Nursing 113: Exam 1
A nurse is providing care for a pregnant 16-year-old client. The client says that she is concerned she may gain too much weight and wants to start dieting. What information will the nurse provide the client as most accurate about nutrition and pregnancy?
"Good nutrition supports the changes in your body and fetal growth and development."
An obese 36-year-old multigravid client at 12 weeks' gestation has a history of chronic hypertension. She was treated with methyldopa before becoming pregnant. When counseling the client about diet during pregnancy, the nurse realizes that the client needs additional instruction when she makes which statement?
"I need to reduce my caloric intake to 1,200 calories a day." Pregnancy is not the time for clients to begin a diet. Clients with chronic hypertension need to consume adequate calories to support fetal growth and development. They also need an adequate protein intake.
The nurse is preparing to administer a 75% strength tube-feeding formula. The full-strength formula is available. To prepare 500 ml of feeding, the nurse would plan to dilute how many milliliters of the full-strength formula with water? Record your answer as a whole number.
375 500*.75=375
A primiparous client is on a regular diet 24 hours postpartum. The client's mother asks the nurse if she can bring her daughter some "special foods from home." The nurse responds, based on the understanding about which principle?
A mother can bring anything the pt desires
What are the symptoms of contact dermatitis?
Bullae, Vesicles, Wheals
The mother of a child with moderate diarrhea asks how to manage her child's illness. What should the nurse suggest?
Continue the child's regular diet.
A client who has had an above-the-knee amputation develops a dime-sized bright red spot on the dressing after 45 minutes in the postanesthesia recovery unit. What should the nurse do first?
Draw a mark around the site
The nurse is counseling a client with osteoporosis about dietary choices to slow bone loss. What foods should the nurse teach the client to avoid?
Foods and beverages high in caffeine
Which nursing action is most appropriate for a client who has urge incontinence?
Have the client urinate on a timed schedule Instructing the client to void at regularly scheduled intervals can help decrease the frequency of incontinence episodes
A nurse is teaching a client with a leg ulcer about tissue repair and wound healing. Which statement by the client indicates understanding?
I'll eat plenty of fruits and vegetables For effective tissue healing, adequate intake of protein and vitamins A, B complex, C, D, E, and K are needed. Therefore, the client should eat a high-protein diet with plenty of fruits and vegetables to take in these nutrients.
For a client in the oliguric phase of acute renal failure (ARF), which nursing intervention is the most important?
Limit fluid intake
A child is prescribed amoxicillin for otitis media. What should the nurse recommend the mother do when the child develops diarrhea?
Offer yogurt multiple times a day
What recommendation should the nurse give a family about appropriate beverages for children?
Sugary drinks, including juice, should be avoided.
When the nurse is conducting a preoperative interview with a client who is having a vaginal hysterectomy, the client states that she forgot to tell her surgeon that she had a total hip replacement 3 years ago. Why should the nurse communicate this information to the perioperative nurse?
The client should not have her hip externally rotated when she is positioned for the procedure.
Which clinical finding should a nurse look for in a client with chronic renal failure?
Uremia Uremia is the buildup of nitrogenous wastes in the blood, evidenced by an elevated blood urea nitrogen and creatine levels.
Which meal would be appropriate for the child with osteomyelitis to choose?
beef and bean burrito with cheese, carrot and celery sticks, and a glass of milk Children with osteomyelitis need a diet that is high in protein and calories. Milk, eggs, cheese, meat, fish, and beans are the best sources of these nutrients.
A client is admitted for an exacerbation of irritable bowel syndrome who insists on being allowed to keep a head covering on at all times. What is the best response by the nurse?
"Please help me to understand this practice." The nurse should demonstrate respect for the client's request. Asking the client to explain the need for this practice in the hospital will lead to a discussion where a reasonable solution can be determined.
A 20-year-old seeks treatment at a local emergency care center after spraining an ankle while playing ball with friends. The ankle is painful and swollen. Which actions should the nurse perform, as ordered by the physician? Select all that apply.
1)Initially apply cold pack. 2)Instruct the client to elevate the ankle for 48 to 72 hours. 3)Provide crutch-gait training. 4)If needed, apply an elastic bandage from the toes to midcalf.
A client has given birth to an 8 lb 2.5 oz (3,700 g) infant. A newborn infant requires 110 to 120 cal/kg/day. What is the minimum number of calories per day this neonate requires? Record your answer using a whole number.
407 3700 grams = 3.7 kg. 3.7 kg x 110 calories/kg/day = 407 calories/day.
