NUR497 EAQ #2

physiological needs safety and security love and belonging self-esteem self-actualization

Arrange the hierarchy of needs in ascending order beginning with the highest priority needs as defined by Maslow.

Glucagon decrease in cortisol levels impairs the glucose metabolism. The client's low blood sugar is indicative of hypoglycemia.

The nurse is caring for a client who reports sweating, tachycardia, and tremors. The laboratory report of the client reveals serum cortisol less than normal and a blood glucose level of 60 mg/dL. Which medication would be administered to this client?

infiltration

The nurse is caring for a client who underwent cardiac catherization. The client's skin was found to be cool, tender to touch, with edema of 15.2 cm (1-6 in) at the site of catheterization. Which condition would the nurse suspect?

maintenance

The nurse is caring for a client with a family history of diabetes mellitus. The client has been following a diet regimen recommended by the dietitian and walking for 45 min daily for the past 8 months. Which would the nurse document the client's stage based on the transtheoretical model of health behavior change?

"I should lose at least half a pound to a pound each week." "I'll make sure to eat foods that meet my daily nutritional requirement." "I should stay away from unhealthy foods between meals and after dinner."

The nurse teaches an obese client measures to calculate the body mass index. Which of these statements by the client indicate effective learning?

kyphosis

Which terms refers to the exaggeration of the posterior curvature of the thoracic spine?

Systemic Corticosteroids

Which type of medication would put a person at risk if they were exposed to the varicella virus?

exhale completely, take a slow, deep breath, hold it as long as possible and slowly exhale

Which would the nurse include when teaching a client about the use of an incentive spirometer?

I will ask the client to move his/her arm toward the body

While assessing a client's range of motion, the nurse explains adduction to the nursing student. Which statement made by the nursing student indicates effective learning?

use of hard soap, frequent bathing

While assessing a client's skin, the nurse notices that the client's skin is dry. Which is the probable cause of this condition?

Muscular spasms in the larger airways (adventitious breathing sound/Rhonchi)

While assessing a client, the nurse finds adventitious breath sounds. Upon further evaluation, the nurse finds loud, low-pitched, rumbling coarse sounds during inspiration. This sound can be clearly heard while the client is coughing. Which could be the reason behind these sounds?

Trauma Paronychia is an abnormality of the nail bed, marked by inflammation of the skin at the base of the nail, may be caused by trauma or local infection

While assessing a client, the nurse finds inflammation of the skin at the bases of the client's nails. Which would be the reason behind this condition?

Client is an older adult Client has a history of smoking. Client has chronic lung disease

While assessing a client, the nurse finds that the ratio of the anteroposterior diameter and transverse diameter of the chest is 1:1. Which is indicated by this finding?

Crossed appearance of eyes, Impaired extraocular muscles

While assessing a pediatric client, an ophthalmologist notices that the child is unable to focus on an object with both eyes simultaneously. Which other findings in the clients confirms the diagnosis as strabismus?

erythema

While assessing the client's skin the nurse notices a skin condition. The nurse the pathophysiology involves increased visibility of oxyhemoglobin caused by an increased blood flow due to capillary dilation. Which skin condition is associated with this client?

elevated intraocular pressure

While assessing the eyes of a client, a health care provider notices there is an obstruction to the outflow of aqueous humor. Which additional finding would be noted to support a diagnosis of glaucoma?

cutting nails after soaking them for 10 min in warm water this should not be performed for diabetic clients because soaking the nails will dry out the hands and feet which may lead to infection

While assessing the nails of a client with diabetes, the nurse finds that the skin on the client's hands and feet are dry due to infection. Which could be the reason for the dryness?

atropine, the intake of eye meds will cause dilatation of the pupils. heroin, morphine and pilocarpine cause pupillary constriction

While assessing the pupils of a client, a health care professional notices pupillary dilatation. Which drug would have resulted in this condition?

older adult client

While auscultating the heart, a health care provider notices S3 heart sounds in 4 clients. Which client is at highest risk for heart failure?

Client 3 irregular, alternating apnea and hyperventilation

While caring for 4 different clients, the nurse assesses their breathing pattern. Which client's assessment findings indicate Cheyne-Stokes respirations?

102.2 °F °F = (°C × 1.8 ) + 32

While caring for a client with heat stroke, the nurse measured the temperature and noticed it as 39°C. What is the temperature in Fahrenheit?

Client with corneal arcus Client with yellow lipid lesions on eyelids (xanthelasma)

which client is suspected to have an increased risk of hyperlipidemia?

Tetany is caused by hypocalcemia. Seizures caused by electrolyte imbalances are associated with low calcium or sodium levels. Because of potassium's role in the sodium/potassium pump, hyperkalemia will cause confusion, weakness, and cardiac dysrhythmias.

which clinical indicators would the nurse expect a client with hyperkalemia to exhibit?

inflating the cuff too slowly

which error will result in false high diastolic readings while measuring a client's blood pressure during a physical examination?

carbon monoxide

which factor would elevate the oxygen saturation during an assessment?

