Pass Point Study Quizzes

A pregnant client with diabetes is admitted to the labor unit. Which action by the nurse would be most appropriate for this situation?

Ask the client about her most recent blood glucose levels. - It would be most important to find out about the client's most recent blood glucose levels because this would provide information about how well her diabetes has been controlled. Oral hypoglycemic drugs are never used during labor because they cross the placental barrier, stimulate fetal insulin production, and are potentially teratogenic. Plans to admit the neonate to the neonatal intensive care unit are premature. Cesarean birth is no longer the preferred birth for clients with diabetes. Vaginal birth is preferred and presents a lower risk to the mother and fetus.

A client is frustrated and embarrassed by urinary incontinence. Which measure should the nurse include in a bladder-retraining program?

Evaluate present elimination patterns. - The guidelines for initiating bladder retraining in a client frustrated by urinary incontinence include evaluating the client's intake patterns, voiding patterns, and reasons for each unintentional voiding. Lowering the client's fluid intake would not reduce or prevent incontinence. The client should actually be encouraged to drink 1.5 qt to 2 qt (1.4 to 1.9 L) of water per day. A voiding schedule should be established after evaluation.

For a client with an exacerbation of rheumatoid arthritis, the physician prescribes the corticosteroid prednisone. When caring for this client, the nurse should monitor for which adverse drug reactions?

Increased weight, hypertension, and insomnia - Prednisone can cause a wide range of adverse reactions, including increased weight caused by fluid retention, hypertension, insomnia, ecchymoses, suppressed inflammation, behavioral changes, and myopathy. However, it doesn't produce the other signs and symptoms.

A client treated with terbutaline for preterm labor is ready for discharge. Which instruction should the nurse include in the discharge teaching plan?

Report a heart rate greater than 120 beats/minute to the health care provider. - Because terbutaline can cause tachycardia, the woman should be taught to monitor her radial pulse and call the health care provider for a heart rate greater than 120 beats/minute. Terbutaline must be taken every 4 to 6 hours around-the-clock to maintain an effective serum level that will suppress labor. A fetus normally moves 10 to 12 times per hour. The client experiencing premature labor must maintain bed rest at home.

A client with diabetes who had a stroke has right-sided paralysis and incontinence and is in the rehabilitation center. Which action should be the nurse's priority in caring for the client?

Wash the client's skin with soap and water, gently patting it dry. - The skin of a client with diabetes should be washed with soap and water and then gently patted dry to prevent breakdown and infection. The nurse should avoid excessive use of powders, which can cake with perspiration and cause irritation. To promote optimal recovery, clients undergoing rehabilitation should sit upright in chairs, except for short rest periods during the day. Because clients with diabetes are prone to infections, the use of indwelling catheters should be avoided because they commonly cause urinary tract infections; other methods should be used to encourage continence.

A nurse is preparing discharge instructions for a client with resistant depression who was prescribed a new medication regimen that includes phenelzine. If the teaching was successful, what foods should the client state that he/she needs to avoid? Select all that apply.

aged cheese wine salami - Phenelzine is an MAO inhibitor. MAO is an enzyme responsible for metabolizing neurotransmitters, serotonin and norepinephrine. This drug requires being on a tyramine-free diet to avoid hypertensive crisis. Aged cheese, salami, and wine will cause vasoconstriction and a rise in blood pressure. Cottage cheese, milk, and fruit are allowed on a tyramine-free diet.

A 5-year-old child sustained third-degree burns to the right upper extremity after tipping over a frying pan. Which skin structures would the nurse include when explaining a third-degree burn to the child's parent?

all skin layers and nerve endings - A third-degree burn involves all of the skin layers and the nerve endings. First-degree burns involve only the epidermis. Second-degree burns affect the epidermis and dermis. Fourth-degree burns involve all skin layers, nerve endings, muscles, tendons, and bone.

When monitoring a child with lead poisoning, the nurse should be alert for which condition that commonly appears first?

anemia - Lead is dangerously toxic to the biosynthesis of heme. The reduced heme molecule in red blood cells causes anemia. Constipation, not diarrhea, and a poor appetite and vomiting, not overeating, are signs of lead poisoning. Paralysis may occur as toxic damage to the brain progresses, but it is not an initial sign.

A client is placed on neutropenic precaution. Which nursing action is appropriate?

avoiding yogurt for breakfast - Yogurt and yogurt products should be avoided because they have live and active cultures, which may predispose a client with low white blood cells (WBC) to infection.

client asks the nurse about the rhythm (calendar-basal body temperature) method of family planning. The nurse explains that this method involves:

determination of the fertile period to identify safe times for sexual intercourse. - The rhythm method of family planning combines basal body temperature measurement with analysis of cervical mucus changes to determine the fertile period. This method helps identify safe and unsafe periods for sexual intercourse. A natural family planning method, the rhythm method doesn't involve use of chemical barriers, hormones, or mechanical barriers.

The nurse is caring for a client with Alzheimer's disease. Which medication does the nurse prepare to administer that will improve cognition and functional autonomy?

donepezil - Donepezil is used to improve cognition and functional autonomy in mild to moderate dementia of the Alzheimer's type. Bupropion is used for depression. Haloperidol is used for agitation, aggression, hallucinations, thought disturbances, and wandering. Triazolam is used for sleep disturbances.

The nurse admits a client with Crohn's disease who is experiencing an exacerbation. Which intervention should the nurse make a priority of care?

promoting bowel rest - Promoting bowel rest is the priority during an acute exacerbation. This is accomplished by decreasing activity and initially putting the client on nothing-by-mouth (NPO) status. Weight loss may occur, but the priority is bowel rest.

A 1-year-old underwent hypospadias repair yesterday; he has a urethral catheter in place and an IV. Which rationale is appropriate for administering propantheline on an as-needed basis?

to prevent bladder spasms while the catheter is present - Propantheline is an antispasmodic that works effectively on children. It prevents bladder spasms while the catheter is in place. It isn't an antibiotic and therefore won't decrease the chance of infection or the number of organisms in the urine. The drug has no diuretic effect and won't increase urine flow.

A client comes to the clinic for a follow-up appointment after diagnostic tests show gastroesophageal reflux disease. What instructions should the nurse reinforce?

"Avoid alcohol and caffeine."

A nurse is caring for a client with thrush. Which instructions would be anticipated for treatment of this disorder?

"Give the solution immediately after feedings." - Nystatin oral solution should be swabbed onto the mouth after feedings to allow for optimal contact with mucous membranes. Administering nystatin before meals or with meals does not allow the best contact with the mucous membranes.

A nurse is reinforcing information about breastfeeding and ways to prevent breast engorgement with a postpartum client. Which client statement best indicates to the nurse that the client understands how to prevent this condition?