Is contact dermatitis chronic or acute?
Can be either/ or
The nurse is caring for a client with severe diarrhea. The nurse recognizes that the client is at risk for developing which of the following acid-base imbalances?
Metabolic Acidosis
What is an appropriate nursing action to detect early signs of metabolic complications in a client receiving total parental nutrition (TPN)?
Monitor urine output Hyperosmolar hyperglycemia is a metabolic complication of TPN. Expansion of the blood volume combined with hyperglycemia may cause osmotic diuresis, presenting as increased urine output. Intake and output should be recorded so that a fluid imbalance can be readily detected. Urine can also be tested for hyperosmolar diuresis.
Which statement by the parent of a toddler diagnosed with nephrotic syndrome indicates that the parent has understood the nurse's teaching about this disease?
My child really likes chips and bologna. I guess we will have to find something else." Children with nephrotic syndrome usually require sodium restriction. Because potato chips and bologna are high in sodium, the mother's statement about finding something else reflects understanding of this need. Although fluid intake is not restricted in children with nephrotic syndrome, 4 L is an excessive amount for a toddler. The typical fluid requirement for a toddler is 115 mL/kg. Surgical intervention and antibiotic therapy are not parts of the treatment plan for nephrotic syndrome.
After 24 hours, a preschool-aged child, hospitalized with gastroenteritis, is to resume eating. What type of food does the nurse anticipate to give the child?
a regular diet Once a child has become rehydrated, a regular diet may be resumed. Studies show a regular diet decreases the duration of diarrhea.
A client is 4 days postoperative from a tibia fracture and has a long leg cast. The nurse is conducting initial teaching for walking with crutches. What is the most important activity for the nurse to encourage the client to do prior to discharge from the hospital?
conduct exercises in bed to strengthen the upper extremities, as this will assist the client in crutch use.
To help minimize calcium loss from a hospitalized client's bones, the nurse should
encourage the client to walk in the hall Calcium absorption diminishes with reduced physical activity because of decreased bone stimulation. Therefore, encouraging the client to increase physical activity, such as by walking in the hall, helps minimize calcium loss.
In the fourth stage of labor, a full bladder increases the risk of what postpartum complication?
hemorrhage A full bladder prevents the uterus from contracting completely, increasing the risk of hemorrhage
A nurse is assessing a client for neurologic impairment after a total hip replacement. Which finding would indicate impairment in the affected extremity?
inability to move
A nurse is providing an education in-service about low-residue diets to a group of clients with colitis in a public health clinic. Which diet choices would show that teaching has been effective?
lean roast beef, buttered white rice with egg slices, white bread with butter and jelly, and tea with sugar
A client with pancreatitis has been receiving total parenteral nutrition (TPN) for the past week. Which nursing intervention best determines the TPN is providing adequate nutrition?
monitoring the client's weight every day
The nurse is aware that frequent repositioning in bed will assist in the prevention of which condition for a client?
pneumonia
A client's nutritional status has been severely compromised through prolonged episodes of nausea and vomiting. Which nutritional therapy will be the most effective in correcting nutritional deficits before surgery?
total parenteral nutrition (TPN) for several days
A client's nutritional status has been severely compromised through prolonged episodes of nausea and vomiting. Which nutritional therapy will be the most effective in correcting nutritional deficits before surgery?
total parenteral nutrition (TPN) for several days TPN bypasses the enteral route and provides total nutrition: protein, carbohydrates, fats, vitamins, minerals, and trace elements.
The nurse teaches the client with a urinary diversion to attach the appliance to a standard urine collection bag at night. The intended outcome of the instruction is to prevent what occurrence?
urine reflux into the stoma The most important reason for attaching the appliance to a standard urine collection bag at night is to prevent urine reflux into the stoma and ureters, which can result in infection
The nurse should advise the mother of a toddler suspected of having pinworms to do the cellophane tape test at which time?
while the child is asleep
After instruction of a primigravid client at 8 weeks' gestation diagnosed with class I heart disease about self-care during pregnancy, which client statement would indicate the need for additional teaching?
"I should reduce my intake of protein in my diet."
During a home visit to a primiparous client 1 week postpartum who is bottle-feeding her neonate, the client tells the nurse that her mother has suggested that she feed the neonate cereal so he will sleep through the night. What would be the nurse's best response?
"It's better to continue feeding only formula until about 4 to 6 months of age." The American Academy of Pediatrics recommends that all neonates should receive only formula or breast milk for the first 4 to 6 months of life.