Abducens nerve The abducens nerve is the VI cranial nerve, which helps in lateral movement of the eyeballs.

while assessing a client who experienced an accident, the nurse found that the client is unable to move the eyeballs laterally. Which nerve damage led to this condition in the client?

heart disease (or lung disease), present with cyanosis (bluish skin) per increased amounts of deoxygenated hemoglobin anemia presents with pallor per reduced amounts of oxyhemoglobin

while assessing a client, the nurse finds bluish coloration of the skin. Which condition would be suspected?

rectum and vagina

while performing a physical assessment of a female client, the nurse positions the client in left lateral recumbent position. Which body system would be assessed in this position?

QRS duration of 0.28

when the nurse is administering intravenous potassium to a client with hypokalemia, which finding is most important to communicate to the health care provider

hypoventilation

which type of breathing pattern is manifested with hypercarbia?

Presence of burns from cigarettes, Presence of bed sores, Presence of unexplained bruises on the wrist(s)

while assessing an older adult during a regular health checkup, the nurse finds signs of elder abuse. Which physical findings would further confirm the nurse's suspicion.

Child protective services for immediate intervention

A 13 year old girl tells the nurse at the pediatric clinic that she took a pregnancy test and got a positive result. She confides that her grandfather, with whom she, her younger sisters, and her mother live, has repeatedly molested her for the past 3 yrs. When the nurse asks the girl whether she has told anyone else, she replies, 'Yes, but my mother doesn't believe me,' Legally, whom would the nurse notify?

90 mL

A 20lb infant has a normal saline enema ordered, at a dose of 10 mL/kg. Which dose would the nurse administer?

9.5 mg

A 28lb toddler is prescribed amoxicillin 145mg by mouth TID. Medication available is supplied as a suspension of 250 mg/5 mL. The safe dosage is 35 mg/kg/24hr. How many milligrams within the safe dosage limit is the dose?

have the child drink the diluted iron preparation through a straw, because it can stain teeth

A 3 yo child is prescribed a liquid iron preparation. The nurse would include which intervention when teaching the parent about the administration of this medication?

Ten 4-oz (120-mL) servings is required

A 4 yo child weighing 33 lb (15kg) has a prescription to receive 100 mL/kg per 24 hrs for the next 10 kg. Which parental statement would the nurse recognize as correctly reflecting the child's recommended daily fluid intake?

Osmotic Diuretics

A child prescribed IV mannitol. The nurse understands mannitol belongs to which classification of diuretics?

red urine

A child with Wilms tumor is prescribed doxorubicin hydrochloride. Which common side effect unique to doxorubicin would the nurse expect to observe in the child?

it is a stimulant that has calming effect on children with ADHD

A child with attention-deficit/hyperactivity disorder (ADHD) is prescribed methylphenidate. The mother asks about its action and side effects. Which response by the nurse is most appropriate?

pulmonary edema, the added cardiac workload from receiving transfusions increases the risk for HF that leads to pulmonary edema.

A child with beta-thalassemia is receiving therapy that includes multiple blood transfusions. The nurse understands the child is at risk for which common complication?

Exploring the parent's understanding of the probable causes of this disorder

A parent whose infant is born with talipes equinovarus (clubfoot) tells the nurse, 'I'm afraid to have more children because they might have the same problem.' Which is the best response by the nurse?

impairment of the extraocular muscles, called Strabismus

After an eye assessment, the nurse finds that both of the client's eyes are not focusing on an object simultaneously and appear crossed. Which could be the cause for this condition?

Blood lab results. Blood lab results provide objective data about fluid and electrolyte status, as well as about hemoglobin and hematocrit.

The nurse is caring for an older adult client with dementia who has developed dehydration as a result of vomiting and diarrhea. Which assessment information BEST reflects the fluid balance of this client?

Client 3, 2 yo 148 90-140 toddler 120-160 infant 80-110 preschooler 60-90 adolescent

The nurse is palpating the peripheral pulse of 4 different clients. Which client has an unacceptable HR?

"My first child was born when I was 32." "I noticed a slight discharge from a nipple." "I consume two to four glasses of alcohol a day."

The nurse is performing a breast assessment. Which statement made by the client indicates a risk of breast cancer?

11 mg

The nurse prepares to admin prednisone to a 4 yo who weighs 48lb. The dose for a child is 2 mg/kg/day in 4 divided doses.

"We'll have her massage her gums and floss her teeth frequently."

The nurse teaches the parents of a child prescribed long-term phenytoin therapy about care. Which statement indicates the teaching has been effective?

heatstroke

The nurse tells a client undergoing diuretic therapy to avoid working in the garden on hot summer days. Which condition is the nurse trying to prevent in this client?