"I'll be sure to breastfeed every 2 to 3 hours." - Frequent breastfeeding keeps the breasts relatively empty and increases circulation, thereby helping to remove fluid that can lead to engorgement. Applying warm compresses to the breasts stimulates the let-down reflex, filling the breasts and increasing engorgement. An electric breast pump usually is not necessary if the neonate breastfeeds frequently. Although a bra can be worn to support the breasts, it does not prevent engorgement.

The nurse is providing teaching for a client with hepatitis A. Which statement by the client indicates the need to reinforce the teaching?

"It is all right to French kiss my partner." - Hepatitis A is an infection transmitted via the fecal-oral route. The client should not share bath towels and utensils with family members. Hand washing is essential to prevent transmission. French kissing the partner may cause transmission of the hepatitis infection and should not be encouraged.

Treatment for a child with sinus bradycardia includes atropine 0.02 mg/kg. If the child weighs 20 kg, how much is given per dose? Record your answer using one decimal place.__________ mg

0.4 - 0.02 mg/kg × 20 kg = 0.4 mg

A nurse is monitoring a client who has just returned from a vein ligation and stripping. Which is an appropriate nursing intervention?

Apply bilateral compression stockings. - Postoperative care of a client with a vein ligation and stripping includes elevation of the extremity, compression stockings, anticoagulant therapy, and assessment of the circulation of the affected extremity. Their is no drain in place after this type of surgery.

A 15-year-old client who sustained a spinal cord injury is on bedrest. Which intervention by the nurse might best help the adolescent cope with the prolonged bedrest?

Encouraging visitation by his friends - Encouraging visitation by friends might best help the adolescent cope with prolonged bedrest. Friends are much more important than family to this age-group. Providing reading material and video games might be somewhat helpful, but not as helpful as encouraging visits from friends.

The nurse is performing her morning assessment when the client says, "I had trouble sleeping last night." Which action should the nurse take first?

Gathering more information about the sleep problem

The nurse is teaching a client with type 1 diabetes how to treat adverse reactions to insulin. To reverse a hypoglycemic reaction, the client ideally should ingest an oral carbohydrate. However, this treatment isn't always possible or safe. Therefore, the nurse should advise the client to keep which alternate treatment on hand?

Glucagon

The nurse is administering theophylline to a client. What is the drug's therapeutic action when used to treat asthma?

Relaxes bronchial smooth muscle - In a reversible obstructive airway disease such as asthma, theophylline and the other methylxanthine agents decrease nonspecific airway reactivity and, in the presence of bronchospasm, relax bronchial smooth muscle. These drugs also directly stimulate the myocardium, cause diuresis, and increase sodium and chloride excretion. In nonreversible obstructive airway disease, such as chronic bronchitis and emphysema, methylxanthine agents stimulate the respiratory drive.

After an upsetting divorce, a client threatens to commit suicide with a handgun and is involuntarily admitted to the psychiatric unit with major depression. Which nursing diagnosis takes highest priority for this client?

Risk for self-directed violence related to plans to commit suicide by handgun

A 40-year-old executive who was unexpectedly laid off from work 2 days ago reports fatigue and an inability to cope. He admits drinking excessively over the last 48 hours. This behavior is an example of which condition?

Situational crisis - A situational crisis results from a specific event in a person's life. The person is overwhelmed by the situation and reacts emotionally. Fatigue, insomnia, and inability to make decisions are common signs and symptoms. The situational crisis may precipitate behavior that causes a crisis (alcohol or drug abuse). There isn't enough information to label this client an alcoholic. A manic episode is characterized by euphoria and labile affect. Symptoms of depression are usually present for 2 or more weeks. This client's symptoms have been present for only 48 hours.

Which nursing intervention would be most helpful for a client experiencing a panic attack?

Staying with the client and remaining calm, confident, and reassuring

A parent, who is visibly upset, carries a 2-month-old infant into a crowded emergency department. The child appears limp and lifeless. The parent screams to the nurse for help. What is the priorityaction by the nurse?

Take the infant and parent to a treatment room. - Taking the limp infant and screaming parent into a treatment room for evaluation provides privacy and a controlled environment. The parent should be allowed to remain with her child if he or she wishes. If the parent does not want to be present, the nurse should find a private area for the parent. The nurse must evaluate the child before calling the resuscitation team. Security is not warranted in this situation.

When administering an oral medication to an infant, the nurse should take which action to minimize the risk of aspiration?

Using an oral syringe to place the medication beside the tongue - When administering an oral medication to an infant, using an oral syringe is the best way to prevent aspiration because it allows controlled administration of a small amount of medication. Administering the medication too quickly could cause aspiration. Putting the drug in a bottle of formula isn't preferred because the infant may not take the entire dose of medication and because the contents of the bottle could interfere with drug absorption or action. Blocking the nasal passages could cause aspiration.

As a result of a viral infection, a client develops gastroenteritis. The physician prescribes kaolin and pectin mixture, 60 ml by mouth after each loose bowel movement, up to eight doses daily. The nurse informs the client that the medication will take effect in how many minutes?

Within 30 minutes - The onset of action of kaolin and pectin occurs within 30 minutes after oral administration. Duration of action is 4 to 6 hours.

A nurse is monitoring a client following an initial administration of sotalol. Which of the following would be of greatest concern to the nurse?

bilateral inspiratory wheezing upon auscultation - Nonselective beta-blocking drugs such as sotalol may cause bradycardia, hypotension, heart block, heart failure, bronchoconstriction, and/or increased airway resistance. Any preexisting respiratory condition such as asthma might be worsened by the concurrent use of these medications. A blood pressure of 102/60 mm Hg is not a critical value but must be compared to the baseline blood pressure. A heart rate of 60 beats/minute is within normal range and is not considered bradycardia. A weight gain of 1 pound in 2 days is not a specific indicator of a worsening condition.

A client with active genital herpes is admitted to the labor and birth area during the first stage of labor. What intervention specific to the client's condition should the nurse anticipate?

cesarean delivery

A client who is minimally responsive requires suctioning to clear airway secretions. Which assessment finding would indicate suctioning has been effective?

clear breath sounds bilaterally

The school nurse is gathering data related to the diabetic status of a 15-year-old athlete. Which physiologic change should the nurse anticipate as a diabetic teenager becomes more physically active during the day?

increased need for food

A nurse is about to give a backrub to a client after a complete bed bath. How should the nurse proceed?

massage gently in areas directly over pressure points - The nurse should massage the client's back gently in areas directly over pressure points. Vigorous massage could damage tissues. The client should be moved near the side of the bed, within the nurse's reach, rather than in the middle of the bed. The nurse should pour lotion onto the palms of the hands to warm it before it touches the client's back. To remove excess lotion, the nurse should pat the area dry with a towel; brisk rubbing could also damage the tissue.

