NCLEX Silversteri : alternative forms 6/10/18

The nurse is caring for the client with epididymitis. Which treatment modalities should be implemented? Select all that apply. 1. Bed rest 2. Sitz bath 3. Antibiotics 4. Heating pad 5. Scrotal elevation

1,2,3,5 Rationale: Common interventions used in the treatment of epididymitis include bed rest, elevation of the scrotum, ice packs, sitz baths, analgesics, and antibiotics. A heating pad should not be used because direct application of heat could increase blood flow to the area and increase the swelling.

The client is admitted to the hospital with a diagnosis of suspected Hodgkin's disease. Which signs and symptoms of the client are associated with Hodgkin's disease? Select all that apply 1. Fatigue 2. Weakness 3. Joint pain 4. Weight gain 5. Night sweats 6. Enlarged lymph nodes

1,2,5,6 Rationale: Hodgkin's disease (lymphoma) is a chronic, progressive neoplastic disorder of the lymphoid tissue that is characterized by the painless enlargement of lymph nodes with progression to extralymphatic sites, such as the spleen and liver. Other signs and symptoms include fatigue, weakness, weight loss, and night sweats. Weight gain and joint pain are not associated with Hodgkin's disease.

Mag sulfate toxicity

M y ( Muscle weakness ) Fuk ( flushing ) B U R P

the primary health care provider (PHCP) prescribes isotretinoin. The nurse reviews the client's medication record and would contact the PHCP if the client is also taking which medication? 1. Digoxin 2. Phenytoin 3. Vitamin A 4. Furosemide

Rationale: 3 Isotretinoin is a metabolite of vitamin A and can produce generalized intensification of isotretinoin toxicity. Because of the potential for increased toxicity, vitamin A supplements should be discontinued before isotretinoin therapy. There are no contraindications associated with digoxin, phenytoin, or furosemide.

-Azole

a -Alcohol avoid z -Sun avoid o -with fOOd l -Liver function study e - Empay stomach NO

The nurse is providing endotracheal suctioning to a client who is mechanically ventilated when the client becomes restless and tachycardic. Which actions should the nurse take? Select all that apply. 1. Notify the RN. 2. Notify the Rapid Response Team. 3. Finish the suctioning as quickly as possible. 4. Discontinue suctioning until the client is stabilized. 5. Contact the respiratory department to suction the client.

.1.4 .Rationale: When suctioning a client with an endotracheal tube, the nurse removes the secretions and clears the airway. If a client becomes cyanotic or restless or develops tachycardia, bradycardia, or another abnormal heart rhythm, the nurse must discontinue suctioning until the client is stabilized. The nurse would also notify the RN. It is also important to monitor the vital signs and the pulse oximetry. If the client's condition continues to deteriorate, then the respiratory department and PHCP may need to be notified. There is no data in the question that indicates that the rapid response team needs to be notified. Client Needs: Physiological Integrity Cognitive Ability: Analyzing Content Area: Adult Health: Respiratory Integrated Process: Nursing Process/Implementation Priority Concepts: Fluids and Electrolytes, Gas Exchange Strategy(ies): ABCs—Airway, Breathing, Circulation, Subject

The nurse has provided instructions to the mother of an infant with viral pneumonia. Which statement by the mother would indicate the need for further teaching? 1. "I understand I will need to have my baby on antibiotics for this pneumonia." 2. "I will need to give a cough suppressant before meals if his cough gets too bad." 3. "I will be careful and allow my baby to sleep, so he can conserve energy and fight this infection." 4. "I understand that my baby has viral pneumonia and I need to monitor his temperature because of the risk for febrile seizures."

1 Rationale: The child with viral pneumonia will not be prescribed antibiotics, it is bacterial pneumonia that requires antibiotics for treatment. It is important to monitor the infant for fever spikes because of the risk for febrile seizures. Use of a cough suppressant may be prescribed before rest times and meals if the cough is disturbing and unproductive. Promoting bed rest to conserve energy, encouraging fluid intake and the administration of antipyretics for fever, and bronchodilators are typical interventions for pneumonia.

The home care nurse is visiting a client who was recently diagnosed with type 2 diabetes mellitus. The client, prescribed repaglinide and metformin, asks the nurse to explain these medications. The nurse should reinforce which instructions to the client? Select all that apply. 1. Diarrhea can occur secondary to metformin. 2. The repaglinide is not taken if a meal is skipped. 3. The repaglinide is taken 30 minutes before eating. 4. Candy or another simple sugar is carried and used to treat mild hypoglycemia episodes. 5. Muscle pain is an expected side effect of metformin and may be treated with acetaminophen. 6. Metformin increases hepatic glucose production to prevent hypoglycemia associated with repaglinide.

1, 2,3,4, Rationale: 1. Repaglinide is a rapid-acting oral hypoglycemic agent that stimulates pancreatic insulin secretion that should be taken before meals and that should be withheld if the client does not eat. 2. Hypoglycemia is a side effect of repaglinide, and the client should always be prepared by carrying a simple sugar with her or him at all times. 3. Metformin is an oral hypoglycemic given in combination with repaglinide and works by decreasing hepatic glucose production. 4. A common side effect of metformin is diarrhea. Muscle pain may occur as an adverse effect from metformin, but it also might signify a more serious condition that warrants PHCP notification, not the use of acetaminophen.

The client diagnosed with acquired immunodeficiency syndrome (AIDS) is taking nevirapine. The nurse should monitor for which side/adverse effects of the medication? Select all that apply.R 1. Rash 2. Hepatotoxicity 3. Hyperglycemia 4. Peripheral neuropathy 5. Reduced bone mineral density

1,2 Rationale: Nevirapine is a nonnucleoside reverse transcriptase inhibitor that is used to treat HIV infection. It is used in combination with other antiretroviral medications to treat HIV. Adverse effects include rash, Stevens-Johnson syndrome, hepatitis, and increased transaminase levels. Hyperglycemia, peripheral neuropathy, and reduced bone density are not side/adverse effects of this medication. ationale: Nevirapine is a nonnucleoside reverse transcriptase inhibitor that is used to treat HIV infection. It is used in combination with other antiretroviral medications to treat HIV. Adverse effects include rash, Stevens-Johnson syndrome, hepatitis, and increased transaminase levels. Hyperglycemia, peripheral neuropathy, and reduced bone density are not side/adverse effects of this medication. Client Needs: Physiological Integrity Cognitive Ability: Analyzing Content Area: Pharmacology: Immune Medications Integrated Process: Nursing Process/Data Collection Priority Concepts: Cellular Regulation, Infection Strategy(ies): Subject

The nurse is preparing for the admission of an infant with a diagnosis of bronchiolitis caused by the respiratory syncytial virus (RSV). Which interventions should be included in the plan of care? Select all that apply. 1. Place the infant in a private room. 2. Place the infant in a room near the nurses' station. 3. Ensure that the infant's head is in a flexed position. 4. Wear a mask at all times when in contact with the infant. 5. Place the child in a tent that delivers warm, humidified air. 6. Position the infant side-lying, with the head lower than the chest.

1,2 Rationale: The infant with RSV should be isolated in a 1. private room or in a room with another child with RSV. 2. The infant should be placed in a room near the nurses' station for close observation. 3. The infant should be positioned with the head and chest at a 30- to 40-degree angle and the neck slightly extended to maintain an open airway and to decrease pressure on the diaphragm. 4. Cool, humidified oxygen is delivered to relieve dyspnea, hypoxemia, and insensible water loss from tachypnea. 5. Contact precautions (wearing gloves and a gown) reduce the nosocomial transmission of RSV.

The nurse is reviewing the prescriptions of a client admitted to the hospital with a diagnosis of acute pancreatitis. Which interventions should the nurse expect to be prescribed? Select all that apply 1. Administer antacids, as prescribed. 2. Encourage coughing and deep breathing. 3. Administer anticholinergics, as prescribed. 4. Maintain the client in a supine and flat position. 5. Encourage small, frequent, high-calorie feedings.

1,2,3 Rationale: The client with acute pancreatitis is normally placed on an 1. NPO status to rest the pancreas and suppress GI secretions. 2. Because abdominal pain is a prominent symptom of pancreatitis, pain medication will be prescribed. 3. Some clients experience lessened pain by assuming positions that flex the trunk and draw the knees up to the chest. A side-lying position with the head elevated 45 degrees decreases tension on the abdomen and may also help ease the pain. 4. The client is susceptible to respiratory infections because the retroperitoneal fluid raises the diaphragm, which causes the client to take shallow, guarded abdominal breaths. 5. Therefore, measures such as turning, coughing, and deep breathing are instituted. 6. Antacids and anticholinergics may be prescribed to suppress GI secretions.

The nurse is preparing a list of self-care instructions for a postpartum client who has been diagnosed with mastitis. Which instructions should be included on the list? Select all that apply. 1. Rest during the acute phase. 2. Wear a supportive, nonunderwire bra. 3. Maintain a fluid intake of at least 3000 mL. 4. Continue to breastfeed if the breasts are not too sore. 5. Take prescribed antibiotics until the soreness subsides. 6. Avoid decompression of the breasts by breastfeeding or breast pumping.

1,2,3,4 Rationale: 1. resting during the acute phase, 2.wearing a supportive nonunderwire bra, 3. maintaining a fluid intake of at least 3000 mL per day, and 3. taking analgesics to relieve discomfort. 4. Antibiotics may be prescribed and are taken until the complete prescribed course is finished. 5. They are not stopped when the soreness subsides. 6. Additional supportive measures include the use of moist heat or ice packs. 7. Continued decompression of the breast by breastfeeding or breast pump is important to empty the breast and prevent the formation of an abscess.

The nurse is planning care for a child with hemolytic-uremic syndrome (HUS). The child has been anuric and will be receiving peritoneal dialysis treatment. The nurse should plan to include which interventions in the care of the child? Select all that apply. 1. Provide adequate nutrition. 2. Restrict fluids, as prescribed. 3. Institute measures to prevent infection. 4. Monitor the arteriovenous (AV) fistula. 5. Administer blood products to treat severe anemia. 6. Anticipate the child will have central nervous system involvement.