Maternal antibodies interfere with the development of active antibodies by the infant when immunized.

The parent of a newborn asks the nurse why, except for hepatitis B vaccine, the immunization schedule does not start until the infant is 2 months old. Which response would the nurse provide?

"Natural enzymes are not as effective as the brand-name product. This is something you need to discuss with your healthcare provider."

The parents of a child with cystic fibrosis tell the nurse they have switched to natural pancreatic enzymes because of financial issues. Which response by the nurse is most appropriate?

Client B loss of central vision

The symptoms of 4 clients with different levels of impaired vision are given in the chart. Which client is expected to be diagnosed with macular degeneration?

I'll make sure to give each pill with 6-8 oz fluid

Trimethoprim / sulfamethoxazole is prescribed for a child with a urinary tract infection. Which statement by the parent indicates the nurse's instructions about administration have been understood?

Perspiring

Which involuntary physiologic response in a client experiencing pain should the nurse monitor for?

Tapping skin with fingertips to vibrate underlying tissues and organs

Which is a description of the percussion technique?

blood uric acid level of 7.5 mg/dL The normal blood uric acid level for children ranges from 2.5-5.5 mg/dL. An increase in the uric acid level caused by the destruction of cells may led to renal problems; increased fluid intake helps dilute the urine. A urine pH of 6 is within the expected range of 4.5 - 8. A blood urea nitrogen level of 15 mg/dL is within the expected range of 5-18 mg/dL.

Which laboratory test result would alert the nurse that fluid intake would need to be increased in a child receiving vincristine?

systemic steroid

Which medication therapy lowers a child's resistance to varicella?

factor VIII concentrate

Which medication would the nurse expect to administer to control bleeding in a child with hemophilia A?

Careful monitoring of intake and output

Which nursing intervention is a priority for a school-age child with lead poisoning undergoing chelation therapy?

Suppressed inflammatory process

Which outcome would the nurse expect when caring for a child receiving adrenocorticosteroid therapy?

Maternal antibodies provide immunity for about 1 year.

Which parent education would the nurse give about why the MMR vaccine is administered at 12-15 months of age?

red and dry skin burns = alcohol abuse vasculitis = cocaine abuse diaphoresis = sedative hypnotic abuse

Which physical assessment of the skin indicates that a client is addicted to phencyclidine?

Auscultation

Which physical assessment technique involves listening to the sounds of the body?

needle marks

Which physical skin finding indicates opioid abuse?

prone

Which position is indicated assess the musculoskeletal system but is contraindicated in clients with respiratory difficulties?

evaluation criteria

Which professional standard is important for critical thinking?

DO you want the IV in your right or left arm

Which response by the nurse is most appropriate when a 6 yo child who is to have an IV catheter inserted, starts to cry?

Which arm should I use to give you the medicine

Which response by the nurse would be most appropriate to promote a sense of control in a 6 yo child who is about to receive an injection?

110/65 mmHg

Which would be a normal BP of a 12 yo client?

30 breaths/min normal = 25-32 breaths/min

Which would be the RR in a 2 yo child?

Perseverance requires the nurse to be cautious of an easy answer. If the nurse clarifies some information after talking to the client directly, Perseverance has been demonstrated.

The nurse suspects that report on a client is incomplete. Which critical thinking attitude is being used when the nurse clarifies information by talking to the client directly?

"I should take three tablets at a time." "I should take the tablet twice a week." "I should take the tablet on an empty stomach."

The nurse teaches a client about cortisone therapy. Which statements made by the client indicate the need for further teaching?

I'll wash my cooking utensils and cutting boards with tap water

The nurse teaches a client about various measures to protect against food-borne illness. Which statement by the client is incorrect?

give in the morning on scheduled days, child gets most benefit during the day while he/she is most active

The nurse teaches the parents of a child with classic hemophilia how to administer plasma component factor VIII prescribed TID. Which instruction would the nurse give the parents about administration time?

A client with severe malabsorption disorder

The nurse is assessing several clients. Which client will require parenteral nutrition?

older adult male with a laceration to the finger

the triage nurse in the emergency department receives 4 clients simultaneously. Which of the clients would the nurse determine could be treated last?

Client 2: eyes open on pain, flaccid motor response, incomprehensible verbal responses

The nurse is assessing the level of consciousness of 4 different clients. Which client would have the lowest neurological function?

It suppresses inflammation

The nurse is caring for a child receiving prednisone. Which consideration is most important for the nurse to remember when administering adrenocorticoid therapy?

it decreases inflammation

The nurse is caring for a child undergoing chemotherapy for acute lymphoid leukemia. The parents ask why the child needs prednisone. Which response by the nurse would be correct?