A client is experiencing a manic episode while the nurse is attempting to obtain subjective data. What is the best method for the nurse to obtain the necessary information to care for the client? Select all that apply.

obtain the data in short sessions obtain the data by watching and listening talk with family members to obtain information - Taking a history from a client that is experiencing mania may be difficult but the nurse learns a significant amount of information by just watching and listening to the client, and talking with family members to get their perspective on the client's behavior and precipitating factors. Use short sessions in order to keep the client focused. Using medications to change the client's behavior and applying restraints are only appropriate if the client is in danger of hurting themselves or someone else.

A client following the administration of an opioid analgesic has a PaCO2 value of 80 mm Hg upon drawing blood gases. What does this blood gas value indicate?

the danger of respiratory arrest - A client about to go into respiratory arrest will have inefficient ventilation and will be retaining carbon dioxide. The PaCO2 value expected would be around 80 mm Hg. It is not indicative of hyperventilation as the CO2 is high, and it does not rise in pneumonia.

A nurse is administering sublingual nitroglycerin to a client with chest pain. Where should the nurse place the medication?

under the tongue - Sublingual medication should be placed under the tongue. Buccal medication should be placed in the cheek. Eyedrops should be instilled in the conjunctival sac in the lower eyelid. Oral medications should be placed on the tongue and then swallowed.

A nurse is concerned about a client's ability to retain information during education sessions. Which of the following techniques would enhance the retention of material in presentations?

using repetition - Repetition is an effective means of reinforcing critical information and enhancing content retention. The other options will not increase the client's ability to retain information and may actually decrease concentration.

The nurse is caring for a female client who underwent surgery 8 hours ago and is unable to void. When placing an indwelling urinary catheter in this client, the nurse should first advance the catheter how far into the urethra?

2" (5 cm) - In a female client, the nurse should first advance an indwelling urinary catheter 2" to 3" (5 to 7.5 cm) into the urethra or until urine appears. When urine appears, the nurse should advance the catheter another 1" to 2" (2.5 to 5 cm). In a male client, the nurse should initially advance the catheter 6" to 8", and then another 1" to 2" after urine appears.

A client with Hashimoto's thyroiditis and a history of two myocardial infarctions and coronary artery disease is to receive levothyroxine. Because of the client's cardiac history, the nurse would expect that the client's initial dose for the thyroid replacement would be:

25 mcg/day. - Elderly clients and clients with cardiac disease should begin with 25 mcg/day of levothyroxine. The dosage is increased at 2- to 4-week intervals until 100 mcg/day is reached. This slow titration prevents further cardiac stress. Younger clients would be started on the usual maintenance dose of 50 to 200 mcg/day. Clients with Hashimoto's thyroiditis don't require surgical intervention.

The nurse just received the shift report on her group of clients. Based on the information she received, which client should she assess first?

A client who underwent a right nephrectomy yesterday and is complaining of pain - The nurse should address pain issues first. After tending to the client with pain, the nurse should assess the client who has a fever. The clients awaiting discharge or cystoscopy can be addressed next, according to their scheduling needs.

After undergoing testing, a client comes to a physician's office for a follow-up appointment. During the appointment, the physician informs the client that she has systemic lupus erythematosus (SLE). Which resource might be helpful for a nurse to recommend to this client?

A support group for clients with SLE

A physician's order states to administer lorazepam, 20 mg by mouth twice per day, to treat anxiety. How should the nurse proceed?

Clarify the order with the prescribing physician because the amount prescribed exceeds the recommended dose. - The recommended dosage of lorazepam for treatment of anxiety is 1 to 10 mg, given in divided doses two to three times per day. The nurse should clarify the order with the prescribing physician because it exceeds the recommended dosage. The liquid form of the drug, not the tablet form, should be added to 30 ml of a diluent before administration.

A client diagnosed with acute arterial occlusive disease is scheduled to undergo an atherectomy. What is the priority nursing intervention for this client immediately after the procedure?

Closely monitor catheter site for bleeding. - Atherectomy is a surgical treatment used for acute arterial occlusive disease. After the procedure, the client should be monitored frequently for bleeding at the catheter site, and vital signs should be taken every 15 minutes times four, and then every hour for the first few hours. Ambulation should be delayed for the first 12 hours, and exercise is not a priority at this time.

A middle-age female complains of anxiety, insomnia, weight loss, the inability to concentrate, and her eyes feeling "gritty." Thyroid function tests reveal the following: a thyroid-stimulating hormone (TSH) level of 0.02 units/ml, a thyroxine level of 20 g/dl, and a triiodothyronine level of 253 ng/dl. A 6-hour radioactive iodine uptake test showed a diffuse uptake of 85%. Based on these findings, the nurse would suspect:

Graves' disease. - Graves' disease, an autoimmune disease causing hyperthyroidism, is most prevalent in middle-age females. In Hashimoto's thyroiditis, the most common form of hypothyroidism, TSH levels would be high and thyroid hormone levels low. In thyroiditis, radioactive iodine uptake is low (‰¤ 2%). A multinodular goiter will show an uptake in the high-normal range (3% to 10%).

A client in a nursing home is diagnosed with Alzheimer's disease. He exhibits the following symptoms: difficulty with recent and remote memory, irritability, depression, restlessness, difficulty swallowing, and occasional incontinence. This client is in what stage of Alzheimer's disease?

II - Stage II is exhibited by the above listed symptoms as well as communication difficulties, motor disturbances, forgetfulness, and psychosis. This stage lasts 2 to 10 years. Stage I, which lasts 1 to 3 years, is characterized by memory loss, poor judgment and problem-solving, difficulty adapting to new environments and challenges, and agitation or apathy. Stage III is characterized by loss of all mental abilities and the ability to care for self. There is no stage IV.

The nurse is gathering data from an older adult client with a fracture. Identify the location of the most common fracture in older adults to cause death within 1 year of sustaining the fracture.

Hip fracture is the most common injury in the older adult population and has a high rate of mortality due to complications of surgery and prolonged immobility.

An adult client was admitted with myasthenia gravis. While reviewing the client's chart, the licensed practical nurse (LPN)/licensed vocational nurse (LVN) noticed the medication administration record (MAR). Based on the information, what should the nurse do next?

Notify the registered nurse and question the morphine sulfate. - Myasthenia gravis is a neuromuscular disease characterized by deficiency of acetylcholine at the myoneural junction, causing extreme voluntary muscle weakness. Clients with myasthenia gravis are usually given an anticholinesterase drug like neostigmine to improve muscle strength. Anticholinesterase drugs may potentiate the effect of morphine. The LPN/LVN should inform the RN and question the medication because narcotic analgesics such as morphine may cause respiratory depression.

A 70-year-old client with a diagnosis of left-sided stroke is admitted to the facility. To prevent the development of disuse osteoporosis, which of the following objectives is appropriate?