The client with type 1 diabetes mellitus says, "If I could just avoid what you call carbohydrates in my diet, I guess I would be okay." What is the best response by the nurse?
"A person with diabetes should monitor their eating of proteins, fats, and carbohydrates."
A nurse is teaching a female client with a history of multiple urinary tract infections (UTIs) about prevention. What statement indicates the client understands the teaching?
"I should take at least 1,000 mg of vitamin C each day." The client demonstrates understanding of teaching when she states that she should take vitamin C each day. Increasing vitamin C intake to at least 1,000 mg per day helps acidify the urine, decreasing the amount of bacteria that can grow.
The nurse is preparing a client for a cardiac catheterization. Which client statement would the nurse need to report to the healthcare provider immediately?
"I took my metformin this morning." The priority would be to notify the healthcare provider of the metformin because it cannot be taken 48 hours before or after contrast, as there is an increased risk of lactic acidosis and acute renal failure with iodinated contrast material
A client is prescribed a brace to support a structural change to the foot. What should the nurse explain to the client about this device?
"The brace is custom-fitted to your foot." A brace is used to support the area, control movement, and prevent injury to a body area. The device is custom-fitted by an orthotist and is indicated for use longer than a few weeks.
The client was recently diagnosed with a musculoskeletal disorder and ordered carisoprodol. The nurse completes teaching about the medication. Which statement by the client indicates a need for more teaching about carisoprodol?
"I will stop the medication as soon as the muscle spasticity goes away."
The triage nurse in the pediatrician's office returns a call to a mother who is breastfeeding her 4-day-old infant. The mother is concerned about the yellow seedy stool that has developed since discharge home. What is the best reply by the nurse?
"Soft and seedy unformed stools with each feeding are normal for this age and will continue through breastfeeding." A soft seedy unformed stool is the norm for a 4-day-old infant. It may surprise the mother as it is a change from the meconium the infant had since birth. This stool is not diarrhea even though it has no form. There is no need for the infant to be seen for this. As long as the infant is breastfeeding, the stools will remain of this color and consistency.
After teaching the parents of a child with lactose intolerance about the disorder, the nurse determines that the teaching was effective when the mother used which statement to describe the condition?
"The lack of an enzyme to break down lactose."
The nurse is caring for an adolescent client after an overdose on barbiturate drugs and alcohol. The client is hypotensive with a mean arterial pressure below 30 mm Hg and a urine output of 5 mL/hr. Serum creatinine and potassium are elevated. The parents of the client ask why there is so little urine in the indwelling catheter drainage bag. What is the best response by the nurse?
"There is not enough blood circulating to the kidneys." The best answer directly and simply explains to the parents that the kidneys are not getting perfused and therefore cannot function. Acute renal failure is often caused by ischemic tubular necrosis.
A pediatric client has recently been diagnosed with asthma and is prescribed theophylline. What should the nurse include in the client's teaching concerning what to avoid when taking theophylline? Select all that apply.
1."You should avoid chocolate when taking theophylline." 2."You should avoid iced tea when taking theophylline." 3."You should avoid caffeinated soft drinks when taking theophylline." Chocolate, some soft drinks, and iced tea contain caffeine and all caffeine should be avoided when taking theophylline.
The nurse is giving prenatal instructions to a 32-year-old primigravida who is 8 weeks' gestation. Which nutritional instructions would the nurse review? Select all that apply.
1.Caloric intake should be increased by 300 cal/day. 2.Protein intake should be increased by 30 g/day. 3.Folic acid intake should be increased to 800 mg/day. 4.Intake of all minerals, especially iron, should be increased.
What is the nursing process for contact dermatitis?
1.Identify agent 2.Develop Strategy 3.Teach
The nurse is planning care for an obese female client. The client experiences dribbling urine when she coughs, sneezes, and changes positions. The nurse should instruct the client to promote urinary health by encouraging which actions? Select all that apply.
1.Participate in a weight loss program. 2.Perform muscle-strengthening exercises (Kegel exercises). 3.Use adult diapers as needed. The goal is to promote health in this client who has stress incontinence. Participating in a weight loss program or support group may decrease the intra-abdominal pressure contributing to the incontinence. Participating in swimming, bicycling, or low-impact exercise is beneficial to weight loss. Kegel exercises are helpful in developing muscle control. Wearing adult diapers will absorb leaked urine and prevent excoriation.