Client B increased cardiac output increased peripheral resistance increased hematocrit

Which client is suspected of having hypertension based on the given data?

the clients with presbyopia and hyperopia

Which clients suffer from impaired near vision?

Atherosclerosis

Which clinical condition will result in changes in the integrity of the arterial walls and small blood vessels?

muscle weakness

Which clinical finding would the nurse associate with hypokalemia?

Correct order of the nursing diagnostic process

1. Assess the client's health status. 2.Validate the data with other sources. 3.Interpret the meaning of the data. 4.Cluster data. 5.Look for defining characteristics. 6.Identify the client's needs. 7.Formulate nursing diagnoses.

Analysis, allows the nurse to be open-minded while looking at the client's information and avoid making assumptions

Which critical thinking skill will help a student nurse avoid making assumptions about clients?

3+

Which degree of edema will result in a 6 mm deep indentation upon pressure application?

Low-grade fever

Which education would the nurse provide parents about the side effects of the Haemophilus influenzae (Hib) vaccine?

talk to client directly bring coworkers together look for a pattern find a solution

It is determined that there is missing client data. Arrange in order the steps the nurse would take to resolve this situation?

kyphosis an increase in the curvature of the thoracic spine and may result from a congenital abnormality

The nurse is assessing an 89 yo client with a history of severe congenital spinal deformity. Which condition would describe the nurse's finding?

slowed neurological responses, forgetfulness about recent events, reduced ability to maintain an erection

The nurse is assessing an older adult male client. Which clinical findings are expected responses to the aging process?

I will advise a client with a BP of 130/80 mmHg to follow up in a year PreHTN 120/80 - 139/89 (1 yr check) Stage 1 HTN 140/90 - 159/99 (2 month check) Stage 2 HTN > 160/100 (1 month check) > 180/110 treat immediately or within 1 week

The RN is teaching a nursing student about when a client with high BP would follow up with the primary health care provider. Which statement made by the nursing student indicates effective learning?

130/100 mm Hg Deflating the cuff too quickly will result in false low systolic and false high diastolic readings. Therefore the client's systolic readings decreased to 130 mm Hg while the diastolic readings increased to 100 mm Hg.

The RN notices that the student nurse who is assessing the BP in a client is deflating the cuff too rapidly. Which is the probable reading of BP that the student nurse could have obtained if the actual BP of the client is 140/90 mmHg?

13 3 = opens eyes on sound of speech 4 = confused verbal responses 6 = obeys commands, motor response

The client is admitted to the hospital after an accident. The nurse uses the Glasgow Coma Scale with the client. The client is alert and opens his/her eyes when there is a sound or when someone talks. When questions are asked, the client answers in a confused manner. The client obeys commands, such as being asked to move a leg. Which would be the client's total score?

auscultate breath sounds

The nurse administers albuterol to a 4 yo child. Which intervention would assist the nurse in evaluating the effectiveness of this medication?

Paronychia

What is the inflammation of the skin at the base of the nail called?

The nurse withdraws from a client to escape the situation.

Which action by the nurse is an example of a protective touch that may elicit negative feelings in a client?

interpreting what the client is saying and restating it for clarification

Which action indicates hat the nurse is actively listening to the client?

having child demonstrate inhaler use

Which action would be the most appropriate way for the nurse to evaluate a child's understanding of how to use an inhaler?

Recalling, thinking, analyzing and learning from day-to-day work situations

Which activity by the nurse demonstrates competence in reflective practice?

ptosis and blurred vision decreased auditory alertness

Which are physiologic symptoms assessed in a client with sleep deprivation?

Fosters development of nursing knowledge, Provides precise definition of the client's problem, Distinguishes the nurse's role from that of other care providers

Which are the benefits of using standard formal nursing diagnostic statements?

local or systemic and usually mild

Which are the characteristics of reactions associated with immunizations for a 2 month old infant?

loss of body weight

a client reports vomiting and diarrhea for 3 days. Which clinical indicator is most commonly used to determine whether the client has a fluid deficit?

Placing the prescribed as-needed warm, wet compress on the elbow

a client with sickle cell anemia is experiencing a painful episode (vasocclusive crisis) and has a patient-controlled analgesia (PCA) pump. The current pain rating is 5 on a scale of 1-10 at the right elbow. The nurse observes that the pump is 'locked out' for another 10 minutes. Which action would the nurse implement?

loss of elasticity of the lens

after performing an optical assessment on a client, a primary healthcare provider notices impaired near vision. Which other finding in this client confirms the diagnosis as presbyopia, which is a condition reported in middle-aged and older adults.

heat stroke

an older adult with a history of diabetes reports giddiness, excessive thirst, and nausea. During an assessment, the nurse notices the client's body temp is 105F (40.6C) orally. Which condition would the nurse suspect in the client?