Promoting weight-bearing exercises - When the mechanical stressors of weight bearing are absent, disuse osteoporosis can occur. Therefore, if the client does weight-bearing exercises, disuse complications can be prevented. Maintaining protein and vitamins levels is important, but neither will prevent osteoporosis. Doing ROM exercises will help prevent muscle atrophy and contractures.

The nurse suspects that a client is not swallowing the administered dose of an anxiolytic medication and is concerned that the client may be disposing of it in the trash. Which action should the nurse take first?

Talk with the client about the concerns. - Before reporting to the primary care provider, the nurse should discuss the perceived problem about the medications with the client in order to gather more information about the client's attitudes toward antianxiety medications. Searching the client's room for the medications is a violation of the client's right to privacy. The nurse and the healthcare provider can talk to the client about the benefits of taking the medication prescribed; however, the client has the right to refuse the medication.

A nurse is caring for a client with left-sided heart failure. Which intervention takes priority in this client's care?

administering diuretics - Diuretics, such as furosemide, reduce total blood volume and circulatory congestion in the client with left-sided heart failure. Obtaining the client's daily weight is important but not the priority. Oxygen administration increases oxygen delivery to the myocardium and other vital organs. Anticoagulants prevent clot formation but do not decrease fluid volume excess.

A client is being returned to his room after a subtotal thyroidectomy. Which piece of equipment is most important for the nurse to keep at the client's bedside?

Tracheostomy set - After a subtotal thyroidectomy, swelling of the surgical site (the tracheal area) may obstruct the airway. Therefore, the nurse should keep a tracheostomy set at the client's bedside in case of a respiratory emergency. Although an indwelling urinary catheter and a cardiac monitor may be used for a client after a thyroidectomy, the tracheostomy set is more important. A humidifier isn't indicated for this client.

The health care provider orders nitroglycerin, 5 mg by mouth twice per day, for a client. The drug is dispensed in 2.5-mg tablets. How many tablets will the nurse administer twice per day?

Two - The nurse will administer two tablets twice per day. Using the ratio method, the equation to solve for X is: 5 mg : X tab :: 2.5 mg : 1 tab. Solving for X determines the quantity of the dosage is two tablets.

The nurse suspects that a client with a temperature of 103.6° F (39.8° C) and an elevated white blood cell count is in the initial stage of sepsis. The nurse reviews the client's chart and expects to find which disorder, which is the most common cause of sepsis in hospitalized clients?

Urinary tract infection (UTI) - Sepsis most commonly results from a UTI caused by gram-negative bacteria. Other causes of sepsis include infections of the biliary, GI, and gynecologic tracts. Respiratory infection, vasculitis, and osteomyelitis rarely cause sepsis in hospitalized clients.

The nurse is caring for a neonate with a rectal temperature of 97.4 F (36.3 C). What is the prioritynursing intervention for this neonate?

Wrap the neonate in two warm blankets and place a cap on the head.

A 2-day-old boy is scheduled for circumcision without anesthesia. When reviewing the neonate's plan of care, which measure would the nurse likely find as most important after the procedure?

charting the time of the neonate's voiding - After a circumcision, urine retention may occur. Therefore the nurse should monitor and document the time of the neonate's voiding. Although the penis should be inspected for swelling and bleeding, further care is unnecessary. A petroleum dressing is commonly applied to the penis; then the neonate is diapered. Because no anesthetic was given, feeding restrictions are unnecessary. Ice should not be used on a neonate.

A client is receiving isophane insulin suspension every morning. When would the nurse expect the client to possibly develop hypoglycemia?

4 to 12 hours - Isophane insulin suspension is an intermediate-acting insulin with a peak (when hypoglycemia is most likely to occur) of 4 to 12 hours. The onset of rapid-acting insulin is 15 minutes to 1 hour. The peak effect of rapid-acting insulin is 2 to 6 hours. Long-acting insulin has a peak effect of 14 to 26 hours.

A client who experienced a stroke that left her with residual right-sided weakness was just discharged to go home. The client lives in a two-story house in which the bathroom is located on the second floor. A home health care nurse is visiting the client for the first time. Which issue should the nurse address during this visit?

Client's ability to climb the stairs while using a walker - The client sustained a stroke but has recovered enough to be discharged to go home. The home health care nurse should first make sure, however, that the client can safely navigate the stairs using a walker. If she's unable to do so, the client might require further assistance at home. Until the client's ability is assessed, it isn't necessary for the nurse to ask whether someone can assist her to the bathroom. It's inappropriate to suggest that the client have a bathroom built on the first floor. The client shows no signs of needing a skilled nursing facility, so suggesting it is inappropriate.

The nurse is teaching a client how to draw up NPH insulin into an insulin syringe. The does is 40 units. The client draws up the insulin using the correct technique. Which syringe shows that the client drew up the correct dose?

Option D correctly shows 40 units of insulin drawn into the syringe. All of the other options show incorrect drug amounts (option A shows 50 units, option B shows 30 units, and option C shows 25 units).

Which intervention should be included in the plan of care for a 6-month-old infant with mild dehydration related to diarrhea and vomiting?

Oral electrolyte replacement solutions, breast milk, or lactose-free formula - Oral electrolyte replacement solutions given in small amounts can replace fluid and electrolyte losses in an infant with mild diarrhea and vomiting. I.V. fluids are usually reserved for clients experiencing severe vomiting and dehydration. Fruit juices, carbonated soft drinks, and the BRAT diet, which are high in carbohydrates and low in electrolytes, aren't recommended.

A nurse is caring for a child with Kawasaki disease. Which symptom is most concerning to the nurse?

abdominal pain with vomiting - The most serious complication of Kawasaki disease is cardiac involvement. Abdominal pain, vomiting, and restlessness are the main symptoms of an acute myocardial infarction in children. Mild diarrhea can be treated with oral fluids. Pain in the joints is an expected sign of arthritis that usually occurs in the subacute phase. An increased erythrocyte sedimentation rate is a reflection of the inflammatory process and may be seen for 2 to 4 weeks after the onset of symptoms.

The nurse is reinforcing education on cast care for a client with a cast on the arm. How should the nurse instruct the client to place the casted limb, if there is swelling?

above the level of the heart - To reduce swelling, place the limb with the cast above the level of the heart. Placing it below or at the level of the heart won't reduce swelling. To elevate a cast, the limb may need to be extended from the body.

A client with a history of hypertension is 15 weeks' pregnant. For which condition should the nurse closely monitor this client?

abruptio placentae - A history of hypertension predisposes the client to developing abruptio placentae. The client is not at risk for developing preterm labor, spontaneous abortion, or anemia.

Which nursing action is appropriate when administering a glycerin suppository to a client?