A client has a transurethral resection of the prostate to treat benign prostatic hyperplasia. The client returns to the room with continuous bladder irrigation and reports bladder pain. What is the priority nursing action?
Assess irrigation catheter for patency and drainage Although postoperative pain is expected, the nurse should make sure that other factors, such as an obstructed irrigation catheter, aren't the cause of the pain.
A client has been unable to void since having abdominal surgery 7 hours ago. What should the nurse do first?
Assist the client up to the toilet to attempt to void.
When instructing the client with severe burns about proper nutrition, the nurse should encourage the client to choose which menu for lunch?
Roast Beef sandwich, milkshake, and cottage cheese
The nurse is concerned about poor nutritional status of several clients on the unit. The nurse recommends placement of a gastrostomy tube for feeding as most appropriate for which client?
a client with dysphagia from a stroke 1 month ago and awaiting extended care A gastrostomy tube (G-tube) is placed through a stoma and remains in situ for long-term enteral feeding. This invasive procedure is not without risk so it is only appropriate for clients who are not able to swallow for a long period of time. The client who has had dysphagia for 1 month is the most appropriate candidate for a G-tube.
A client has nephrotic syndrome. To aid in the resolution of the client's edema, the health care provider prescribes 25% albumin. In addition to an absence of edema, the nurse should evaluate the client for which expected outcome?
blood pressure elevation Albumin is a colloid that remains in the intravascular space, pulling fluid out of the intracellular and interstitial space. The client with nephrotic syndrome loses excessive amounts of protein, mainly albumin, in the urine. Because fluid is drawn into the intravascular space, blood pressure will increase.
The client who is receiving chemotherapy is not eating well but otherwise feels healthy. What should the nurse suggest the client eat?
broiled chicken, green beans, and cottage cheese
A nurse is caring for a client who had a stroke. Which nursing intervention promotes urinary continence?
encouraging intake of at least 2 L of fluid daily Encouraging a daily fluid intake of at least 2 L helps fill the client's bladder, thereby promoting bladder retraining by stimulating the urge to void.
A client is admitted with multiple pressure ulcers. When developing the client's diet plan, the nurse should include
ground beef patties. Meat is an excellent source of complete protein, which this client needs to repair the tissue breakdown caused by pressure ulcers
A client reports that she wishes to attempt to breastfeed her newborn. The client indicates that she was unsuccessful at breastfeeding her first child and switched to bottle feeding after 3 days. Which approach by the nurse will be most effective in facilitating the client's current breastfeeding efforts?
having the newborn room-in with the client and teaching the client about feeding cues One way to help support this client's current wishes to breastfeed is to instruct her to room-in with her neonate so she can respond to the neonate's cues.
Which diet would be most appropriate for the client with ulcerative colitis?
high-protein, low-residue Clients with ulcerative colitis should follow a well-balanced high-protein, high-calorie, low-residue diet, avoiding such high-residue foods as whole-wheat grains, nuts, and raw fruits and vegetables.
The topic of physiologic changes that occur during pregnancy is to be included in a parenting class for primigravid clients who are in their first half of pregnancy. Which topic would be important for the nurse to include in the teaching plan?
increased risk for urinary tract infections During pregnancy, urinary tract infections are more common because of urinary stasis. Clients need instructions about increasing fluid volume intake.
Which nutritional deficiency may delay wound healing?
lack of vitamin C Vitamins A, C, and K; pyridoxine; riboflavin; and thiamin are necessary for wound healing. Adequate protein intake is necessary for improving skin integrity.
A pregnant mother who has brought her toddler to the clinic for a check-up asks the nurse how she can keep her next baby from becoming obese. The mother plans to bottle-feed her next child. Which information should the nurse include in the teaching plan to help the mother avoid overnourishing her infant?
recognizing clues indicating that a baby is full Infants generally do not overeat unless they are urged to do so. Parents should watch for clues indicating that the infant is full—for example, stopping sucking and pushing the nipple out of the mouth. Bottle-feeding instead of breast-feeding is more likely to lead to excessive caloric intake.
A client is scheduled to undergo transurethral resection of the prostate. The procedure is to be done under spinal anesthesia. What should the nurse assess the client for after surgery?
respiratory paralysis
Which positioning technique is most effective when there is only one person to assist the client to move from the left side to the right side if the client has hemiparalysis?
rolling the client onto the side
A client with respiratory complications of multiple sclerosis (MS) is admitted to the intensive care unit. Which equipment is most important for the nurse to keep at the client's bedside?
suction machine with catheters
A client is diagnosed with rheumatoid arthritis and is ordered oral indomethacin. What should the nurse include in the client's teaching concerning the administration of indomethacin? Select all that apply.