4+

the nurse is assessing a client's degree of edema and finds 8 mm of depth. Which would be correct to document this condition?

client 2 food = milk products and seafood symptoms = ab cramps and diarrhea onset = 12 hrs after ingestion

the nurse is assessing clients with gastrointestinal problems. Which client would the nurse suspect to have shigellosis?

Percuss and palpate the hypogastric region

the nurse suspects that a client has a distended bladder. Which method is correct to assess for this condition?

By respecting the right of others to have different opinions By becoming sensitive to the possibility of their own prejudices

Which characteristics of the nurse demonstrates open-mindedness as part of critical thinking behavior?

88F (31.1C) 92F (33.3C)

Which client body temp are indicative of moderate hypothermia?

autoimmune disorder (vitiligo)

While performing a physical assessment of a client, the nurse notices patchy areas with loss of pigmentation on the skin, hands, and arms. Which is the probable cause for this condition?

recommending that the client's pharmacy relabel the medication in large letters

The nurse finds that a visually impaired client is having difficulty in determining which medications to take after being discharged from the hospital. Which intervention would be best in this situation?

remittent

The nurse finds that the client's fever spikes and falls without return to a normal level. Which pattern of fever is this characteristic of?

Have you noticed any unintentional weight loss in the past six months?

The nurse is performing a weight assessment for different people in a community. Which question would the nurse ask a client to determine a disease-related change in weight?

offering warm saline mouthwash

A 5 yo child is receiving dactinomycin and doxorubicin therapy after nephrectomy for Wilms tumor. Which intervention would the nurse include when planning care?

respiratory rate 14 blood pressure 110/70 oxygen saturation 92%

A 50 yo client is diagnosed with COPD. The clinical data on admission: HR 100 bpm, BP 138/82 mmHg, RR 32 Temp 98.2, SaO2 80% Which vital signs obtained by the nurse indicates a positive outcome?

"I'll check for white patches in the mouth."

A 6 yo child with asthma is prescribed an inhaled corticosteroid. The nurse would conclude the mother understands teaching about the medication side effects when the mother makes which statements?

S3 is normal in pregnant women The S3 can be heard when the heart attempts to fill an already distended ventricle. This sound may be common and normal in the last stages of pregnancy, but not in all stages. This sound may be heard in heart failure clients. The S3 sound is abnormal in adults over the age of 31. This sound is normally heard in children and young adults.

A RN is teaching a nursing student about the 3rd heart sound (S3). Which statement given by the nursing student is incorrect?

Start an IV line Obtain consent for blood product admin

A child is prescribed IV immunoglobin (IVIG) for Kawasaki disease. Before admin of IVIG which actions would the nurse take?

Ensuring meticulous oral hygiene

A child is prescribed dactinomycin and doxorubicin therapy after a nephrectomy for Wilms tumor. Which intervention would the nurse include in the plan of care?

Watch for white patches in the mouth and report to the health care provider

A child is prescribed fluticasone after an acute asthma attack. Which instruction would the nurse give the family about the administration of this medication?

"offer a snack to prevent hypoglycemia during the night"

A child is prescribed insulin glargine before breakfast. Which instruction is most appropriate for the nurse to give the parents regarding a bedtime snack?

preventing exposure of the child to infection

A child recovering from severe asthma attack is given oral prednisone 15 mg BID. Which intervention would be a priority for the nurse?

10 mg

A child who weighs 44 lb is prescribed prednisone. The recommended dosage for children is 2 mg/kg/day given in 4 divided doses. Which amount would the nurse administer to the child in each dose?

passage of worms

A child with pinworms is prescribed mebendazole. Which expected response to the medication would the nurse teach the parents watch for?

checking for protein in the urine, both lead toxicity and calcium EDTA damage the proximal renal tubules, resulting in increased excretion of protein and other substances.

A child with plumbism is prescribed edetate calcium disodium (calcium EDTA). Which assessment would be the most appropriate for the nurse to conduct before administering EDTA?

High velocity airflow through an obstructed airway wheezing is a high-pitched sound that may be caused by a high velocity airflow through an obstructed/narrowed airway. Inflammation of the pleura may produce pleural friction rubs. Muscular spasms in larger airways/any new growth causing turbulence may produce rhonchi, which is a loud and low-pitched sound. Sudden reinflation of groups of alveoli may produce crackling sounds.

A client complains of difficulty breathing. The nurse auscultates wheezing in the anterior bilateral upper lobes. Which could be the possible reason for this sound?

preauricular

A client complains of pain in the ear. While examining the client, the nurse finds swelling in front of the left ear. Which lymph node would the nurse expect to be involved?

The client's fever spikes and falls without a return to normal temperature levels.

A client experiencing chills and fever is admitted to the hospital. After assessing the client's vitals and medical history, the nurse concludes that the client's fever pattern is remittent. Which assessment finding led to this conclusion?

intermittent

A client has a fever spike combined with normal temp levels. The client's body temp returns to normal body temp at least once a day. Which type of fever can be assessed in the client?

