased bowel sounds) is also common with hypokalemia. However, the most serious complication is cardiac arryhtymias.

A 3-month-old infant has irritability, facial edema, a 1-day history of diarrhea with adequate oral intake, and sz activity. during assessment, the parents state that they have recently been diluting formula to save money. Which is the most likely cause for the infant's symptoms? 1. Hypernatremia due to diarrhea 2. Hypoglycemia due to excess gastrointestinal output 3. Hypokalemia due to excess gastrointestinal output 4. Hyponatremia due to water intoxication

4 Infants are susceptible to hyponatremia secondary to water intoxication, which can present with neurological symptoms (lethargy, irritability, sz). Breast milk and/or formula provide sufficient hydration for the first 6 months of life. Hypoglycemia may present with irritability and seizures, but facial edema and recent history of over-diluting the formula should alter the nurse that water intoxication with hyponatremia is the most likely cause. Hypokalemia secondary to diarrhea may present with irritability, muscle weakness, and cardiac arrhythmias

The public health nurse conducts a teaching program for parents of infants. Which statement by a participant indicates that teaching has been successful? 1. After age 6 months, it is safe to use honey to sweeten my infants formula 2. I should wait until my infant is 1 year old to introduce egg products 3. I will switch my 1-year-old to low-fat milk instead of commercial formula 4. My infant should be able to pick up small finger foods by age 10 months

4 common allergenic foods (eggs, fish peanut products) should be introduced starting at 4-6 months infants should be transitioned to whole milk, not low-fat milk, at age 12 months