1,2,3,5,6 Rationale: HUS is thought to be associated with bacterial toxins, chemicals, and viruses that cause acute kidney injury in children. A child with HUS who is undergoing peritoneal dialysis for the treatment of anuria will be prescribed fluid restrictions. The treatment also involves providing adequate nutrition, preventing infection and anticipating CNS involvement which may include seizure, stupor, and coma. Peritoneal dialysis does not require an AV fistula (only hemodialysis does).

The nurse is planning to begin a continuous tube feeding on a client with a nasogastric (NG) tube. Which interventions should the nurse perform before initiating the feeding? Select all that apply. 1. Explain the procedure to the client. 2. Irrigate the NG tube with saline. 3. Aspirate all stomach contents and discard. 4. Elevate the head of the bed to 45 degrees. 5. Have a pair of scissors for emergency use at the bedside. 6. Ensure that the end of the NG tube is in the esophagus.

1,2,4 Rationale: When a tube feeding is initiated, the most important intervention is to 1. make sure the NG tube is properly placed in the stomach to prevent aspiration of the formula. After explaining the procedure to the client and assessing placement of the tube, 2. the nurse should irrigate the tube with saline to ensure the formula flows well through the tube. When a tube feeding is administered, 3. the client is placed in a high-Fowler's position for a bolus feeding and in a semi-Fowler's position (30-45 degrees) for a continuous feeding to allow gravity to help the flow of formula and to prevent reflux and aspiration. 4. There is no need to aspirate contents because the formula has not been given and the contents are gastric secretions. 5. Scissors are not kept at the bedside with an NG tube but with the Sengstaken-Blakemore tube used to treat bleeding esophageal varices. 6.The correct placement for the end of the NG tube is in the *stomach*, not the esophagus.

A client is being prepared for a thoracentesis. The nurse reinforces instructions with the client given by the registered nurse. Which points should be included in the instructions? Select all that apply. 1. The client leans over a bedside table. 2. The client should sit on the edge of the bed. 3. The procedure involves obtaining a biopsy. 4. A time-out is performed before the procedure. 5. The procedure is performed during a bronchoscopy. 6. A local anesthetic is administered before the procedure.

1,2,4.6 The "time out" represents the final recapitulation and reassurance of accurate patient identity, surgical site, and planned procedure. Rationale: A thoracentesis is a procedure in which fluid is removed from the pleural space. i) involves insertion of a needle percutaneously and then removal of the fluid by connecting the needle to a vacuum bottle. ii) Before the thoracentesis, the nurse needs to check for allergies because a local anesthetic is administered. iii) A time-out is performed in which the client identification, coagulation studies, and area of the pleural effusion is verified. iv) A chest x-ray is performed after the procedure. A potential complication is a pneumothorax. *Position* : v) The client sits on the bedside and leans over a bedside table, which exposes the area between the ribs. vi) A lung biopsy is often done during a *bronchoscopy*.

he nurse is told that an assigned client will have a fenestrated tracheostomy tube inserted. The nurse plans care knowing that which facts are true with the use of a fenestrated tracheostomy tube? Select all that apply. 1.Enables the client to speak 2.Is necessary for mechanical ventilation 3.Must have the cuff deflated when capped 4.Eliminates the need for tracheostomy care 5.Prevents air from being inhaled through the tracheostomy opening

1,3 Rationale: A fenestrated tracheostomy tube is used when a client is being weaned from breathing through the tracheostomy to breathing normally through the nose and mouth. 1. A fenestrated tube has a small opening in the outer cannula that allows some air to escape through the larynx; this type of tube enables the client to speak. 2. The cuff of the tracheostomy tube must always be *deflated* before the fenestrated tube is capped. When the cuff is inflated, 3. the tracheostomy tube can be used for mechanical ventilation. When the cuff is deflated and the cap is applied, the client can breathe around the tracheostomy tube. 4. The client continues to need cleaning of the tracheostomy site. The client is unable to breathe through the tracheal opening or at all if the cuff is inflated and the opening capped.

The nurse is monitoring a client in preterm labor who is receiving intravenous magnesium sulfate. The nurse should monitor for which adverse effects of this medication? Select all that apply. 1. Flushing 2. Hypertension 3. Increased urine output 4. Depressed respirations 5. Extreme muscle weakness 6. Hyperactive deep tendon reflexes

1,4,5 Rationale: 1. Magnesium sulfate is a central nervous system depressant and relaxes smooth muscle, including the uterus. 2. It is used to halt preterm labor contractions and is used for preeclamptic clients to prevent seizure. 3. Adverse effects include i) *flushing*, ii) *depressed respirations*, iii) *depressed deep tendon reflexes*, iv) *hypotension*, v) *extreme muscle weakness*, v) *decreased urine output*, vi) *pulmonary edema*, and vii) *elevated serum magnesium levels*.

The nurse is preparing to administer an intermittent tube feeding to a client with a nasogastric (NG) tube. The nurse checks the residual and obtains an amount of 200 mL. Which actions should the nurse take? Select all that apply. 1. Listen to the client's bowel sounds. 2. Document and discard the residual. 3. Offer the client sips of water to drink. 4. Question the client regarding nausea. 5. Determine whether the client has abdominal distension. 6. Hold the feeding after flushing the tubing with 30 mL saline.

1,4,5,6 Rationale: Large-volume aspirates in clients receiving intermittent tube feedings indicate delayed gastric emptying and place the client at risk for aspiration. The nurse should obtain data concerning the 1. p resence of nausea, bowel sounds, and abdominal distention indicating possible bowel obstruction. When 200 mL of residual formula is obtained, 2. the feeding is held and the RN is notified because this is an indication that the feeding is not being absorbed. If the residual is less than 100 mL, the feeding is usually administered. 3. If the feeding will be held, the tubing should be flushed with 30 mL saline to decrease the risk of the tube clogging from residual formula. 4. In addition, the nurse should always check the PHCP's prescriptions and agency policy regarding residual amounts. 5. The residual amount should be documented, but the residual aspirated is returned to the client to avoid electrolyte imbalance. There is no indication to give the client sips of water.

The nurse has provided discharge instructions to a client with an application of a halo device. The nurse determines that the client needs further teaching if which statement is made? 1. "I will use a straw for drinking." 2. "I will drive only during the daytime." 3. "I will use caution because the device alters balance." 4. "I will wash the skin daily under the lamb's-wool liner of the vest."

2 ationale: The client should not drive because the device impairs the range of vision. The halo device alters balance and can cause fatigue because of its weight. The client should cleanse the skin daily under the vest or the device to protect the skin from ulceration and should use powder or lotions sparingly or not at all. The wool liner should be changed if odor becomes a problem. The client should have food cut into small pieces to facilitate chewing and use a straw for drinking. Pin care is done as instructed.

A licensed practical nurse (LPN) is preparing to assist a registered nurse (RN) with removing a nasogastric (NG) tube from the client. Which interventions should be included in the procedure? Select all that apply 1. Remove the air from the balloon. 2. Explain the procedure to the client. 3. Ask the client to take a deep breath and hold. 4. Pull the tube out in one continuous steady motion. 5. Remove the device or tape securing the tube from the nose.

2,3,4,5 Rationale: Before removing the tube, the client should be told about the procedure and review the instructions. The tape or securing device needs to be removed from the client's nose. When the NG tube is removed, the client is instructed to take and hold a deep breath. This will close the epiglottis, and the airway will be temporarily obstructed during the tube removal. This allows for the easy withdrawal of the tube through the esophagus into the nose. The tube is removed with one very smooth, continuous pull. There is no balloon that needs to be deflated on an NG tube.

The nurse is assigned to assist the primary health care provider (PHCP) with the removal of a chest tube. Which interventions should the nurse anticipate performing during this process? Select all that apply. 1. Reinforce instructions to breathe deeply while the tube is removed. 2. Cover the site with an occlusive dressing after the tube is removed. 3. Clamp the chest tube near the insertion site just before the removal. 4. Raise the drainage system to the level of the chest tube insertion site. 5. Have the client perform the Valsalva maneuver as the chest tube is pulled out.

2,5 Rationale: A chest tube is removed when the lung has fully reexpanded or there is limited drainage. 1. When the chest tube is removed, the client is asked to perform a *Valsalva maneuver* (i.e., take a deep breath, exhale, and bear down), 2. the tube is quickly withdrawn, and an airtight (occlusive) dressing is taped in place. An alternative instruction is to ask the client to take a deep breath and hold the breath while the tube is removed. After the tube is removed, 3. the client should take deep breaths to ensure adequate lung expansion. 4> The tube is *not usually clamped* before it is removed, and the drainage apparatus 5. must always be lower than the chest tube site.

The nurse is preparing to set up a sterile field using the principles of aseptic technique to perform a dressing change. Which should the nurse include in the preparations? Select all that apply. 1. Use a dry table that is below waist level. 2. Open the distal flap of a sterile package first. 3. Prepare the sterile field just before the planned procedure. 4. Don clean gloves before touching items on the sterile field. 5. Place the sterile field 1 foot behind the working area and out of view of the client. 6. Avoid placing items within 1 inch of any area surrounding the outer edge of the sterile field.

2. 3, 6 Rationale: 1. Sterile packages are opened away from the nurse's body, and the distal flap of a sterile package is opened first. This prevents contaminating the pack by reaching over the exposed sterile contents after the other flaps are opened (option 2). 2. To avoid contamination, the sterile field should be prepared just before the planned procedure, and supplies should be used immediately (option 3). 3. The outer 1-inch border of the sterile field must be considered unsterile, and sterile items are not placed within this 1-inch area (option 6). 4. A dry table that is at waist level (not below) is used to set up a sterile field. 5. Moisture will contaminate the sterile field, and anything below waist level is considered contaminated, according to the principles of surgical asepsis. 6. The sterile field must be kept in sight at all times, and the nurse should not turn away from it. If this happens, the nurse cannot be sure that it is still sterile. 7. Sterile gloves, not clean gloves, are used. An unsterile item touching a sterile item contaminates the sterile item.