Precontemplation The client is experiencing a relapse while attempting to make behavioral changes to his or her lifestyle. When relapse occurs, the client returns to the contemplation or precontemplation stage before attempting to change again. The action stage lasts for up to six months during which the client is actively engaged in strategies to change behavior. During the preparation stage, the client begins to believe that advantages outweigh disadvantages of behavior change. The maintenance stage begins six months after the change has started and continues indefinitely.

A client has relocated to a new city for work. The client is unable to continue the practice of walking for 30 min daily and exercising 5 days a week. Which stage of the transtheoretical model of health behavior change is the client experiencing?

please wait, I will update you as soon as I have any information

A client injured in a motor vehicle accident was brought to the emergency department and taken immediately for a scan. The client's family arrives and asks about the client's condition. Which response would the nurse provide?

Candida albicans

A client is diagnosed with acquired immunodeficiency syndrome (AIDS). When examining the client's oral cavity, the nurse assesses white patchy plaques on the mucosa. The nurse recognizes that this finding most likely represents which opportunistic infection?

Kussmaul's respirations

A client shows an increase in respiratory rate that is abnormally deep and regular. Which condition would the nurse expect?

23.53

A client weighs 150 lbs and is 5ft 7in tall. What is this client's body mass index (BMI)?

Femoral In a client with cardiac arrest, the most appropriate place to check the pulse rate is the femoral site, because other pulses may not be palpable at this time.

A client who has been admitted to the hospital with chest pain complains of shortness of breath, weakness, and vomiting. The nurse suspects cardiac arrest. Which site is correct to check the client's pulse rate?

Respiratory rate of 14 breaths/minute Blood pressure of 120/80 mmHg Oxygen saturation of 95% In pulmonary infections, the respiratory rate may increase and oxygen saturation may decrease. In fluid volume deficit, the blood pressure may be decreased. A respiratory rate of 14 breaths/minute, a blood pressure of 120/80 mmHg, and an oxygen saturation of 95% are normal readings.

A client with a history of cardiac dysrhythmias is admitted to the hospital due to fluid volume deficit caused by a pulmonary infection. The registered nurse is assessing the vital signs recorded by the student nurse. Which vital sign assessments require reassessment based on the data given by the student nurse?

1.6 mL

A health care provider prescribes 160 mg acetaminophen elixir for child. The label on the bottle reads "100 mg/mL." How many mL of acetaminophen would the nurse administer?

Administer the platelets rapidly through the IV line Platelets are fragile and should be administered as quickly as possible, within 1 hr, or as fast as the child can tolerate the infusion. Per minimal RBCs and WBCs in it, the risk of sever reaction is reduced.

A platelet transfusion is to be administered to a child with acute lymphocytic leukemia. Which step would the nurse do 1st?

Lithotomy position Lithotomy position provides maximum exposure to the female genitalia and easy examination of the region. Therefore this position is recommended for examining pregnant women.

A pregnant woman in her 2nd trimester arrived at the hospital for a general health checkup for a pelvic examination. Which position is correct for assessing the client in this condition?

Take the child for regularly scheduled blood tests adverse reactions include thrombocytopenia, lymphocytosis. Tablets should not be broken, crushed or chewed. Sudden stop of meds could cause seizure, rash should be reported to HCP.

A school-age child with a seizure disorder is prescribed divalproex. The nurse would include which instruction when teaching the parents about administering this medication?

Turbulence due to muscular spasm and fluid or mucus in the larger airways

After assessment the nurse documents auscultation of course rhonchi in the anterior upper lung fields bilaterally that clears with coughing. Which would be the cause of these sounds?

With the other medicines, it helps you get rid of the things that are making you sick

Allopurinol is prescribed for a child undergoing chemotherapy for cancer of the bone. When given the medication the child asks "why do I have to take this pill?" Which response by the nurse is most appropriate?

assessment by the nurse was incomplete and as a result the treatment was insufficient

An adolescent is taken to the emergency department of the local hospital after stepping on a nail. The nurse asks if the client has had a tetanus immunization. The adolescent responds that all immunizations are up to date. A few days later, the client is admitted to the hospital with a diagnosis of tetanus. Which describes the nurse's responsibility in this situation?

Sodium lactate it is converted to sodium bicarbonate, it helps correct the sodium deficiency and the metabolic acidosis. Normal saline solution results in the combination of the chloride with the hydrogen ion, intensifying the acidosis.

An infant undergoes surgery for the repair of a myelomeningocele and develops metabolic acidosis, accompanied by decreased urine output. Which medication would the nurse anticipate providing teaching for?

arcus senilis

An older adult is found to have a thin white ring around the margin of the iris. Which condition would this suggest?