1)"Avoid any hazardous activity until you know how you react to this drug." 2)"Tell your health care provider immediately about changes in your hearing." 3)"Do not use aspirin while taking this drug."
During a prenatal visit, a pregnant client with cardiac disease and slight functional limitations reports increased fatigue. The nurse knows that the client understands the management of the disorder when the client says
"I will eat five or six small meals each day and have some protein with each meal."
A mother tells the nurse she understands breastfeeding is the best, but will change to formula feedings when she returns to work in a few weeks. What should the nurse tell this mother about formula feedings? Select all that apply.
1."When mixing the powdered formula, be sure to follow the manufacturer's directions on the container to ensure proper nutrition." 2."All babies on formula should have an iron-fortified formula to ensure healthy brain growth." 3."Speak to your baby's health care provider about the best formula to use when you plan to change from breast to formula feeding."
What are the expected outcomes of contact dermatitis?
1.Control of dermatitis 2.No infection occurs 3.Triggers identified and eliminated 4.Sleep is minimally disturbed by itching.
The nurse is caring for a 9-month-old child who was admitted with severe dehydration after several days of diarrhea. The child has completed initial rehydration therapy. The nurse is instructing the parents on the best way to maintain adequate fluids. Which course of treatment should the nurse recommend?
Continue with breast milk or lactose-free formula.
A client diagnosed with chronic renal failure is undergoing hemodialysis. Post dialysis, the client weighs 59 kg. The nurse should teach the client to make which dietary changes?
Control the amount of protein intake to 59 to 70 g/day.
What is an expected assessment finding when caring for a client with a percutaneous feeding tube?
Dark pink stoma without drainage
When caring for a client who has recently given birth, the nurse assesses the client for urinary retention with overflow. Which sign or symptom provides the most accurate picture of retention with overflow?
a varying urge to urinate with an average output of 100 ml
A client had a cystoscopy to remove a renal stone. Which laboratory data warrants immediate intervention by the nurse?
a white blood cell count of 14,000 mm/dL (14.00 x 109/L) The high white blood cell count signals infection and needs to be treated immediately.
A client who has been diagnosed with bladder cancer is scheduled for an ileal conduit. Prior to surgery, what comment by the client indicates that the client understands the procedure?
"My urine will come out through an opening on my abdomen." An ileal conduit is a permanent urinary diversion in which a portion of the ileum is surgically resected and one end of the segment is closed. The ureters are surgically attached to this segment of the ileum, and the open end of the ileum is brought to the skin surface on the abdomen to form the stoma. The client must wear a pouch to collect the urine that continually flows through the conduit.
A nurse is calling report to the medical-surgical floor staff regarding a client with acute diverticulitis. Which symptoms does the nurse anticipate? Select all that apply.
1.cramping pain in the left lower abdominal quadrant 2.bowel irregularity 3.intervals of diarrhea Acute diverticulitis is a common digestive disease typically found in the large intestine. Signs and symptoms of acute diverticulitis include bowel irregularity, intervals of diarrhea, abrupt onset of cramping pain in the left lower abdomen, and a low-grade fever.
A client who takes ibuprofen for pain tells the nurse, "I have frequent indigestion." Which action should the nurse take?
Ask the client to describe the indigestion.
The nurse is planning care for a client with osteomyelitis. The client is taking an antibiotic, but the infection has not resolved. What should the nurse advise the client to do?
Eat a high diet in Vitamin C and Vitamin D
Which nursing diagnosis takes highest priority for a client with hyperthyroidism?
Imbalanced nutrition: Less than body requirements related to thyroid hormone excess In the client with hyperthyroidism, excessive thyroid hormone production leads to hypermetabolism and increased nutrient metabolism. These conditions may result in a negative nitrogen balance, increased protein synthesis and breakdown, decreased glucose tolerance, and fat mobilization and depletion. These changes put the client at risk for marked nutrient and calorie deficiency, making Imbalanced nutrition: Less than body requirements related to thyroid hormone excess the most important nursing diagnosis.
The nurse is developing a teaching plan for the client with hepatitis A. What should the nurse tell the client to do?
Increase carbohydrates and protein in the diet. A low-fat, high-protein, high-carbohydrate diet is encouraged for a client with hepatitis to promote liver rejuvenation. Nutrition intake is important because clients may be anorexic and experience weight loss.