The nurse should implement which interventions for a child older than 2 years with type 1 diabetes mellitus who has a blood glucose level of 60 mg/dL (3.4 mmol/L)? Select all that apply. Client Needs: Physiological Integrity Cognitive Ability: Analyzing Content Area: Pediatrics: Metabolic/Endocrine Integrated Process: Nursing Process/Implementation Priority Concepts: Clinical Judgment, Glucose Regulation Strategy(ies): Subject 1. Administer regular insulin. 2. Encourage the child to ambulate. 3. Give the child a teaspoon of honey. 4. Provide electrolyte replacement therapy intravenously. 5. Wait 30 minutes and confirm the blood glucose reading. 6. Prepare to administer glucagon subcutaneously if unconsciousness occurs.

3,6 Rationale: Hypoglycemia is defined as a blood glucose level less than 70 mg/dL (4 mmol/L). Hypoglycemia occurs as a result of too much insulin, not enough food, or excessive activity. If possible, the nurse should confirm hypoglycemia with a blood glucose reading. Glucose is administered orally immediately; 2 rapid-releasing glucose is followed by a complex carbohydrate and protein, such as a slice of bread or a peanut butter cracker. An extra snack is given if the next meal is not planned for more than 30 minutes or if activity is planned. 3 If the child becomes unconscious, cake frosting or glucose paste is squeezed onto the gums, and the blood glucose level is retested in 15 minutes; if the reading remains low, additional glucose is administered. If the child remains unconscious, administration of 4 glucagon may be necessary, and the nurse should be prepared for this intervention. Encouraging the child to ambulate and administering regular insulin would result in a lowered blood glucose level. 5 Providing electrolyte replacement therapy intravenously is an intervention to treat * *diabetic ketoacidosis*. Waiting 30 minutes to confirm the blood glucose level delays necessary intervention.

The nurse should expect to note which interventions in the plan of care for a client with hypothyroidism? Select all that apply. 1. Provide a cool environment for the client. 2. Instruct the client to consume a high-fat diet. 3. Instruct the client about thyroid replacement therapy. 4. Encourage the client to consume fluids and high-fiber foods. 5. Inform the client that iodine preparations will be prescribed to treat the disorder. 6. Instruct the client to contact the primary health care provider (PHCP) if episodes of chest pain occur.

3. 4.6 Rationale: The clinical manifestations of hypothyroidism are the result of decreased metabolism from low levels of thyroid hormone. Interventions are aimed at replacement of the hormones and providing measures to support the signs and symptoms related to a decreased metabolism. The nurse encourages the client to consume a well-balanced diet that is low in fat for weight reduction and high in fluids and high-fiber foods to prevent constipation. The client often has cold intolerance and requires a warm environment. The client would notify the PHCP if chest pain occurs because it could be an indication of overreplacement of thyroid hormone. Iodine preparations are used to treat hyperthyroidism. These medications decrease blood flow through the thyroid gland and reduce the production and release of thyroid hormone.

The nurse is reinforcing instructions to a client regarding how to decrease the intake of phosphorus in the diet. The nurse should tell the client that which food items are allowed with few restrictions in a phosphorus-restricted diet? Select all that apply. 1. Fish 2. Apples 3. Almonds 4. White bread 5. Egg whites 6. Whole-grain pasta

Rationale: Phosphorus is in many foods, especially meats, dairy, and whole grains. Foods *low in phosphorus* include 1 apples, 2. white bread, and 3. egg whites. 1. Fish, 2. almonds, and 3. whole grain pasta have significant amounts of phosphorus. *pHosperous* - for PH and H for White bread/ white eggs. and apple ( white inside ) -- LOW

The nurse is asked to assist with preparing a client who will be receiving a continuous total parenteral nutrition (TPN) solution via a central line. The nurse plans to institute which interventions for this client related to the TPN? Select all that apply. 1. Central line dressing changes per protocol 2. Blood glucose monitoring around the clock 3. Monitoring central venous pressure every shift 4. Using an electronic infusion pump with the infusion 5. Applying sequential compression devices (SCD) to the legs 6. Reviewing prescribed blood laboratory values including electrolytes

Rationale: 1,2,4,6 The client receiving TPN is at an increased risk for fluid and electrolyte imbalance, hyperglycemia, and infection. 1. The central line dressing is changed according to protocols set up to prevent infection. 2. The TPN rate of infusion needs to be closely regulated with use of an electron infusion pump. 3. The TPN contains increased concentration of glucose, so the blood glucose levels are monitored around the clock. 4. Blood laboratory values are monitored often (3 times per week) because the electrolyte balance is totally dependent on the prescribed TPN solution. 5. The TPN formula is adjusted and prescribed according to the client's laboratory results. 6. Administration of TPN does not involve monitoring central venous pressure although that is possible through a central intravenous line. The client will be able to ambulate and so SCD are not required but may be prescribed for other reasons.

The nurse in a medical unit is caring for a client with heart failure. The client suddenly develops extreme dyspnea, tachycardia, and lung crackles, and the nurse suspects pulmonary edema. The nurse immediately notifies the registered nurse (RN) and expects which interventions to be prescribed? Select all that apply. 1. Administering oxygen 2. Inserting a Foley catheter 3. Administering furosemide 4. Administering morphine sulfate intravenously 5. Transporting the client to the coronary care unit 6. Placing the client in a low-Fowler's side-lying position

Rationale: 1,3,4,5 Pulmonary edema is a life-threatening event that can result from severe heart failure. During pulmonary edema the left ventricle fails to eject sufficient blood, and pressure increases in the lungs because of the accumulated blood. 1. Oxygen is always prescribed, and the client is placed in a 2. high-Fowler's position to ease the work of breathing. 3. Furosemide, a rapid-acting diuretic, will eliminate accumulated fluid. 4.A Foley catheter is inserted to accurately measure output. Intravenously administered 5. morphine sulfate reduces venous return (preload), decreases anxiety, and reduces the work of breathing. Transporting the client to the coronary care unit is not a priority intervention. In fact, this may not be necessary at all if the client's response to treatment is successful.

The nurse is preparing to administer an enema to an adult client. Which interventions should the nurse plan to perform for this procedure? Select all that apply. 1. Apply disposable gloves. 2. Place the client in the right Sims' position. 3. Lubricate the enema tube and insert it approximately 4 inches. 4. Clamp the tubing if the client expresses discomfort during the procedure. 5. Hang the enema solution container 24 inches above the client's anus. 6. Ensure that the temperature of the solution is between 100° F (37.8° C) and 105° F (40.5° C).

Rationale: 1,3,4,6 The administration of an enema is a clean procedure, and standard precautions must be used. 1. The nurse applies disposable gloves when administering an enema to prevent the transfer of microorganisms. 2. To administer an enema, the nurse places the client in the left Sims' position because the enema solution will flow downward by gravity along the natural curve of the sigmoid colon and rectum, improving retention of the enema solution. 3. The tube is *lubricated* for easy insertion and is inserted approximately *3 to 4 inches* in an adult. 4. If the client complains of cramping or discomfort during the procedure, the nurse *clamps* the tubing until the discomfort subsides. 5. The container containing the enema solution is hung about *12 to 18 inches* above the client's anus. 6. A flow of solution that is too forceful can damage the bowel. The temperature of the solution should be between * *100° F (37.8° C) and 105° F (40.5° C)*. Solution that is too hot will burn the client, and solution that is too cool will cause cramping.

The nurse is reviewing the laboratory results of a client who is receiving chemotherapy and notes that the platelet count is 10,000 mm3 (10 × 109/L). On the basis of this laboratory value, the nurse should perform which interventions? Select all that apply. 1. Monitor stools for occult blood. 2. Keep away from persons who have colds or feel ill. 3. Instruct the client not to bend over at the waist or lift. 4. Floss teeth and rinse mouth with mouthwash after every meal. 5. Instruct the client to blow nose very gently without blocking either nostril.

Rationale: 1,3,5 Platelets or thrombocytes are necessary for a client to clot. A high risk of hemorrhage exists when the platelet count drops below 20,000 mm3 (20 × 109/L). Fatal central nervous system hemorrhage or massive GI hemorrhage can occur when the platelet count is less than 10,000 mm3 (10 × 109/L). The client may be treated with medications or platelet or blood transfusions to improve the platelet count. The nurse should monitor the 1. client's stools for blood, both obvious and occult. 2. The client should be very gentle if blowing the nose and not cause any pressure to build up in the head. 3. The client also needs to avoid starting bleeding from epistaxis (nosebleed). 4. The client should not bend over at the waist because this action would increase the pressure within the head and increase the risk for an intracerebral bleed. 5. Clients with decreased immunity, which is not stated in the question, should avoid ill persons. The client should not floss the teeth and only use a soft toothbrush to avoid bleeding in the mouth.

restraints

The belt restraint should be secure, and one to two fingers should easily slide between the restraint and the client's skin. The client should be able to turn from back to side while in the restraint. A purpose of a restraint is to remind the client not to get out of bed alone.

Cyclobenzaprine is prescribed for a client to treat muscle spasms, and the nurse is reviewing the client's record. Which disorder would indicate a need to contact the primary health care provider (PHCP) regarding the administration of this medication? 1. Glaucoma 2. Emphysema 3. Hyperthyroidism 4. Diabetes mellitus

1 Rationale: Because this medication has anticholinergic effects, it should be used with caution in clients with a history of urinary retention, angle-closure glaucoma, and increased intraocular pressure. Cyclobenzaprine hydrochloride should be used only for short-term 2- to 3-week therapy. The disorders in options 2, 3, and 4 are not a concern when the client is taking cyclobenzaprine.