Applying a lubricant to the suppository - A suppository should be lubricated before insertion to ease insertion and reduce discomfort. The nurse should assist the client in a left-side lying position (not right-side lying) to ease insertion. Because suppositories melt at body temperature, they usually require refrigeration until administration. Instructing the client to bear down would cause the anal sphincter to contract, making insertion difficult.

A client delivers a neonate prematurely at 28 weeks' gestation. The neonate is placed in the neonatal intensive care unit (NICU). Three days later, the client's husband seems withdrawn and barely speaks to the staff when visiting his child in the NICU. Which of the following nursing action should the nurse take?

Ask the father if he would want to talk about his feelings regarding the newborn and being in the intensive care. - Option a is not therapeutic and does not acknowledge the client's feelings. Option b is correct because it acknowledges the client's feelings and provides an opportunity for the father to verbalize his feelings. The nurse is not equipped to provide counseling; rather, he or she may refer the client to the appropriate person for counseling. The father may not be ready to hold the baby at this time.

For a client with an endotracheal (ET) tube, which nursing action is most essential?

Auscultating the lungs for bilateral breath sounds - For a client with an ET tube, the most important nursing action is auscultating the lungs regularly for bilateral breath sounds to ensure proper tube placement and effective oxygen delivery. Although the other options are appropriate for this client, they're secondary to ensuring adequate oxygenation.

The nurse is teaching the parents of a child with cystic fibrosis about proper nutrition. Which of the following instructions should the nurse include?

Encourage a high-calorie, high-protein diet. - The child should eat a high-calorie, high-protein diet. In cystic fibrosis, the enzymes from the pancreas (lipase, trypsin, and amylase) become so thick that the ducts become plugged. Without these enzymes, the duodenum isn't able to digest fat, protein, and some sugars; therefore, the child can become malnourished. Because fats aren't easily tolerated, they may need to be restricted. The child with cystic fibrosis needs to drink plenty of fluid and take salt supplements, especially on warm days or when exercising. Water- soluble forms of the fat-soluble vitamins (A, D, E, and K) are necessary because the inability to absorb fats results in a deficiency of these vitamins. Clients with cystic fibrosis don't have a problem absorbing water-soluble vitamins such as vitamin B.

A dystonic reaction can be caused by which medication?

Haloperidol - Haloperidol is a phenothiazine and is capable of causing dystonic reactions. Diazepam and clonazepam are benzodiazepines, and amitriptyline is a tricyclic antidepressant. Benzodiazepines don't cause dystonic reactions; however, they can cause drowsiness, lethargy, and hypotension. Tricyclic antidepressants rarely cause severe dystonic reactions; however, they can cause a decreased level of consciousness, tachycardia, dry mouth, and dilated pupils.

A 35-year-old female client is requesting information about mammograms and breast cancer. She is not considered at high risk for breast cancer. What should the nurse tell this client?

"A low-fat diet has been shown to decrease your risk of breast cancer." - A low-fat diet (one that maintains weight within 20% of recommended body weight) has been found to decrease a woman's risk of breast cancer. A baseline mammogram should be done between the ages of 30 and 40. Monthly breast self-examinations should be done between days 7 and 10 of the menstrual cycle. Women are encouraged to become familiar with their breasts so that they can detect changes and seek care. The client should continue to perform monthly breast self-examinations even when receiving yearly mammograms.

A client is being seen for a routine physical exam. The client reports concern because their parent has been diagnosed with dementia and the client fears "getting it" when getting older. Which response by the nurse is most appropriate?

"Although getting older and a family history elevate your risk there is no guarantee that you will develop dementia."

The employer of a client on a psychiatric unit calls the nursing station inquiring about the client's progress. The nurse is unsure whether the client has given consent for information to be shared with callers on the phone. Which response by the nurse would be best?

"I can't confirm whether your employee is a client here." - The nurse's release of information to the client's employer without the client's consent is a breach of confidentiality. The stigma associated with psychiatric illness may affect the client's employment; therefore, it is better to maintain confidentiality and refrain from disclosing any information about the client, including whether the employee is a client in the hospital.

When reinforcing education with parents of an infant newly diagnosed with diabetes insipidus, which statement by the parent indicates an appropriate understanding of this condition?

"I realize that treatment for diabetes insipidus is lifelong."

The nurse is teaching a client about oral contraceptive therapy. The client reports missing three doses of the scheduled medication. Which statement made by the client indicates understanding of the teaching regarding oral contraceptives?

"I will discard the pack, use an alternative contraceptive method until my menses begins, and start a new pack on the regular schedule." - A client who misses three or more pills in a row should discard the pack, use an alternative contraceptive method until her menses begins, and start a new pack on the regular schedule. The other options listed don't assure effectiveness and also increase the risk of adverse reactions.

When reinforcing discharge education for a client with ulcerative colitis, the nurse emphasizes the importance of regular examinations. Which statement by the client indicates an understanding of the instructions?

"I will need to have routine screenings because having ulcerative colitis places me at risk for colon cancer."

The nurse is reinforcing education to parents of a child prescribed sulfamethoxazole-trimethoprim for a urinary tract infection. What education should the nurse include?

"Make sure your child takes the medication for 10 days even if his symptoms improve in a few days." - Discharge instructions for parents of children receiving an anti-infective medication should include taking all of the prescribed medication for the prescribed time. The child will not need to have a culture repeated until the medication is completed. Drinking highly acidic juices, such as cranberry juice, may help maintain urinary health, but will not get rid of an infection already present.

A client reported chest pain and received sublingual nitroglycerin. Which statement by the client indicates that this drug is producing its therapeutic effect?

"My chest pain is decreasing."

The nurse is caring for a client who just received instruction on breast self-examination. The unlicensed assistive personnel (UAP), who was in the room during the teaching states, "Why is it important to press your hands in your hips when performing your breast examination?" What appropriate response would the nurse give the UAP?

"This position contracts the pectoral muscles and enhances any breast changes." - When the arms are pressed in the hips, the pectoral muscles contract and accentuate any breast retractions. Taking a deep breath will relax the shoulders and arms. Lying supine will allow the breasts to spread thinly and evenly over the chest wall. Leaning forward allows the breasts to hang freely away from the chest.

A nurse is providing care for a pregnant client with gestational diabetes. The client tells the nurse, "I know that the other nurse explained about how gestational diabetes can affect my pregnancy and birth. But I am so overwhelmed that I am having trouble understanding everything." Which explanation would the nurse most likely include when reinforcing the previous teaching?

"You may have to be induced early to give birth." - Early induction and early cesarean birth are possibilities if the client has diabetes and blood glucose control has not been achieved during pregnancy. However, cesarean birth is not always necessary in the client with gestational diabetes. The neonate may or may not need to be cared for in the neonatal intensive care unit (NICU). This decision will be determined by the neonate's condition. Together the client and client's healthcare provider will discuss the client's options, and then together, the decision will be made.