38.5ºC (101.3 °F) Chill is a feeling of coldness that will only be experienced when the fever is high °F = (°C × 1.8 ) + 32

An older adult with chills arrived to the hospital. The nurse assesses the client's vital signs and determined the client has fever. Which would be the client's rectal temp?

Human papilloma virus infection

The nurse is performing an assessment of the client's reproductive system. Which finding in the past medical history indicates the client is at risk of cervical cancer?

crackles

The nurse assesses the lungs of a client and auscultates soft, crackling bubbling breath sounds that are more obvious on inspiration. Which would the nurse document these sounds as?

promoting health in healthy individuals

The nurse at a community health care center focuses on providing primary preventative care. Which is the focus of primary preventative care?

Erythrocytes

The nurse caring for a child with a low platelet count would monitor the child's urine for the presence of which component?

Flushed face; increased pulse rate High body temperature will have vasodilation and increase heart rate to meat cooling demand

The nurse expects a client with an elevated temp to exhibit which indicators of pyrexia?

hyperopia and presbyopia

The nurse is performing an eye assessment in an older adult. The older adult is unable to see near objects. Which conditions would be suspected in the older adult?

Determine what the adolescent knows about diabetes.

The nurse is planning to teach an adolescent about diabetes and self-administration of insulin. which would the nurse complete first?

ADPIE Assessment Diagnosis Planning Implementation Evaluation

The nurse applies the nursing process while caring for clients. Which is the correct order of steps of the nursing process?

Cranial Nerve XI: Accessory

The nurse asks the client to shrug the shoulders and to turn the head against passive resistance. Which cranial nerve is involved in this action?

Not be contacted, because treatment at the clinic is confidential

The nurse in the family planning clinic reviews the health history of a sexually active 16-year-old girl whose chief concern is a thick, burning vaginal discharge accompanies by low abdominal pain. After her examination. the girl is informed that she may have a sexually transmitted infection (STI) that requires treatment. The adolescent is concerned that her parents will discover that she is sexually active. She asks the nurse whether her parents will be contacted. How would the nurse respond?

Client D 145 cm (4'9") 56 kg (147.4 lbs)

The nurse is assessing 4 clients. Which client is at the highest medical risk of coronary heart disease and HTN?

Epitaxis (nosebleed)

The nurse is assessing a child receiving chemotherapy for treatment of leukemia. Which side effect would the nurse anticipate?

The client reports pain with movement. The client has pain over the surgical area. The client rates the pain as 8 on a scale of 0 to 10.

The nurse is assessing a client after abdominal surgery. Which assessment findings would the nurse use to form a data cluster?

the client's pain is 7 on scale of 1-10

The nurse is assessing a client who had knee replacement surgery. Which assessment finding gathered by the nurse is an example of subjective data?

self-perception-self-tolerance pattern

The nurse is assessing a client who is undergoing chemotherapy. The nurse notes that the client is using a scarf to cover the head. The nurse asks the client about coping with the altered body image. Which functional pattern would the assessment include?

visceral pain

The nurse is assessing a client who underwent abdominal surgery 10 days ago. The client complains of pain in the abdomen. Which type of pain would the client experience?

lung cancer, emphysema, heart disease

The nurse is assessing a client with a history of marijuana use. Which long-term effects are associated with marijuana?

Inactivity A DVT, or thrombus, may form as a result of venous stasis. It may lodge in a vein and can cause venous occlusion. Inactivity is a major cause of venous stasis leading to DVT. Pregnancy and tight clothing are also risk factors for DVT secondary to inactivity. Aerobic exercise is not a risk factor for DVT.

The nurse is teaching a health awareness class. Which situation would the nurse as being the highest risk factor for the development of a deep vein thrombosis (DVT)?

"I will consult w/ my PHCP when there is a rash/ulcer on my genitalia"

The nurse is teaching a male client about measures to maintain sexual health and prevent transmission of STIs. Which statement by the client indicates effective learning?

Low grade fever

The nurse is teaching parents about the side effects of immunization vaccines. Which expected side effect associated with the Haemophilus influenzae (Hib) vaccine would the nurse include in the teaching?

after breakfast

The nurse is teaching the parents of 6 yo child with attention-deficit/hyperactivity disorder (ADHD) about the administration of methylphenidate. Which statement by the parents indicates an understanding of when they should administer the medication?

precontemplation, contemplation, preparation, action, maintenance

The nurse must understand the process of changing behaviors to be able to support difficult behavioral changes in clients. Arrange the stages of Health Behavior Change as described by DiClemente and Prochaska (1998) in the transtheoretical model change?

bradypnea

The nurse noticed the respiratory rate as regular and slow while assessing a client. Which would be the condition of the client?

lips

The nurse notices cyanosis in a client with heart disease. Which site would the nurse assess to confirm cyanosis?

wheezes

The nurse performs a respiratory assessment and auscultates breath sounds that are high pitched, creaking, and accentuated on expiration. Which term correctly describes the findings?