MAOI medications

1. Isoxarboxazid ( marplan ) 2.Selegiline ( emsam) 3. Phenelzine ( Nardil ) 4. Tranylcypromine ( Parnate )

squamous cell carcinoma

squeeze out the bump

During the monitoring of a client's response to disease-modifying antirheumatic drugs (DMARDs), which findings should the nurse interpret as acceptable responses? Select all that apply. 1. Symptom control during periods of emotional stress 2. Normal white blood cell, platelet, and neutrophil counts 3. Radiological findings that show nonprogression of joint degeneration 4. An increased range of motion in the affected joints 3 months into therapy 5. Inflammation and irritation at the injection site 3 days after injection is given 6. A low-grade temperature when rising in the morning that remains throughout the day

1, 2, 3, 4, Rationale: Because emotional stress frequently exacerbates the symptoms of rheumatoid arthritis, the absence of symptoms is a positive finding. DMARDs are given to slow progression of joint degeneration. In addition, the improvement in the range of motion after 3 months of therapy with normal blood work is a positive finding. Temperature elevation and inflammation and irritation at the medication injection site could indicate signs of infection.

Rifabutin is prescribed for a client with active Mycobacterium avium complex (MAC) disease and tuberculosis. The nurse should monitor for which side/adverse effects of the medication? Select all that apply. 1. Signs of hepatitis 2. Flu-like syndrome 3. Low neutrophil count 4. Vitamin B6 deficiency 5. Ocular pain or blurred vision 6. Tingling and numbness of the fingers

1,2,3, 5 Rationale: Rifabutin may be prescribed for a client with active MAC disease and tuberculosis. It inhibits mycobacterial DNA-dependent RNA polymerase and suppresses protein synthesis. 1. Side effects include *rash, GI disturbances, neutropenia (low neutrophil count), red-orange body secretions, uveitis (blurred vision and eye pain), myositis, arthralgia, hepatitis, chest pain with dyspnea, and flu-like syndrome*. 2. Vitamin B6 deficiency and numbness and tingling in the extremities are associated with the use of isoniazid. Ethambutol also causes peripheral neuritis.

The client is diagnosed with pleurisy. The nurse should expect to see which signs and symptoms? Select all that apply. 1. Pleural friction rub 2. Sharp, knife-like pain 3. Cyanosis of lips and nailbeds 4. Pain that occurs on both sides of the chest 5. Pain that occurs most often during inspiration

1,2,5 Rationale: Pleurisy is inflammation of the pleura. The most characteristic symptom of pleurisy is 1. abrupt and severe pain. The pain almost always occurs on one side of the chest. 2. Pleurisy pain is sharp, knife-like, and abrupt in onset and is most evident during inspiration. 3. This causes shallow breathing. A pleural friction rub may be heard.

A child is admitted to the hospital with a probable diagnosis of nephrotic syndrome. Which findings should the nurse expect to observe? Select all that apply. 1. Ascites 2. Anorexia 3. Weight loss 4. Proteinuria 5. Decreased serum lipids 6. Periorbital and facial edema

1,4,6 Rationale: Nephrotic syndrome is a kidney disorder that is characterized by 1. massive proteinuria, 2. hypoalbuminemia, 3. periorbital and facial edema, 4. ascites, 5. elevated serum lipids, and 6. anorexia. 7. The urine volume is decreased and the urine is *dark and frothy* in appearance. 8The child with this condition gains weight.

The nurse is applying a topical corticosteroid to a client with eczema. The nurse should apply the medication to which body area? Select all that apply. 1. Back 2. Axilla 3. Eyelids 4. Soles of the feet 5. Palms of the hands

1.4.5.6 Rationale: Topical corticosteroids can be absorbed into the systemic circulation. Absorption is higher from regions where the skin is especially permeable (scalp, axilla, face, eyelids, neck, perineum, genitalia), and lower from regions where permeability is poor (back, palms, soles). The nurse should avoid areas of higher absorption to prevent systemic absorption.

he nurse is evaluating the client's use of a cane for left-sided weakness. The nurse should intervene and correct the client if the nurse observed that the client performed which action? 1. Holds the cane on the right side 2. Moves the cane when the right leg is moved 3. Leans on the cane when the right leg swings through 4. Keeps the cane 6 inches out to the side of the right foot

2 Rationale: The cane is held on the stronger side to minimize stress on the affected extremity and provide a wide base of support. The cane is held 6 inches lateral to the fifth great toe. The cane is moved forward with the affected leg. The client leans on the cane for added support, while the stronger side swings through.

The nurse caring for an infant with congenital heart disease is monitoring the infant closely for signs of heart failure (HF). The nurse should observe for which early sign of HF? Select all that apply. 1. Cough 2. Irritability 3. Scalp diaphoresis 4. Tachypnea, tachycardia 5. Slow and shallow breathing

2,3,4 Rationale: The early signs of HF include tachycardia, tachypnea, profuse scalp sweating, fatigue, irritability, sudden weight gain, and respiratory distress. A cough may occur with HF as a result of mucosal swelling and irritation, but it is not an early sign. Slow and shallow breathing is not associated with heart failure.

he nurse is assigned to care for a child who is scheduled for an appendectomy. Which prescriptions should the nurse anticipate to be prescribed? Select all that apply. 1. Administer a Fleet enema. 2. Initiate an intravenous line. 3. Maintain nothing-by-mouth status. 4. Administer intravenous antibiotics. 5. Administer preoperative medications. 6. Place a heating pad on the abdomen to decrease pain.

2,3,4,5, Rationale: During the preoperative period, enemas or laxatives should not be administered. In addition, heat should not be applied to the abdomen. Any of these interventions can cause the rupture of the appendix and resultant peritonitis. Intravenous fluids would be started, and the child should receive nothing by mouth while awaiting surgery. Antibiotics are usually administered because of the risk of perforation. Preoperative medications are administered as prescribed.

The nurse is reviewing the primary health care provider's (PHCP'S) prescriptions written for a client admitted with acute pancreatitis. Which PHCP prescription should the nurse verify if noted in the client's chart? 1. NPO status 2. An anticholinergic medication 3. Supine and flat client positioning 4. Insertion of a nasogastric tube

3 Rationale: The pain associated with acute pancreatitis is aggravated when the client lies in a supine and flat position. Therefore, the nurse would verify this prescription. Options 1, 2, and 4 are appropriate interventions for the client with acute pancreatitis.

The client is receiving external radiation to the neck for cancer of the larynx. The nurse monitors the client knowing that which are side/adverse effects of the external radiation? Select all that apply. 1. Dyspnea 2. Diarrhea 3. Sore throat 4. Constipation 5. Red and dry skin over neck

3,5 Rationale: External radiation is used to treat cancer in a specific area by emission of ionizing radiation beams that destroy cancer cells and have minimal damage to the surrounding normal cells. The client receiving external radiation experiences both general side/adverse effects such as 1. fatigue, nausea, anorexia and localized side/adverse effects in the specific area receiving radiation. 2. A client who is receiving radiation to the larynx is most likely to experience a i) sore throat and dry, ii) reddened skin in the throat area. 3. Diarrhea or constipation occur with radiation to the gastrointestinal (GI) tract. 4. Dyspnea may occur with lung involvement.

A licensed practical nurse (LPN) attends a session about bioterrorism agents including anthrax. Which statement by an attendee demonstrates the need for further teaching about anthrax? 1. Anthrax is treated with antibiotic medications. 2. The most lethal form of anthrax is contacted by inhalation of the spores. 3. Anthrax can be transmitted by consumption of meat from an infected animal. 4. Anthrax bacteria produces a neurotoxin leading to a serious, possibly fatal paralysis.

Ans : 4 Rationale: Anthrax is caused by Bacillus anthracis, and it can be contracted through the digestive system, abrasions in the skin, or inhalation. Antibiotics are administered. Botulism is caused by a neurotoxin that causes severe paralysis and can be fatal.

A licensed practical nurse is explaining the appropriate methods for measuring an accurate temperature to an unlicensed assistive personnel (UAP). Which method, if noted by the UAP as being an appropriate method, indicates the need for further teaching? 1 Taking a rectal temperature for a client who has undergone nasal surgery 2. Taking an oral temperature for a client with a cough and nasal congestion 3. Taking an axillary temperature on a client who has just consumed hot coffee 4. Taking a temporal temperature on the neck behind the ear on a client who is diaphoretic

Ans: 2 Rationale: An oral temperature should be avoided if the client has nasal congestion. One of the other methods of measuring the temperature should be used according to the equipment available. Taking a rectal temperature for a client who has undergone nasal surgery is appropriate. Other, less invasive measures should be used if available; if not available, a rectal temperature is acceptable. Taking an axillary temperature on a client who just consumed coffee is also acceptable; however, the axillary method of measurement is the least reliable, and other methods should be used if available. If temporal equipment is available and the client is diaphoretic, it is acceptable to measure the temperature on the neck behind the ear, avoiding the forehead.

The nurse is reviewing the client's record and notes that the primary health care provider (PHCP) has documented that the client has a renal disorder. Which laboratory results would indicate a decrease in renal function? Select all that apply. 1. Elevated serum creatinine level 2. Elevated thrombocyte cell count 3. Decreased red blood cell (RBC) count 4. Decreased white blood cell (WBC) count 5. Elevated blood urea nitrogen (BUN) level

Rationale: 1,5 BUN testing is a frequently used laboratory test to determine renal function. The BUN and serum creatinine levels start to rise when the glomerular filtration rate falls below 40% to 60%. A decreased RBC count may be noted if erythropoietic function by the kidney is impaired. An increased WBC is most likely to be noted in renal disease. Thrombocyte cell counts do not indicate decreased renal function.

The nurse is educating a new nurse about mass casualty events (disasters). Which statement by the new nurse indicates a need for further teaching? Select all that apply 1. "An event is termed a mass casualty when it overwhelms local medical capabilities. 2. "Mass casualty events do not require an increase in the number of staff that are needed." 3. "A mass casualty event occurs only within the heath care facility and could endanger staff." 4. "Mass casualty events may require the collaboration of many local agencies to handle the situation." 5. "A mass casualty event occurs if a fight between visitors occurs in the emergency department."

.2, 3, 5 Rationale: Mass casualty events, also known as disasters, overwhelm local medical capabilities and may require the *collaboration of multiple* agencies and health care facilities to handle the crises. This type of event can occur in the *health care* facility or *outside of it* .*Fights in the emergency department are not termed mass casualty events* but are agency security and local enforcement issues. Mass casualty events almost always require an increase in staffing to ensure safe client care.