The nurse is performing an assessment in the nursery on an infant with a developmental hip dysplasia. Which findings should the nurse anticipate?
Ortolani's sign Assessment in a child with a congenital hip dislocation typically reveals Ortolani's sign
What are some irritants of contact dermatitis?
Plants (poison) Drugs acids Alkalies latex soaps perfumes deodorants, and materials. Rubber cosmetics / hair dye.
Define contact dermatitis
The inflammation of skin characterized by damage to the dermis and epidermis
The nurse is caring for an infant diagnosed with nonorganic failure to thrive. Which action should be included in the plan of care for the infant?
Weighing the unclothed infant at the same time every day. Daily weights are an appropriate intervention for an infant with failure to thrive
A client in cardiac rehabilitation would like to eat the right foods to ensure adequate endurance on the treadmill. Which nutrient is most helpful for promoting endurance during sustained activity?
carbohydrate
A nurse is caring for a client who had hip pinning surgery 6 hours ago to treat intertrochanteric fracture of the right hip. What assessment finding requires further investigation by the nurse?
client anxious and confused The client is anxious and confused is the appropriate answer. Postoperative complications of hip fractures include hemorrhage, pulmonary emboli, and fat emboli. Anxiety and confusion may be indicative of hypoxia as a result of any of these complications and needs further investigation.
A nurse should encourage a client with a wound to consume foods high in vitamin C because this vitamin
enhances protein synthesis
A nurse is helping a client move up in the bed. Which action maintains good body mechanics?
having the client help as much as possible
A child with cystic fibrosis has been admitted to the pediatric unit. What type of diet should the nurse request for the client?
high-calorie, high-protein
A nurse is caring for an elderly client with a pressure ulcer on the sacrum. When teaching the client about dietary intake which foods should the nurse emphasize?
lean meats and low-fat milk Although the client should eat a balanced diet, including foods from all food groups, the diet should emphasize foods that supply complete protein, such as lean meats and low-fat milk. Protein helps build and repair body tissue, which promotes healing.
A nurse is assessing a 15-year-old adolescent who's being admitted for treatment of anorexia nervosa. Which clinical manifestation is the nurse most likely to find?
muscle weakness Anorexia nervosa frequently causes muscle weakness resulting from starvation or electrolyte imbalance.
A breastfeeding primiparous client who gave birth 8 hours ago asks the nurse, "How will I know that my baby is getting enough to eat?" Which guideline should the nurse include in the teaching plan as evidence of adequate intake?
six to eight wet diapers by the fifth day
A 10-month-old child with phenylketonuria (PKU) is being weaned from breast-feeding. When teaching the parents about the proper diet for their child, the nurse should stress the importance of restricting meats and dairy products because:
they contain high levels of phenylalanine PKU is an inherited disorder characterized by the inability to metabolize phenylalanine, an essential amino acid. Phenylalanine accumulation in the blood results in central nervous system damage and progressive intellectual disability. However, early detection of PKU and dietary restriction of phenylalanine can prevent disease progression.
When teaching the child with scoliosis being treated with a Boston brace about exercises, the nurse explains that the exercises are performed primarily for what reason?
to strengthen the back and abdominal muscles
The nurse is caring for a preterm neonate in the neonatal intensive care unit receiving enteral feedings. The nurse notes an increase in respiratory rate, increase in regurgitation of feeding solution, and moderate abdominal distention. What action does the nurse take based on these findings?
Stop the enteral feeding
A student with type 1 diabetes tells the nurse she is feeling light-headed. The student's blood sugar is 60 mg/dL (3.3 mmol/L). Using the 15-15 rule, what should the nurse do to treat the blood glucose?
Administer 15 g of carbohydrate and retest the blood sugar in 15 minutes.
When providing discharge teaching for a client with uric acid calculi, the nurse would include an instruction to avoid which type of diet?
High Purine
A client had a total hip replacement today. How should the nurse position the client when the client is transferred from the transport cart to the bed?
Maintain the affected extremity in slight abduction using an abduction splint or pillows placed between the thighs. After total hip replacement, proper positioning by the nurse prevents dislocation of the prosthesis. The nurse should place the client in a supine position and keep the affected extremity in slight abduction using an abduction splint or pillows or Buck's extension traction.
To reduce the possibility of catheter-related urinary tract infections (CAUTIs), the nurse should take which precaution?
Minimize urinary catheter use and duration of use in all clients
Parents of a preschool-age child ask the nurse about nutrition. Which statement about a preschooler's nutritional requirements is accurate?