Client C: Dorsalis pedis pulse located along the top of the foot resulting in the status of circulation to the foot The ulnar site, found on the ulnar side of the forearm at the wrist, is used to assess the status of circulation to the hand and to perform the Allen test. The carotid site is found along the medial edge of the sternocleidomastoid muscle of the neck. It is easily accessible in times of physiological shock or cardiac arrest when other sites are not palpable. The posterior tibial site is found below (not above) the medial malleolus. It is used to assess the status of circulation in the foot.

The nursing student has prepared pulse assessment plans for several clients. Which client's assessment plan is correct and will yield effective results?

Turgor

Which assessment finding of the skin refers to elasticity?

female genitalia

Which assessment is expected when a client is placed in the lithotomy position during physical examination?

Call the clinic if marked drowsiness occurs.

Which education would the nurse provide the parents of an infant receiving the first diphtheria and tetanus toxoids and acellular pertussis vaccine (DTaP) at 2 months of age?

Continuity of care by the nursing staff Collection of data about the client's clinical condition Engagement in a caring relationship without assumptions

Which factors enable the nurse to know a client better?

High fever after the first dose

Which health history would the nurse consider a contraindication to administering the 2nd DTap immunization to a 4 month old infant?

Pertussis, Inactivated polio virus, Tetanus immune globulin

Which immunizations would the nurse determine are safe for a child who is receiving prednisone?

the teeth may become stained

Which information would the nurse include when teaching parents about the side effects of iron supplements?

adjusting the bed and asking if the client is comfortable

Which intervention improves client satisfaction?

help the family set up home care if required, determine the client and family's strengths and weaknesses, Arrange for church or community support for the family

Which interventions would the nurse implement for a dying client and the family?

English speaking nurse conducts admission interview of PR immigrant with limited knowledge of English

Which scenario would contribute to health disparities?

Sclera

Which site is best used to assess a client for jaundice

Posterior tibial artery Dorsalis pedis artery

Which site would be monitored for a pulse to assess the status of circulation to the foot?

independence is fostered

Which statement by the nurse is most appropriate regarding the greatest advantage of using an insulin pump?

the family has an ability to cope with stressors

Which statement defines the term family resiliency?

syringe towards back of the mouth

Which technique would the nurse use to administer ferrous sulfate to a 12 month infant?

bruit

Which term refers to a blowing sound created by turbulence caused by narrowing of arteries while assessing for carotid pulse?

Magicoreligious belief

The nurse is caring for an African American client with renal failure. The client states that the illness is punishment for sins. Which cultural health belief is the client communicating?

I will increase my meat consumption high meat consumption may lead to obesity, which is a risk factor for breast cancer

The nurse is teaching a client about different prevention and detection practices to ensure breast health. Which statement made by the client indicates the need for further teaching?

learn to use the needle and syringe by practicing on an insulin pad first

The nurse plans to teach a 5th grader with Type 1 diabetes how to self-administer lispro and glargine insulin. Which action would the nurse include in the teaching plan?

normal finding

The nurse is assessing a client's nails and finds a slight convex curve at the angle from the skin to nail base of about 160 degrees. Which condition would the nurse suspect?

Launching children and moving on

The nurse is assessing a middle-aged client whose children have left home in search of work. The client is trying to adjust to these family changes. Which family life-cycle is the client going through?

Client C: 103, 101, 104, 102

The nurse is assessing the body temperature of 4 febrile clients over 4 days. Which client is suffering from remittent fever?

preventing infection

The nurse is caring for a child who has an external fixation device on the leg. Which is the nurse's priority goal when providing pin care?

at scheduled intervals

The nurse is caring for a child with an exacerbation of leukemia. The nurse would plan to administer the prescribed analgesic for bone pain at which time?

33° C A body temperature between 36° to 38° C is normal. When skin temperature drops below 35° C, the client may exhibit uncontrolled shivering, loss of memory, depression, and poor judgment as a result of hypothermia. A body temperature lower than 30° C represents severe hypothermia. In this condition, the client will demonstrate a lack of response to stimuli and extremely slow respiration and pulse. Based on the signs given, the client's temperature is most likely 33° C.

While conducting an assessment, the nurse finds that the client shivers uncontrollably and experiences memory loss, depression and poor judgement. Which might the client's body temperature be.

Vesicle

While examining a client, the nurse finds a 0.6 cm circumscribed elevation of the skin filled with serous fluid on the cheek. Which would the nurse suspect the finding to be?

HIV

While performing a neck assessment, the nurse finds the client has enlarged lymph nodes. The client also had a history of intravenous drug use and bisexual activity. Which would be the possible diagnosis?