A hospitalized child is to receive 75 mg of acetaminophen for fever control. How much will the nurse administer if the acetaminophen concentration is 40 mg per 0.4 ml? Record your answer using two decimal places.

0.75 - Use the following equations: Dose on hand/Quantity on hand = Dose desired/X 40 mg/0.4 ml = 75 mg/X X = 0.75 ml

The licensed practical nurse is collaborating with the registered nurse validating a test dose of mannitol solution IV for a client with marked oliguria. The ordered test dose is 0.2 g/kg of 15% mannitol solution IV. The client weighs 132 lb (59.8 kg). How many grams should the nurse administer? Record your answer as a whole number.

12 - First, convert the client's weight from pounds to kilograms: 132 lb divided by 2.2 kg/lb = 60 kg. Then, to calculate the number of grams to administer, multiply the ordered number of grams by the client's weight in kilograms: 0.2 g/kg X 60 kg = 12 g.

The nurse is completing the intake and output record for a client. The client has had the following intake and output during the shift:Intake: 4 oz (120 mL) of cranberry juice, 1/2 bowl of oatmeal, 2 slices of toast, 8 oz (240 mL) of black decaffeinated coffee, tuna fish sandwich, 1/2 cup (120 mL) of fruit-flavored gelatin, 1 cup (240 mL) of cream of mushroom soup, 6 oz (180 mL) of 1% milk, and 16 oz (480 mL) of water.Output: 1,300 mL of urine.How many milliliters should the nurse document as the client's intake? Record your answer using a whole number.

1380 - There are 30 mL in each fluid ounce and 240 mL in each cup. The fluid intake for this client includes 4 oz (120 mL) of cranberry juice, 8 oz (240 mL) of coffee, 1/2 cup (120 mL) of fruit-flavored gelatin, 1 cup (240 mL) of cream of mushroom soup, 6 oz (180 mL) of milk, and 16 oz (480 mL) of water, for a total of 1,380 mL.

The nurse views the laboratory results for a 9-year-old child hospitalized with severe vomiting and diarrhea. Which serum potassium level would the nurse expect to observe in this child?

2.5 to 3.4 mmol/L - Potassium is lost through diarrhea and is expected to be low normal or low. A level below 3.5 mmol/L should be expected with severe diarrhea. The normal potassium level in children ranges from 3.5 to 4.8 mmol/L. Levels of 4.5 to 7.2 mmol/L are observed in premature infants. Potassium levels of 3.7 to 5.2 mmol/L are observed in full-term infants. Potassium levels of 3.5 to 5.5 mmol/L are usually seen in adults.

The nurse is preparing to give a 9-year-old client a preoperative I.M. injection. Which size needle should the nurse use?

22G, 1" - The nurse should first evaluate the muscle mass and amount of subcutaneous fat and then select the correct size needle. Without more information, the nurse would select the 22G, 1" needle, appropriate for an average-sized school-age child. The 20G, 1" needle would be unnecessarily large. The 22G, 1½" needle would be too long. The 20G, 1½" needle would be both too long and unnecessarily large.

A client is using the rhythm (calendar-basal body temperature) method of family planning. In this method, the unsafe period for sexual intercourse is indicated by:

3 days of elevated basal body temperature and clear, thin cervical mucus. - Ovulation (the period when pregnancy can occur) is accompanied by a basal body temperature increase of 0.7° F to 0.8° F (.39° C to .44° C) and clear, thin cervical mucus. A return to the preovulatory body temperature indicates a safe period for sexual intercourse. A slight rise in basal temperature early in the cycle isn't significant. Breast tenderness and mittelschmerz aren't reliable indicators of ovulation.

A client is admitted to the hospital in the manic phase of bipolar disorder. Which foods are most appropriate for this client?

A cheese sandwich, carrot sticks, grapes, and cookies - The client may have difficulty sitting long enough to eat his meal. Therefore, finger foods that can be eaten easily are most appropriate. The other foods require the client to sit and eat, a task the client can't achieve at this time.

When giving an intramuscular (IM) injection, which angle should the nurse insert the needle into the muscle?

90 degrees

After checking the client's chart for possible contraindications, the nurse is administering meperidine, 50 mg I.M., to a client with pain after an appendectomy. The nurse would question which medication if noted on the physician's orders for this client?

A monoamine oxidase (MAO) inhibitor - MAO inhibitors increase the effects of meperidine and can cause rigidity, hypotension, and excitation. The client shouldn't receive meperidine within 14 days after administration of an MAO inhibitor. Antibiotics, antiemetics, and loop diuretics don't cause significant drug interactions when administered concurrently with meperidine.

When assessing a client for signs and symptoms of ectopic pregnancy, what is the most common sign or symptom associated with this antepartum complication the nurse would expect to find?

Abdominal pain - Abdominal pain is the most common finding in ectopic pregnancy, occurring in more than 90% of women with this antepartum complication. Temperature elevation, vaginal bleeding, and nausea and vomiting are less commonly associated with ectopic pregnancy.

A nurse is gathering data from a client who was admitted to the emergency department with suspected appendicitis. Identify the area of the abdomen that the nurse should palpate last.

An acute attack of appendicitis localizes as pain and tenderness in the lower right quadrant, midway between the umbilicus and the crest of the ilium. This area should be palpated last in order to determine if pain is also present in other areas of the abdomen.

A child with thoracic water-seal drainage is on the elevator. The transport aide has placed the drainage system on the stretcher. What action should the nurse on the elevator take first?

Assist the aide in placing the drainage system lower than the child's chest.

When caring for a client during the second stage of labor, which action would be most appropriate?

Assisting the mother with pushing - Nursing care for the client during the second stage of labor should include assisting the mother with pushing, helping position her legs for maximum pushing effectiveness, and monitoring the fetal heart rate. During this time, the client is usually offered ice chips rather than clear liquids. The client should be encouraged to ambulate and void every 2 hours during the first stage of labor, not the second.

The nurse is caring for a child admitted with acute exacerbation of asthma and receiving oxygen via nasal cannula at 2 L/minute and who needs magnetic resonance imaging (MRI) without contrast. What is the priority nursing action for this client?

Avoid having an oxygen cylinder in the MRI area. - The priority nursing action is to ensure that the oxygen cylinder is not taken into the MRI area to avoid injury. Instructing the child on the procedure and consent ensures his or her cooperation. Allergy is not a concern with this procedure because the procedure requires imaging only and no dye.

The nurse is examining a client's scalp for evidence of lice. The nurse should pay particular attention to which part of the scalp?

Behind the ears - Adult lice usually bite the scalp behind the ears and along the back of the neck. Because such lice are tiny (1 to 2 mm) with grayish white bodies, they are hard to see. However, their bites result in visible pustular lesions. Although lice may bite any part of the scalp, bites are less common on the temporal area, top of the head, and middle area.