The nurse is reinforcing home-care instructions to the parents of a 3-year-old child with scabies. Which statement by a parent indicates the need for further teaching? 1. "I understand that I need to leave the scabicide on for 4 hours before washing it off." 2. "I will need to seal up all my child's nonwashable toys in a plastic bag for at least 4 days." 3. "I realize that everyone who has come in contact with my child will need to be treated for scabies." 4. "I know I need to wash all the clothing and bedding in hot water with detergent and dry in a hot dryer."

1 Rationale: The treatment for scabies involves applying a scabicide to cool, dry skin at least 30 minutes after bathing, which needs to be left on the skin for 8 to 14 hours, then washed off. The other statements are correct.

The nurse is assisting in planning care for a client with a chest tube. The nurse should suggest to include which interventions in the plan? Select all that apply. 1. Pin the tubing to the bed linens. 2. Be sure all connections remain airtight. 3. Be sure all connections are taped and secure. 4. Monitor closely for tubing that is kinked or obstructed. 5. Empty the drainage from the drainage collection chamber daily.

2,3,4, Rationale: The chest tube system must be maintained as a closed system in order for the air to be removed by suction and for the lungs to reexpand to a normal state. 1. The connections should be air tight (no leaks), and all connections should be tapes and secure. 2, It is important that the tubes to the suction and the chest tube be patent (without kinks or obstructions). 3. Chest-tube tubing is never pinned to the bed linens because this presents the risk of accidental dislodgment of the tube when the client moves. 4.The chest tube system is not opened and emptied because a * *closed system must be maintained*; if the system is opened, air pressure causes air to rush in, and lung collapse can occur.

The nurse is caring for a client after a Billroth II (gastrojejunostomy) procedure. During review of the postoperative prescriptions, which should the nurse clarify? 1. Leg exercises 2. Early ambulation 3. Irrigating the NG tube 4. Coughing and deep-breathing exercises

3 Rationale: In a Billroth II resection, the proximal remnant of the stomach is anastomosed to the proximal jejunum. Patency of the NG tube is critical for preventing the retention of gastric secretions. The nurse, however, should never irrigate or reposition the NG tube after gastric surgery unless specifically prescribed by the PHCP. In this situation, the nurse should clarify the prescription. Options 1, 2, and 4 are appropriate postoperative interventions.

A client returns to the clinic for follow-up treatment after a skin biopsy of a suspicious lesion that was performed 1 week ago. The biopsy report indicates that the lesion is a melanoma. The nurse understands that which characteristics describe this type of a lesion? Select all that apply. 1. Metastasis is rare. 2. It is encapsulated. 3. It is highly metastatic. 4. It is characterized by local invasion. 5. Lesion is a nevus that has changed in color.

3,6 Rationale: Melanomas are pigmented malignant lesions that originate in the melanin-producing cells of the epidermis. 1. The lesion is a nevus that changes in color. 2. This skin cancer is highly metastatic and a person's survival depends on early diagnosis and treatment. 3. Basal cell carcinomas arise in the basal cell layer of the epidermis. - Early malignant basal cell lesions often go unnoticed, and although metastasis is rare, underlying tissue destruction can progress to include vital structures. 5. Squamous cell carcinomas are malignant neoplasms of the epidermis. - They are characterized by local invasion and the potential for metastasis.

The nurse is assisting with monitoring the functioning of a chest-tube drainage system in a client who just returned from the recovery room after a thoracotomy with wedge resection. Which findings should the nurse expect to note? Select all that apply. 1. Excessive bubbling in the water-seal chamber 2. Vigorous bubbling in the suction-control chamber 3. 50 mL of drainage in the drainage-collection chamber 4. The drainage system is maintained below the client's chest. 5. An occlusive dressing is in place over the chest-tube insertion site. 6. Fluctuation of water in the tube of the water-seal chamber during inhalation and exhalation

3,4,5,6 Rationale: In a thoracotomy the lung is opened and exposed, and a wedge resection is the removal of part of the lung. 1) The chest tube is placed during the surgery to remove fluid and air so the remaining lung can reinflate. 2) The bubbling of water in the water-seal chamber should be gentle and indicates air drainage from the client. This is usually seen when intrathoracic pressure is greater than atmospheric pressure, and it may occur during exhalation, coughing, or sneezing. 3) The fluctuation of water in the tube in the water-seal chamber during inhalation and exhalation is expected. An absence of fluctuation may indicate that the chest tube is obstructed, the lung has reexpanded, or no more air is leaking into the pleural space. 4) Gentle (not vigorous) bubbling should be noted in the suction-control chamber. 5) A total of 50 mL of drainage is not excessive in a client returning to the nursing unit from the recovery room; however, drainage of more than *70 mL/hour to 100 mL/hour* is considered excessive and requires RN and PHCP notification. 6) The chest-tube insertion site is covered with an occlusive (airtight) dressing to prevent air from entering the pleural space. 7) Positioning the drainage system below the client's chest allows gravity to drain the pleural space. 8) Excessive and/or vigorous bubbling in the water-seal chamber may indicate an air leak, which is an unexpected finding.

The nurse is collecting data from a client who has been diagnosed with placenta previa. Which findings should the nurse expect to note? Select all that apply. 1. Uterine rigidity 2. Uterine tenderness 3. Severe abdominal pain 4. Bright red vaginal bleeding 5. Soft, relaxed, nontender uterus

4,5 Rationale: 1. Painless bright red vaginal bleeding during the second or third trimester of pregnancy is a sign of placenta previa. 2, The client will have a soft and relaxed nontender uterus. In clients with abruptio placentae, 3. placental abruption i) Uterine tenderness accompanies placental abruption. ii) feel hard and board-like during palpation as the blood penetrates the myometrium and causes uterine irritability.

The nurse notes that a hospitalized client has experienced a positive reaction to the tuberculin skin test. Which action by the nurse is priority? 1. Report the findings. 2. Document the finding in the client's record. 3. Call the employee health service department. 4. Call the radiology department for a chest x-ray.

Rationale: 1 The nurse who interprets a tuberculin skin test as positive notifies the PHCP immediately. The PHCP would prescribe a chest x-ray to determine whether the client has clinically active tuberculosis or old healed lesions. A sputum culture would be done to confirm the diagnosis of active tuberculosis. The client is placed on tuberculosis precautions prophylactically until a final diagnosis is made. The findings are documented in the client's record, but this action is not the highest priority. Calling the employee health service would be of no benefit to the client.

The client is receiving meperidine hydrochloride for pain. Which signs/symptoms are side and adverse effects of this medication? Select all that apply. 1. Diarrhea 2. Tremors 3. Drowsiness 4. Hypotension 5. Urinary frequency 6. Increased respiratory rate

Rationale: 2,3,4 Meperidine hydrochloride is an opioid analgesic. Side and adverse effects include 1. respiratory depression, 2. drowsiness, 3. hypotension, 4 . constipation, 5. urinary retention, 6. nausea, 7. vomiting, and 8. tremors. O: COnstipation, vOmiting , Nausea p : hyPotension i : o: tremOr i : urInary Retension d Depression Respiratory

Ketoconazole is prescribed for a client with a diagnosis of candidiasis. Which interventions should the nurse include when administering this medication? Select all that apply. 1. Restrict fluid intake. 2. Monitor liver function studies. 3. Instruct the client to avoid alcohol. 4. Administer the medication with an antacid. 5. Instruct the client to avoid exposure to the sun. 6. Administer the medication on an empty stomach.

Rationale: 2,3,5 Ketoconazole is an antifungal medication. 1. It is administered with *food* (not on an empty stomach), and antacids are avoided for 2 hours after taking the medication to ensure absorption. 2. The medication is hepatotoxic, and the nurse monitors *liver function studies*. 3. The client is instructed to avoid exposure to the sun because the medication increases *photosensitivity*. 4. The client is also instructed to avoid *alcohol*. There is no reason for the client to restrict fluid intake. In fact, this could be harmful to the client.

The client with carcinoma of the lung develops the syndrome of inappropriate antidiuretic hormone (SIADH) as a complication of the cancer. Besides treatment of the lung cancer, the nurse anticipates that which interventions may be prescribed to treat the SIADH? Select all that apply. 1.Increase fluid intake. 2.Decrease sodium intake. 3.Institute safety measures. 4.Frequently monitor sodium blood levels. 5.Gather data about the neurological status frequently. 6. Administer medication that is antagonistic to antidiuretic hormone (ADH).

Rationale: 3,4,5,6 Syndrome of inappropriate ADH (SIADH) is a condition in which excessive amounts of water are reabsorbed by the kidney and put into the systemic circulation. 1. The increased water causes hyponatremia (decreased serum sodium levels) and some degree of fluid retention. SIADH is a potential complication associated with cancer, especially small cell lung cancer. SIADH is managed by treating the condition and its cause. 2. The SIADH induces low sodium blood levels and results in altered neurological states, 3. including confusion and unresponsiveness. 4. Treatment of SIADH includes fluid restriction, increased sodium intake, and a medication with a mechanism of action that is antagonistic to ADH, such as demeclocycline. 5. Sodium blood levels and neurological status are monitored closely and 6. safety interventions must be instituted. The client should not be treated with an increase in fluid intake or a decrease in the sodium intake.

anti cholnergic vs. cholnergic

anti cholnergic vs. cholnergic 1.SNS ( Sympath) PNS ( Parasymp) 2 Cant see 2. Yes See 3. Cant Shee 3. Yes shee 4. Can't spit 4. Yes spit / Digest and rest only activate Activate GI fight and flight heart/ lung/ muscles

multiple myeloma

cancer of plasma cells

acute pancreas N/I

p -Pain ( Morphine ) a -Anticholnergic drugs for GI suppression n- NPO c - Coughing. deep breathing exercise r - Replace Fluid shift e - Endocrine enzyme replace a - Antibiotics for Fever s -Steroid

A 4-year-old child is hospitalized with a suspected diagnosis of Wilms' tumor. The nurse reviews the plan of care and should question which intervention that is written in the plan? 1. Palpate the abdomen for a mass. 2. Check the urine for the presence of hematuria. 3. Monitor the blood pressure for the presence of hypertension. 4. Monitor the temperature for the presence of a kidney infection.