The quality of food that a preschooler consumes is more important than the quantity
A client with a spinal cord injury has spinal shock. What should the nurse expect the client's bladder function to be at this time?
atonic During the period of spinal shock, the bladder is completely atonic and will continue to fill passively unless the client is catheterized.
An adult with type 2 diabetes mellitus has been NPO since 2200 in preparation for having a nephrectomy the next day. At 0600 on the day of surgery, the nurse reviews the client's medical record and laboratory results. Which finding should the nurse report to the health care provider (HCP)?
blood glucose of 140 mg/dL (7.8 mmol/L The client's blood glucose level is elevated, beyond levels accepted for fasting; normal blood glucose range is 70 to 120 mg/dL (3.9 to 6.7 mmol/L).
A client with severe inflammatory bowel disease is receiving total parenteral nutrition (TPN). When administering TPN, the nurse must take care to maintain the ordered flow rate because giving TPN too rapidly may cause
hyperglycemia
While assessing a male neonate whose mother desires him to be circumcised, the nurse observes that the neonate's urinary meatus appears to be located on the ventral surface of the penis. The health care provider (HCP) is notified because the nurse suspects which complication?
hypospadias The condition in which the urinary meatus is located on the ventral surface of the penis, termed hypospadias, occurs in 1 of every 500 male infants. Circumcision is delayed until the condition is corrected surgically, usually between 6 and 12 months of age.
The nurse is creating a plan of care for an older adult client with osteoarthritis. Which nursing diagnosis is most appropriate?
risk for injury related to altered mobility
The nurse enters the room to do an initial assessment on a client with a fracture of the femoral head. What would be the expected findings on the affected limb?
shortening of the affected extremity with external rotation
Which finding indicates that the infant has adequately evacuated the barium after undergoing a barium enema?
stools that progress from clay-colored to brown The presence of barium produces white or clay-colored stools. A change in stool color from clay-colored to normal brown is an indication that the barium has been evacuated.
The nurse teaches the client to perform isometric exercises to strengthen the leg muscles after arthroplasty. Isometric exercises are particularly effective for clients with rheumatoid arthritis because they:
strengthen the muscles while keeping the joints stationary An exercise program is recommended to strengthen muscles after arthroplasty. Isometric (or muscle-setting) exercises strengthen muscles but keep the joint stationary during the healing process.
To promote early and efficient ambulation for a client after an above-the-knee amputation, the nurse is aware that the leg will need to be positioned in which way?
in functional alignment
A client has a prescription for an oil retention enema and a cleansing enema. The client asks the nurse to explain the purpose of the enemas. What is the most accurate response by the nurse?
"Oil retention enemas soften stool, and cleansing enemas stimulate a bowel movement." The oil retention enema is given first to soften the stool, and then the cleansing enema is given to stimulate peristalsis
A client has a cast applied to the left leg after sustaining a femur fracture during a skiing accident. Which interventions would the nurse provide to avoid complications from the cast application? Select all that apply.
1.Monitor distal pulses of the affected extremity. 2.Maintain the leg elevated above the level of the heart. 3.Administer anticoagulation per healthcare provider's order The nurse would monitor the tightness of the cast by assessing the distal pulses and tightness of the cast. Edema can cause the cast to become tight and lead to compartment syndrome. Unless contraindicated, the leg would be elevated above the heart in order to increase venous return and decrease edema. Prophylactic anticoagulation will decrease the risk of clot formation.
What should the nurse do to prevent catheter-associated urinary tract infection? Select all that apply.
1.Provide perineal care at least once a day. 2.Maintain a closed drainage system. 3.Encourage the client to drink 3,000 mL of fluids a day.
The nurse is caring for a child with acute glomerulonephritis and is meeting with the family to discuss discharge instructions. Which of the following are important teaching points for the nurse to review with the child's family? Select all that apply.
1.Restrict the intake of sodium. 2.Monitor fluid intake and output. 3.Report any signs of infection.
A 2-month-old infant is at risk for an ileus after surgery to correct intussusception. What should be included in a focused assessment for this complication? Select all that apply.
1.assessment of bowel sounds 2.characteristics of the first stool 3.measurement of gastric output
The nurse advises a client recovering from a myocardial infarction to decrease fat and sodium intake. Which foods should the nurse instruct the client to avoid? Select all that apply.
1.pepperoni pizza 2.bacon 3.cheese 4.soft drinks
A nurse is caring for a client that received a colostomy 2 days ago. Which is the priority intervention?