A 14-month-old child weighing 26 lb (11.8 kg) is admitted for traction to treat congenital hip dislocation. When preparing the client's room, the nurse anticipates using which traction system?

Bryant's traction - Bryant's traction is used to treat femoral fractures or congenital hip dislocation in children younger than age 2 who weigh less than 30 lb (13.6 kg). Buck's extension traction is skin traction used for short-term immobilization or to correct bone deformities or contractures; overhead suspension traction is used to treat fractures of the humerus; and 90-90 traction is used to treat femoral fractures in children older than age 2.

A nurse is feeding a child with a cleft palate. Which nursing action would be a priority?

Burp the infant often. - Infants with cleft lip and palate have a tendency to swallow an excessive amount of air, so they need burping often. The amount of formula they eat at each feeding is the same as an infant without cleft lip or palate, and scheduled feedings are not necessary. Loud noises are common when these infants eat.

The nurse is aware that Standard Precautions represent the first tier of Centers for Disease Control guidelines for isolation precautions. Which is the nurse's primary responsibility when following Standard Precautions?

Consider all body substances potentially infectious. - Standard precautions are based on the concept that all body substances are potentially infectious and direct contact with them must be avoided. The nurse should wear gloves when contact with body substances — not unsoiled articles or intact skin — is anticipated. Because all body substances from all clients are considered potentially infectious, signs on doors are unnecessary. Gloves and gowns are necessary only when contact with body fluids is likely.

A child admitted with pneumonia has a history of cystic fibrosis (CF). Which statement made by the parents best demonstrates an understanding of cystic fibrosis?

Cystic fibrosis (CF) is an inherited disease characterized by an abnormality in the body's salt, water- and mucus-making cells. - Cystic fibrosis (CF) is an inherited disease characterized by an abnormality in the body's salt, water- and mucus-making cells. In recessive disorders such as cystic fibrosis, both parents must pass the defective gene or set of genes to the child. Dominant disorders are characterized by only one defective gene or set of genes passed by one parent. Sex-linked genetic disorders are carried on the X chromosome. It is a chronic disease and is progressive.

A licensed practical nurse (LPN) is providing care to a client and is uncertain about a health care provider's prescription regarding a medication prescribed for the client. Which action would be most appropriate?

Decide whether to follow the prescription after conferring with the supervising registered nurse (RN). - Ambiguous prescription must be clarified with the health care provider. If the LPN believes the health care provider's prescription to be incorrect, the nurse should confer with the supervising RN about it. If they decide that the prescription is inappropriate, the supervising nurse can contact the health care provider about any concerns. The nurse's decision and all communication with the health care provider about the prescription must be documented.

A client is admitted with the following vital signs: temperature, 102° F (38.9° C); heart rate, 144 beats/minute and irregular; and respiratory rate, 22 breaths/minute. Which nursing diagnosis takes highest priority when planning this client's care?

Decreased cardiac output - A heart rate of 144 beats/minute indicates decreased diastolic filling time and a reduced blood volume ejected with each contraction, resulting in decreased cardiac output. The client's temperature and respiratory rate are elevated but not enough for a diagnosis of Ineffective thermoregulation or Ineffective breathing pattern to take precedence over one of Decreased cardiac output. The client's vital signs don't suggest a diagnosis of Ineffective renal tissue perfusion.

A client comes to the emergency department reporting pain in the right leg. When obtaining his history, the nurse learns that the client was diagnosed with diabetes mellitus at age 12. The nurse knows that this disease predisposes the client to which musculoskeletal disorder?

Degenerative joint disease - Diabetes mellitus predisposes the client to degenerative joint disease. It isn't a predisposing factor for muscular dystrophy, scoliosis, or Paget's disease.

A client with colorectal cancer being prepared for colostomy placement tells the nurse, "I am very nervous and unsure about this surgery." What should the nurse's initial action be when caring for this client?

Determine what the client already knows about colostomies. - Initially, the nurse should determine not only what the client already knows but also what the client wants to know. The nurse should evaluate the client's perceptions of how a colostomy will affect the client's lifestyle and sexuality. Providing written materials and pictures and arranging for a visit by someone who has an ostomy are all appropriate interventions when the client is ready to receive more detailed information.

A client is receiving oxytocin to treat postpartum hemorrhage. The nurse recognizes which common adverse reactions may be associated with the medication?

Hypertension and tachycardia - Oxytocin may cause hypertension and tachycardia. The nurse should monitor the client for these adverse effects. Abdominal cramps, diarrhea, headache, facial flushing, blurred vision, and dizziness aren't typically associated with oxytocin.

Which of the following actions displayed by a grieving husband over his dying wife would cause the nurse to suggest counseling?

He refuses to acknowledge his wife's family and blames them for her current health problems. - Abnormal grief may manifest itself as exaggerated or excessive expressions of normal grief reactions, such as anger, sadness, or depression. It's therapeutic to review a person's life with loved ones. Funeral planning can be therapeutic because it allows the individual to do one last thing for his loved one. It's therapeutic to share treasured items with staff and other family members.

A nurse is assisting in developing a plan of care for a pediatric client with a diagnosis of atopic dermatitis. Which actions would the nurse most likely include in the plan? Select all that apply.

Help the client develop a daily skin care schedule. Lubricate the skin after bathing. Shampoo often if the scalp is involved. - Tepid baths and moisturizers are indicated for eczema to keep the infected areas clean and to minimize itching. Clients should lubricate the skin directly after bathing to reduce dryness and pruritus. Clients should shampoo their scalp frequently. Hot baths can exacerbate the condition and increase itching. Tepid baths are indicated for these clients, not hot showers.

A nurse is providing care to a client who was admitted with pneumonia, Alzheimer's disease (AD) and a history of multiple fractures. The nurse observes multiple bruises in various stages of healing. Which action by the nurse would be most important?

Inform the supervising registered nurse. - Based on the client's history and symptoms, the nurse should suspect that the client may be experiencing elder abuse. The nurse should report the findings to the supervising registered nurse who then would notify local authorities, including local social service or law enforcement agencies. Once the findings are reported, the nurse should then document the findings and include illustrations to support the evaluation. Questioning the client about the bruises may or may not be helpful because a client with Alzheimer's disease may not be able to accurately inform the nurse about what happened. Reporting findings to the health care provider may not be sufficient for fulfilling the nurse's legal responsibility.

A client with type 1 diabetes is admitted to an acute care facility with diabetic ketoacidosis. To correct this acute diabetic emergency, which measure should the health care team take first?