1 Rationale: Wilms' tumor is an intraabdominal and kidney tumor. If Wilms' tumor is suspected, the mass should not be palpated. Excessive manipulation can cause seeding of the tumor and thus cause the spread of the cancerous cells. Hematuria, hypertension, and fever are signs and symptoms that are associated with Wilms' tumor.

The nurse reinforces instructions to the parents of a child with leukemia regarding measures related to monitoring for infection. Which statement by the parents indicates the need for further teaching? 1. "I need to use proper hand-washing techniques." 2. "I need to take my child's rectal temperature daily." 3. "I need to inspect my child's skin daily for redness." 4. "I need to inspect my child's mouth daily for lesions."

2 Rationale: The risk of injury to the fragile mucous membranes is so great in the child with leukemia that only oral, axillary, or temporal or tympanic temperatures should be taken. Rectal abscesses can easily occur in damaged rectal tissue, so no rectal temperatures should be taken. In addition, oral temperatures should be avoided if the child has oral ulcers. Options 1, 3, and 4 are appropriate teaching measures.

The nurse is assigned to care for a client with a diagnosis of detached retina. Which findings would indicate that bleeding has occurred as a result of retinal detachment? Select all that apply. 1. Total loss of vision 2. Vision may be cloudy 3. A reddened conjunctiva 4. A sudden sharp pain in the eye 5. Complaints of a burst of black spots or floaters 6. Vision is clear straight ahead but not to the right

2,5 Rationale: Complaints of a sudden burst of black spots or floaters indicate that bleeding has occurred as a result of the detachment. Vision may also be cloudy. Options 1, 3, 4 and 6 are not specifically associated with bleeding as a result of detached retina.

The nurse needs to increase the calcium in the diet of a client who is lactose intolerant. Which food items should the nurse encourage? Select all that apply. 1. Milk 2. Tofu 3. Cheese 4. Broccoli 5. Sardines 6. Mustard greens

2.4,5 Rationale: Lactose-intolerant clients should not eat dairy products. Therefore, these clients need high-calcium foods from nondairy sources. Tofu, broccoli, mustard greens, and sardines are foods that are high in calcium that do not come from dairy sources. Although milk and cheese are high in calcium, they are dairy products, which lactose-intolerant clients need to avoid.

A mother of a child with a diagnosis of intussusception calls the nurse into the hospital room because the child is screaming in pain. Which manifestations of perforation should the nurse report immediately? Select all that apply. 1. Fever 2. Ribbon-like stools 3. Increased heart rate 4. Hypoactive bowel sounds 5. Profuse projectile vomiting 6. Change in the level of consciousness

1, 3,6 Rationale: The child with intussusception classically presents with 1. severe abdominal pain that is crampy and intermittent and that causes the child to draw in his or her knees to the chest. 2. The signs of perforation and shock are evidenced by i) fever, an ii) increased heart rate, a iii) change in the level of consciousness or blood pressure, and iv) respiratory distress and need to be reported immediately. 3. The options for i) hypoactive bowel sounds, profuse projectile ii) vomiting, and iii) ribbon-like stools are a part of the presentation picture of a child with intussusception but are not signs of shock.

The nurse is told in a report that the client has hypocalcemia. Which signs should the nurse expect to note during the data collection? Select all that apply. 1. Coma 2. Tetany 3. A positive Chvostek's sign 4. Hypoactive bowel sounds 5. A positive Trousseau's sign

2,3,5 Rationale: Calcium is an electrolyte that is necessary for muscle movement. The adult normal calcium level is 9 to 10.5 mg/dL (2.25-2.75 mmol/L). A low calcium tends to cause muscle irritability. 1. A positive Chvostek's sign (striking the side of the face and noting twitching) and 2. positive Trousseau's sign (applying a blood pressure cuff and pumping it up above the systolic BP for 3 to 5 minutes results in a carpal spasm or palmar flexion) are indicative of hypocalcemia. Other signs and symptoms include 3. tachycardia, 4. hypotension, 5. paresthesia, twitching, 6. cramps, tetany, seizures, 7. hyperactive bowel sounds, and a 8. prolonged QT interval on the electrocardiogram rhythm.

The nurse is preparing to administer a medication through a nasogastric (NG) tube that is connected to suction. Which interventions should be included to accurately administer the medication? Select all that apply. 1. Position the client supine to assist with medication absorption. 2. Clamp the NG tube for 30 minutes after medication administration. 3. Before medication administration, verify correct placement of tube. 4. Flush the NG tube with saline before and after medication administration. 5. Discontinue the suction from the tube during administration of medication.

2.3,4,5, Rationale: Oral medications are sometimes administered to a client who is prescribed suction through a nasogastric (NG) tube. 1. The nurse must verify that the tube has correct placement by checking drainage characteristics and pH to avoid aspiration of the medication into the trachea. 2. The NG tube should be flushed with saline before and after medication administration to facilitate delivery and promote absorption. 4. The suction must be stopped during administration and then the tube is clamped for 30 minutes afterward. (to increase absorption, and reconnect the suctioning ) 5. The client should be in an upright position at least 30 degrees, but higher is better to avoid aspiration. Medications should not be given in the supine position.

The nurse is preparing to administer an intermittent tube feeding to a client. The nurse aspirates 90 mL of residual from the tube. What should the nurse do? Select all that apply. 1. Hold the feeding. 2. Document the amount of residual. 3. Place it into a container for laboratory analysis. 4. Reinstill the residual and administer the feeding. 5. Deduct the amount of the residual from the new feeding before administering.

2.4 Rationale: 1) Unless otherwise instructed or if the residual contents appear abnormal, an amount of less than 100 mL is reinstilled; 2) then a normal amount of prescribed tube feeding is administered. 3) The amount of residual should be documented. It is important to return the contents to the stomach to prevent electrolyte imbalances. 4) The feeding is not held, and the residual is not sent to the laboratory. The tube feeding should continue at the prescribed rate.

A hospitalized client with coronary artery disease complains of substernal chest pain. After checking the client's heart rate and blood pressure, the nurse administers nitroglycerin, 0.4 mg, sublingually. After 5 minutes, the client states, "My chest still hurts." Which appropriate actions should the nurse take? Select all that apply. 1. Call a code blue. 2. Contact the client's family. 3. Check the client's pain level. 4. Check the client's blood pressure. 5. Administer a second nitroglycerin, 0.4 mg, sublingually.

3,4,5 Rationale: The usual guideline for administering nitroglycerin tablets for a hospitalized client with chest pain is to administer one tablet every 5 minutes PRN for chest pain for a total dose of three tablets. The registered nurse is notified immediately if a client complains of chest pain. In this situation, because the client is still complaining of chest pain, the nurse would administer a second nitroglycerin tablet. The nurse would check the client's pain level and the client's blood pressure before administering each nitroglycerin dose. There are no data in the question that indicate the need to call a code blue. In addition, it is not necessary to contact the client's family unless the client has requested this.

Which findings indicate to the nurse that placental separation has occurred? Select all that apply. 1. Lengthening of umbilical cord 2. Sudden trickle or spurt of blood 3. Fundus is boggy following separation 4. Change from globular to discoid shape 5. Fetal membranes are seen at the introitus

1,2,5 Rationale: As the placenta separates, it settles downward into the lower uterine segment, the umbilical cord lengthens, a sudden trickle or spurt of blood appears and fetal membranes may appear at the introitus. The fundus changes from discoid to globular shape. The fundus should not become boggy.

The nurse is assisting with caring for a client with cancer who is receiving cisplatin. Which adverse effects are associated with this medication? Select all that apply. 1. Tinnitus 2. Ototoxicity 3. Hyperkalemia 4. Hypercalcemia 5. Nephrotoxicity 6. Hypomagnesemia

1,2,5,6 Rationale: Cisplatin is an alkylating medication. 1. Alkylating medications are cell cycle phase nonspecific and affect the synthesis of DNA by causing its cross-linking to inhibit cell reproduction. 2. Cisplatin may cause i) ototoxicity, ii) tinnitus, iii) hypokalemia, iv) hypocalcemia, v) hypomagnesemia, and vi) nephrotoxicity. Amifostine may be administered before cisplatin to reduce the potential for renal toxicity.

The nurse is reviewing the postoperative prescriptions for an infant with hydrocephalus, who came back from surgery with a ventriculoperitoneal shunt. Which of the primary health care provider's prescriptions does the nurse question? 1. Position the infant on the inoperative side. 2. Keep the head of the bed elevated 45 degrees. 3. Monitor for signs of infection and check dressings for drainage. 4. Observe for irritability, a high shrill cry, lethargy, and poor feeding.

2 Rationale: Postoperative management for infants with hydrocephalus who have undergone ventriculoperitoneal shunt should be flat in bed to avoid the rapid reduction of intracranial fluid. Observe for increased ICP, if it occurs elevate the head of the bed to 15 to 30 degrees to enhance gravity flow through the shunt. Position the infant on the inoperative side to prevent pressure on the shunt valve. Monitor for signs of infection and check dressings for drainage. A high shrill cry in an infant can be a sign of increased ICP.

The nurse is preparing to care for a newborn who is receiving phototherapy. Which measures should be implemented? Select all that apply. 1. Avoid stimulation. 2. Decrease fluid intake. 3. Expose all of the newborn's skin. 4. Monitor the skin temperature closely. 5. Reposition the newborn every 2 hours. 6. Cover the newborn's eyes with shields or patches.