Assess the drainage from the stoma.
The nurse is caring for a client with graduated compression stockings. The nurse removes the stockings and assessment findings include a blister on the right heel. What is the next action by the nurse?
Discontinue the graduated compression stockings and notify the healthcare provider When a client has prescribed graduated compression stockings, the nurse would remove the stockings and inspect the skin at least every 8 hours. If the client has discoloration, markings, or blisters on the heel, the nurse would discontinue the stockings and notify the healthcare provider because sequential compression devices may be used instead to prevent deep vein thrombosis.
The nurse is caring for a client during the postoperative period. The client was prescribed thigh high antiembolism stockings and pneumatic compression devices for prevention of deep vein thrombosis. Assessment data reveal +3 pitting edema to the lower extremities bilaterally. What is the priority action by the nurse?
Measure client's thighs and calves to ensure the antiembolism stockings are the correct size.
A client with a leg incision has a prescription for graduated compression stockings. The client rates the incision pain at 8/10. What is the best action by the nurse prior to applying the graduated compression stockings?
Premedicate the client with prescribed morphine 1 mg I.V. 15 minutes prior to application The application of graduated compression stockings will increase the incisional pain for this client, therefore the client should be premedicated with prescribed morphine 1 mg I.V. 15 minutes prior to application.
The client with Cushing's disease needs to modify dietary intake to control symptoms. In addition to increasing protein, which strategy would be most appropriate?
Restrict Sodium
What is the etiology of allergic contact dermatitis?
Result of immune response to a subsequent response. Meaning the 1st time the body does not react to it but the 2nd time the body reacts.
The school nurse is planning an educational session to prevent injuries in children with juvenile arthritis. Which information should the nurse include in the teaching?
Schedule the completion of daily range-of-motion exercises to support joint mobility.
What kind of cells in the body cause the body to have the reaction of contact dermatitis?
T Lymphocytes
A postpartum client has a nursing diagnosis of risk for impaired urinary elimination related to loss of bladder sensation after birth. What priority outcome criteria should the client achieve?
The client will void more than 30 mL/hour without urinary retention beginning 1 hour after birth. A nursing diagnosis of risk for impaired urinary elimination related to loss of bladder sensation after birth can cause several problems for the client. The outcome that is to be achieved is that the client will void more than 30 mL/hour 1 hour after birth and have no urinary incontinence.
A severely dehydrated adolescent admitted to the hospital with hypotension and tachycardia undergoes evaluation for electrolyte disturbances. The client's history includes anorexia nervosa and a 20-lb (9.1-kg) weight loss in the past month. She is 5′ 7″ (1.7 m) tall and weighs 80 lb (36.3 kg). Which nursing intervention takes highest priority?
initiating caloric and nutritional therapy as ordered
A parent of a 7-year-old child with Hirschsprung's Disease and chronic constipation asks about increasing dietary fiber in the child's diet. Which food could the nurse recommend?
popcorn
A new mother states, "My baby spits up after every feeding." Which interventions should the nurse teach to this mother first?
Burp the infant more frequently during each feeding
The nurse is teaching an adolescent with celiac disease about dietary changes that will help maintain a healthy lifestyle. Which of the following foods can the nurse safely recommend as part of the adolescent's diet? Select all that apply.
1.potatoes 2.apples 3.corn
The nurse notes a client has produced 1700 mL of dilute urine in the 12-hour period following cesarean birth. What action would the nurse take based on this finding?
Document the finding, and complete routine postpartum assessment It is normal for the client to experience diuresis in the first 24 hours after birth (whether vaginal or cesarean). An amount of 3 liters in 24 hours is not unusual. Also, the client will have received IV fluids during labor, which increases input significantly.
A client with acute renal failure is undergoing dialysis for the first time. The nurse monitors the client closely for dialysis disequilibrium syndrome. Which assessment is the priority?
Neurological Status Clients experiencing dialysis for the first time often have confusion and even seizures and should be monitored closely. Vital signs and laboratory values are important assessments but do not specifically address dialysis disequilibrium syndrome
A nurse is providing health teaching to a group of adolescent females. The focus is on urinary tract infections. One of the adolescents tells the nurse that she wants to know what cystitis is. Which statement by the nurse is the most appropriate response?
"This condition can result from irritation and inflammation from sexual activity." Cystitis is a lower urinary tract infection. It is sometimes seen among young adolescent females after the first sexual intercourse experience. The urinary tract infections occur because of inflammation and local irritation caused by sexual activity.