4,5,6 Rationale: 1. Phototherapy is the use of intense fluorescent lights to reduce serum bilirubin levels in the newborn. Injury from treatment (e.g., eye damage, dehydration, sensory deprivation) can occur. Interventions include exposing as much of the newborn's skin as possible; 2. however, the genital area is covered. The newborn's eyes are also covered with shields or patches to ensure that the eyelids are closed. 3 The shields or patches are removed at least once per shift to inspect the eyes for infection or irritation and to allow for eye contact. The nurse measures the quantity of light every 8 hours, monitors the skin temperature closely, and increases fluids to compensate for water loss. 4. The newborn will have loose green stools and green-colored urine. The newborn's skin color is monitored with the fluorescent light turned off every 4 to 8 hours, 5. and he or she is monitored for bronze baby syndrome, which is a grayish-brown discoloration of the skin. 6. The newborn is repositioned every 2 hours, and stimulation is provided. After treatment, the newborn is monitored for signs of hyperbilirubinemia, because rebound elevations are normal after therapy is discontinued.

The nurse monitors a 5-year-old child admitted to the hospital for a neuroblastoma for signs and symptoms related to the location of the tumor in the adrenal gland. Which descriptions would the nurse expect to be documented in the child's record specific to this tumor? Select all that apply. 1.Respiratory impairment 2.Anorexia and weight loss 3.Pallor, weakness, irritability 4.Supraorbital ecchymosis and periorbital edema 5.Firm, nontender, irregular mass in the abdomen 6.Urinary frequency or retention from compression on the bladder

5,6 Rationale: The signs and symptoms of a neuroblastoma depend on the location of the tumor. When the tumor is found on the adrenal gland, the findings will be consistent with a firm, nontender, irregular mass in the abdomen. This will likely cause some degree of urinary frequency or retention from compression on the ureter, or kidney.

The nurse is caring for a client with a diagnosis of pemphigus. The nurse should include which interventions in the plan of care for the client? Select all that apply. 1.Administering prescribed acyclovir 2.Applying prescribed topical antibiotic 3.Administering prescribed corticosteroid 4.Administering prescribed oral amphotericin B 5.Applying Domeboro solution to the affected skin

2.3. 5 Rationale: Pemphigus is a chronic autoimmune condition in which 1. Bullae (blisters) develop on the face, back, chest, groin, and umbilicus. 2. The blisters rupture easily, releasing a foul- smelling drainage. 3. Potassium permanganate baths, *Domeboro* solution, and oatmeal products with oil may be prescribed to soothe the affected areas, reduce odor, and decrease the risk of infection. 4. Treatments may include corticosteroids, other immunosuppressants, and oral or topical antibiotics. 5. *Acyclovir* is an antiviral medications used to treat *chickenpox or shingles*. 6. Amphotericin B is an antifungal used to treat fungal infections.

A newborn has just been circumcised and is being discharged home in 2 hours. Which instructions should be provided by the nurse to the parents? Select all that apply. 1. Use only baby wipes to cleanse the penis. 2. Remove the yellow exudate which forms by 24 hours post circumcision. 3. Do not wash penis with soap until the circumcision is healed, which takes 5 to 6 days. 4. Change diaper every 4 hours or more often to inspect the penis for drainage or infection. 5. Monitor the circumcision; penis may appear reddened with small amount of bloody drainage shortly after the procedure.

3,4,5 Rationale: 1. The glans penis is normally dark red. 1. Use only water to cleanse the glans penis until complete healing has occurred around day 5 to 6. 2, Diapers should be changed at least every 4 hours to inspect the glans penis for drainage or signs of infection. 4, After circumcision, a small amount of bloody drainage is expected. Baby wipes may contain alcohol and should not be used to cleanse the glans penis. 5. During the normal healing process, the glans becomes covered with a yellow exudate. This exudate should not be removed. 6. If excessive bleeding is noted from the circumcision, the parent should be instructed to apply gentle pressure to the site of bleeding with a sterile gauze pad. If the bleeding is not controlled, the primary health care provider is notified because a blood vessel may need to be ligated.

The nurse is caring for a client who has been prescribed furosemide and is monitoring for adverse effects associated with this medication. Which should the nurse recognize as potential adverse effects? Select all that apply. 1. Nausea 2. Tinnitus 3. Hypotension 4. Hypokalemia 5. Photosensitivity 6. Increased urinary frequency

Rationale: 2,3,4 Furosemide is a loop diuretic; therefore, an *expected effect* is 1. increased urinary frequency. 2. Nausea is a frequent side effect, not an adverse effect. 3. Photosensitivity is an occasional side effect. *Adverse effects* include 1. tinnitus (ototoxicity), 2. hypotension, and 3. hypokalemia and occur as a result of sudden volume depletion.

The nurse is assisting with caring for a client after a craniotomy. Which are the positions that can be used for the client? Select all that apply. 1. Prone position 2. Supine position 3. Semi-Fowler's position 4. Dorsal recumbent position 5. With the foot of the bed flat 6. With the foot of the bed elevated 30 degrees

Rationale: 3,5,6 1) After a craniotomy, the client is at risk for developing complications of increased intracranial pressure and cerebral edema. 2) The head of the bed is *elevated* *30 degrees* (semi-Fowler's position), and the client's head is maintained in a midline, neutral position to facilitate venous drainage. 3) The foot of the bed should be *flat* because flexion at the hips will impair venous drainage. Blocking venous drainage increases the risk for increased intracranial pressure and cerebral edema. 4) Remember there are no valves in the veins that drain the head.

The nurse working in a prenatal clinic reviews a client's chart and notes that the primary health care provider documents that the client has a gynecoid pelvis. The nurse plans care understanding that which findings are characteristic of this type of pelvis? Select all that apply. 1. Round shape 2. Shallow depth 3. Narrow pubic arch 4. Diagonal conjugate measures 12.5 cm to 13 cm 5. Blunt, somewhat widely separated ischial spines

1,,4,5 Rationale: A gynecoid pelvis is a normal female pelvis, and it is the most favorable for successful labor and birth. Characteristics of a gynecoid pelvis include a round shape, blunted ischial spines that are widely separated, a diagonal conjugate of at least 12.5 cm to 13 cm, a wide pelvic arch, and an adequate depth.

The nurse has delegated several nursing tasks to staff members. Which is the nurse's primary responsibility after the delegation of tasks? 1. Document that the task was completed. 2. Assign the tasks that were not completed to the next nursing shift. 3. Allow each staff member to make judgments when performing the tasks. 4. Perform follow-up with each staff member regarding the performance and outcome of the task.

ans: 4 Rationale: The ultimate responsibility for a task lies with the person who delegated it. Therefore, it is the nurse's primary responsibility to follow-up with each staff member regarding the performance of the task and the outcomes related to implementing the task. Not all staff members have the education, knowledge, and ability to make judgments about tasks being performed. The nurse documents that the task has been completed, but this would not be done until follow-up was implemented and outcomes were identified. It is not appropriate to assign the tasks that were not completed to the next nursing shift.

The nurse educator is asking the nursing student to recall the signs/symptoms of hypothyroidism. The nurse educator determines that the student understands this disorder if which are included in the student's response? Select all that apply. 1. Dry skin 2. Irritability 3. Palpitations 4. Weight loss 5. Constipation 6. Cold intolerance

1,5,6 Rationale: Signs of hypothyroidism include dry skin, hair, and loss of body hair; constipation; cold intolerance; lethargy and fatigue; weakness; muscle aches; paresthesia; weight gain; bradycardia; generalized puffiness and edema around the eyes and face; forgetfulness; menstrual disturbances; cardiac enlargement; and goiter. Irritability, palpitations, and weight loss are signs of hyperthyroidism.

The nurse is assisting with developing a plan of care for the client with multiple myeloma. Which nursing intervention should be included to prevent renal failure for this client? Select all that apply. 1. Encouraging fluids 2. Providing frequent oral care 3. Coughing and deep breathing 4. Monitoring the red blood cell count 5. Monitoring serum calcium and uric acid levels

1. 5 Rationale: In order to prevent renal failure in the client with multiple myeloma, 1. the nurse should encourage fluids and monitor serum calcium and uric acid levels. 2. Hypercalcemia secondary to bone destruction is a priority concern in the client with multiple myeloma. The nurse should encourage fluids in adequate amounts to maintain an output of 1.5 L to 2 L a day. 3. Clients require about 3 L of fluid per day. The fluid is needed not only to dilute the calcium and uric acid, but also to prevent protein from precipitating in the renal tubules. 4. Oral care, encouraging coughing and deep breathing, and monitoring the red blood cell count are important for clients with cancer, but these interventions are not specific to prevention of renal failure.

The nurse is caring for a client hospitalized with acute exacerbation of chronic obstructive pulmonary disease (COPD). Which should the nurse expect to note in this client? Select all that apply. 1. Hypocapnia 2. Dyspnea during exertion 3. Presence of a productive cough 4. Difficulty breathing while talking 5. Increased oxygen saturation with exercise 6. A shortened expiratory phase of respiration

2,3,4 Rationale: Clinical manifestations of COPD include 1. hypoxemia, 2. hypercapnia, and 3. dyspnea during exertion and at rest, 4. oxygen desaturation with exercise, 5. use of accessory muscles of respiration, 6. and a prolonged expiratory phase of respiration. The client may also exhibit difficulty breathing while talking, and may have to take breaths between every one or two words. Some clients with COPD, especially those with a history of smoking, often have a productive cough particularly when arising in the morning. The chest x-ray will reveal a hyperinflated chest and a flattened diaphragm if the disease is advanced.

A pregnant client is receiving magnesium sulfate for the management of *preeclampsia*. The nurse determines that the client is experiencing toxicity from the medication if which findings are noted during assessment? Select all that apply. 1. Proteinuria of 3+ 2. Respirations of 10 breaths/minute 3. Presence of deep tendon reflexes 4. Urine output of 20 mL in an hour 5. Serum magnesium level of 6 mEq/L (3 mmol/L)

2,4 Rationale: 1. Magnesium toxicity can occur from magnesium sulfate therapy. 1. Signs of magnesium sulfate toxicity relate to the central nervous system depressant 2. effects of the medication and include respiratory depression, 3*loss of deep tendon reflexes* , and a 4. sudden decline in fetal heart rate and maternal heart rate and blood pressure. 5. Urine output should be at least 25 mL to 30 mL per hour. 6. Therapeutic serum levels of magnesium are 4 mEq/L to 7 mEq/L (2 to 3.5 mmol/L). Proteinuria of 3+ is an expected finding in a client with preeclampsia.

The nurse is reinforcing discharge instructions to a client with cancer of the prostate after a suprapubic prostatectomy. The nurse should reinforce which discharge instruction? Select all that apply. 1. Avoid driving a car for 1 week. 2. Restrict fluid intake to prevent incontinence. 3. Take the prescribed stool softener every day. 4. Avoid lifting objects heavier than 20 pounds for 6 weeks. 5. Inspect the incision on the scrotum every day for any redness. 6. Notify the primary health care provider (PHCP) if small blood clots are noticed during urination.

Rationale: 1,3,4 A suprapubic approach involves a 1. lower abdominal incision to remove the prostate to treat prostate cancer. 2. The nurse will reinforce instructions about the incision activity, medications, and when to contact the urologist. 3. The client should take the prescribed stool softener because constipation will lead to straining and cause pain and tension on the surgical site. 4. The client should avoid lifting more than 20 pounds for 6 weeks to avoid tension on the surgical site. 5. Driving a car and sitting for long periods of time are restricted for at least *3 weeks*. 6. A daily fluid intake of 2 L to 2.5 L per day (unless contraindicated) should be maintained to limit clot formation and prevent infection. 7. The incision is not on the scrotum but in the lower abdominal area. 8. Small pieces of tissue or blood clots can be passed during urination for up to 2 weeks after surgery and do not need to be reported.

The nurse is preparing a list of homecare instructions for the client who has been hospitalized and treated for tuberculosis. Which instructions should the nurse reinforce? Select all that apply. 1. Activities should be resumed gradually. 2. Avoid contact with other individuals except family members for at least 6 months. 3. A sputum culture is needed every 2 to 4 weeks once medication therapy is initiated. 4. Respiratory isolation is not necessary because family members have already been exposed. 5. Cover the mouth and nose when coughing or sneezing and confine used tissues to plastic bags. 6. When one sputum culture is negative, the client is no longer considered infectious and can usually return to his or her former employment.

Rationale: 1,3,4,5 The nurse should provide the client and family with information about tuberculosis and allay concerns about the contagious aspect of the infection. 1. The client is reassured that after 2 to 3 weeks of medication therapy, it is unlikely that the client will infect anyone. 2. The client is also informed that activities should be resumed gradually. 3. The client and family are informed that respiratory isolation is not necessary because family members have already been exposed. 4. The client is instructed about thorough hand washing, to cover the mouth and nose when coughing or sneezing, and to confine used tissues to plastic bags. 5. The client is informed that a sputum culture is needed every 2 to 4 weeks once medication is initiated and that when ---the results of three sputum cultures are negative, the client is no longer considered infectious and can usually return to his or her former employment.

The client with squamous cell carcinoma of the larynx is receiving bleomycin intravenously. The nurse caring for the client anticipates that which diagnostic study will be prescribed? Select all that apply. 1. Chest x-ray 2. Echocardiography 3. Electrocardiography 4. Cervical radiography 5. Pulmonary function studies

Rationale: 1,5 1. Bleomycin is an antineoplastic medication that can cause interstitial pneumonitis, which can progress to pulmonary fibrosis. 2. During pulmonary fibrosis, the lung tissue becomes very scarred and hard. Pulmonary fibrosis is not reversible and the client is continuously short of breath. 3. Pulmonary function studies and chest x-ray, along with hematological, hepatic, and renal function tests need to be monitored. 4. The nurse needs to monitor lung sounds for dyspnea and adventitious sounds, which could indicate pulmonary toxicity. 5. The medication needs to be discontinued immediately if pulmonary toxicity occurs. Cardiac studies such as an echocardiogram and electrocardiogram, and a cervical radiograph are unrelated to the specific use of this medication.

The nurse is reviewing the health care record of a client with a lesion that has been diagnosed as basal cell carcinoma. The nurse should expect which characteristics of this type of lesion to be documented in the client's record? Select all that apply. 1. Lesion has a waxy border 2. An irregularly shaped lesion 3. Papule, with a red, central crater 4. A small papule with a dry, rough scale 5. A firm nodular lesion topped with a crust

1,2 Rationale: Basal cell carcinoma appears as a 1. pearly papule with a central crater and a rolled, waxy border. A melanoma is an irregularly shaped pigmented papule or plaque with a red, white, or blue color. 3. Squamous cell carcinoma is a firm nodular lesion that is topped with a crust or a central area of ulceration. 4. Actinic keratosis, which is a premalignant lesion, appears as a small macule or papule with a dry, rough, adherent yellow or brown scale.

The primary health care provider (PHCP) is going to perform carotid massage on a client with rapid rate atrial fibrillation. Which interventions should the nurse anticipate? Select all that apply. 1. The client should be placed on a cardiac monitor. 2. The PHCP massages the carotid artery for a full minute. 3. The head should be turned toward the side to be massaged. 4. Rhythm strips should be obtained before, during, and after the procedure. 5. Monitor the vital signs, cardiac rhythm, and level of consciousness after the procedure.

Rationale: 1,4,5 Carotid sinus massage is one maneuver used for vagal stimulation to decrease a rapid heart rate and possibly terminate a tachydysrhythmia. This eliminates option 3. 1. The PHCP or cardiologist will massage only one carotid artery for a *few seconds* to determine whether a change in cardiac rhythm occurs. This eliminates option 2. 2. The client needs to be on a cardiac monitor throughout the procedure and obtain rhythm strips before, during, and after the procedure. 3. Continue to monitor the client's cardiac rhythm as well as vital signs and level of consciousness.

The mother of a child with Marfan syndrome asks the nurse what can be done at home to help her child. Which are the best responses by the nurse? Select all that apply. 1. "You may need to consider surgery in the future." 2. "You will need to make regular pediatric appointments for your child." 3. "You will need to keep your child indoors and avoid sports." 4. "You will need to make regular eye examination appointments for your child." 5. "You will need to have your child take cardiac medication(s) to decrease stress on the aorta." 6. "You will need to let the dentist know that antibiotics should be given before any procedure."

1,2,4.5.6 Rationale: Parents of the child with Marfan syndrome should be instructed to monitor for vision problems and get regular eye examinations, avoid participation in contact sports, but it is not necessary to stay indoors. Monitor the curvature of the spine as the child grows, anticipate that antibiotics should be taken before any dental procedure to prevent endocarditis, cardiac medications to decrease stress on the aorta, and surgical replacement of the aortic root and valve may be necessary. Making regular pediatric appointments is important for monitoring the child.

The licensed practical nurse (LPN) is assisting the registered nurse (RN) to create a teaching plan for the client receiving an antineoplastic medication. The LPN expects which information to be included? Select all that apply. 1. Rinse mouth after meals and use a soft toothbrush. 2. Notify the PHCP if the temperature is above 101° F (37.7° C). 3. Maintain oral hygiene and inspect the mouth for sores daily. 4. A sore throat is expected so the client should suck on soothing throat lozenges. 5. Consult with primary health care provider (PHCP) before receiving immunizations.

Rationale: 1,2,3,5 Because antineoplastic medications affect the bone marrow, 1. clients are often anemic, have lower immunity, and may be at *risk for bleeding*. 2. Oral hygiene is important and clients should inspect their mouths daily, rinse after meals, and use a *soft toothbrush*. 3. The client should check with the PHCP before receiving any immunizations. 4. The client should notify the PHCP for a *low grade temperature* such as *99.5° F* (39.7° C) and 5. a *sore throat* . These are often associated with low white blood cell counts.

The nurse is reviewing the postoperative primary health care provider's (PHCP'S) prescriptions for a 3-week-old infant with Hirschsprung's disease admitted to the hospital for surgery. Which prescriptions documented in the child's record should the nurse question? Select all that apply. 1. Measure abdominal girth daily. 2. Monitor strict intake and output. 3. Take temperature measurements rectally. 4. Start clear liquid diet after 8 hours postoperative. 5. Maintain IV fluids until the child tolerates oral intake. 6. Monitor the surgical site for redness, swelling, and drainage.

3,4 Rationale: Postoperative management of Hirschsprung's disease includes taking vital signs, but avoiding taking the temperature rectally. The client needs to remain NPO (nothing by mouth) status until bowel sounds return or flatus is passed, usually within 48 to 72 hours. The other options are correct postoperative management.

The nurse is caring for a client with a health care associated infection caused by methicillin-resistant Staphylococcus aureus. Contact precautions are prescribed for the client. The nurse prepares to irrigate the wound and apply a new dressing. Which protective interventions should the nurse use to perform this procedure? Select all that apply. 1. Put on a mask. 2. Don gown and gloves. 3. Apply shoe protectors. 4. Wear a pair of protective goggles. 5. Have the client wear a mask and goggles.

1,2,4 Rationale: Contact precautions are in place, which include wearing gloves and a gown while providing care to the client. The mask and goggles are indicated because of the potential of splash contact during the wound irrigation procedure. Goggles are worn to protect the mucous membranes of the eye during interventions that may produce splashes of blood, body fluids, secretions, and excretions. Shoe protectors are not necessary and are used in operating rooms in the surgical departments. If the client is under airborne or droplet precautions, a mask is worn by the client when going outside of the room. Goggles are not worn by clients.

The nurse reviews the home care instructions with a parent of a 3-year-old with pertussis. Which statement by the parent indicates a need for further teaching? 1. "I know that my child will make a loud whooping sound." 2. "I understand this whooping cough is viral and I have to let it run its course." 3. "I understand that I need to watch for respiratory distress signs with pertussis." 4. "I can reduce the environmental factors that can trigger coughing, like dust and smoke."

2 Rationale: 1. Pertussis is caused by the bacteria Bordetella pertussis and treatment requires antimicrobial therapy. 2. Symptoms of pertussis consist of a respiratory infection followed by increased severity of cough with a loud whooping on inspiration. 3. The child may experience respiratory distress, and the parents should be instructed on reducing environmental factors that cause coughing spasms, such as dust, smoke, and sudden changes in temperature.