Initiate fluid replacement therapy. - The health care team first initiates fluid replacement therapy to prevent or treat circulatory collapse caused by severe dehydration. Although diabetic ketoacidosis results from insulin deficiency, the client must have an adequate fluid volume before insulin can be administered; otherwise, the drug won't circulate throughout the body effectively. Therefore, insulin administration follows fluid replacement therapy. Determining and correcting the cause of diabetic ketoacidosis are important steps, but the client's condition must be stabilized first to prevent life-threatening complications.

A nurse is preparing a presentation for a pregnant client with diabetes. Which information would the nurse include to explain why a pregnant diabetic client is at risk for having a large-for-gestational-age infant?

Insulin acting as a growth hormone on the fetus - Insulin acts as a growth hormone on the fetus. Therefore, pregnant diabetic clients must maintain good glucose control. Large babies are prone to complications and may have to be delivered by cesarean section. Neither excess sugar nor excess insulin reduces placental functioning. A high-calorie diet helps control the mother's disease and doesn't contribute to neonatal size.

A client who has a pulmonary embolism has the potential to develop chest pain. What would be the nurse's best explanation for this when reinforcing education for the client?

It is pleuritic pain due to inflammation. - Pleuritic pain is caused by the inflammatory reaction of the lung parenchyma to the pulmonary embolism. The pain isn't associated with myocardial infarction, costochondritis, or referred pain from the pelvis to the chest.

When caring for a client who has had a cesarean section, which of the following actions is appropriate?

Monitoring pain status and providing necessary relief - The nurse should monitor the client's pain status and provide relief as needed. Nursing care should never include removing the initial dressing put on in the operating room. Appropriate nursing care for the incision would include circling any drainage, reporting findings to the physician, and reinforcing the dressing as needed. The nurse should monitor vital signs every 15 minutes until the client is stable. Breast-feeding should be initiated as soon as the mother feels like trying. The nurse shouldn't begin bottle- feeding the baby unless the mother is physically unable to breast-feed.

The nurse is caring for a client with postoperative urine retention. Which intervention should the nurse provide first?

Pour warm water over the perineum. - Urine retention reflects bladder distention from urine. Sitting upright and pouring water over the perineum may help the client void. A diuretic is not necessary. If these measures are not successful, the nurse should consider inserting a bladder catheter to drain the bladder, which requires an order from the health care provider.

A client on a low-phosphate diet receives a breakfast tray that includes scrambled eggs, cream of wheat, strawberries, coffee, and low-fat milk. What is the nurse's best action?

Remove the milk carton from the tray. - Foods high in phosphate include milk, other dairy products, bran, organ meats, some fish, and dried beans and peas. Fruit and eggs are not high in phosphate and are not restricted.

Which information is important for the nurse to include in a teaching plan for a schizophrenic client taking clozapine?

Report a sore throat or fever to the physician immediately. - A sore throat and fever are indications of an infection caused by agranulocytosis, a potentially life-threatening complication of clozapine. Because of the risk of agranulocytosis, white blood cell (WBC) counts are necessary weekly, not monthly. If the WBC count drops below 3,000/μl, the medication must be stopped. Hypotension may occur in clients taking this medication. Warn the client to stand up slowly to avoid dizziness from orthostatic hypotension. The medication should be continued, even when symptoms have been controlled. If the medication must be stopped, it should be slowly tapered over 1 to 2 weeks and only under the supervision of a physician.

A physician is administering a medication by intraosseous infusion to a child. Intraosseous drug administration is typically used for a child who is:

younger than age 3 in an emergency situation when I.V. access isn't available. - In an emergency, intraosseous drug administration is typically used when a child is critically ill and younger than age 3.

The licensed practical nurse (LPN) is assigned to care for a 4-year-old child who had a Harrington rod inserted the day before and notices the client is receiving antibiotics by a syringe pump. The nurse is IV certified, but uncomfortable because they are unfamiliar with the equipment. What would be the best course of action?

Request in-service education for use of the syringe pump. - Using this piece of equipment is within the LPN's scope of practice, so it's inappropriate to refuse the assignment. Reading the policy and procedure manual is a good first step but not sufficient to ensure that they will be rendering safe care. Although requesting another assignment, it is best to request in-service education; the nurse is taking responsibility for the lack of experience in order to care for the child in a safe manner.-

The nurse has an order to administer an intramuscular (I.M.) injection using the Z-track technique. When carrying out this order, what nursing intervention should the nurse implement?

Simultaneously withdraw the needle and release the skin. - When giving an I.M. injection using the Z-track technique, the nurse pulls the skin laterally away from the injection site, inserts the needle at a 90-degree angle, waits 10 seconds after injecting the medication, and then simultaneously withdraws the needle and releases the skin.

A client with type 2 diabetes comes to the clinic with a diabetic foot ulcer on his left heel that hasn't responded to treatment. Which action should a nurse take after assessing the ulcer?

Suggest a consult with a wound care specialist. - Because the wound is not responding to the current treatment plan, a consult with the wound care specialist should be suggested. Cleaning and redressing the wound and telling the patient that the lack of a response to treatment is expected don't address the problem with healing. Completing vitals signs and documenting any changes in body temperature are appropriate; however, a client needs more care before he is sent home with an appointment to return in 1 week.

One day after an appendectomy, a 9-year-old client rates his pain at 4 out of 5 on the pain scale but is playing video games and laughing with his friend. Which of the following would the nurse document on the child's chart?

The child rates pain at 4 out of 5. Pain medication administered as prescribed. - Pain is what the child says it is, and the nurse must document what the child reports. If a child's behavior appears to differ from the child's rating of pain, believe the pain rating. A child who uses a passive coping behavior (such as distraction) may rate pain as more intense than children who use active coping behavior (such as crying). Making judgments about pain based on behavior can result in children being inadequately medicated for pain.

A client who comes to the labor and delivery area tells the nurse she believes her membranes have ruptured. When obtaining her history, what should the nurse ask about first?

The time of membrane rupture - First, the nurse should ask the client when her membranes ruptured because the risk of perinatal infection increases with the time elapsed between membrane rupture and the onset of contractions. After determining the time of membrane rupture, the nurse should ask about the frequency of contractions and find out whether the client has back pain or bloody show.

While reading a journal article, a nurse comes across a discussion of the causes of dissociative disorders. Which information would the nurse most likely find in the discussion?

They occur as a result of the brain trying to protect the person from severe stress. - The best description of the cause of a dissociative disorder is that the brain tries to protect the person from severe stress. Incest or any sexual trauma is only one of many reasons dissociative disorders occur. Typically, substance abuse isn't a cause (but may be an effect) of a dissociative disorder. Dissociative disorders are actually rare.

When developing a plan of care for a child, the nurse identifies which Eriksonian stage as corresponding to Freud's oral stage of psychosexual development?

Trust versus mistrust - Freud defined the first 2 years of life as the oral stage and suggested that the mouth is the primary source of satisfaction for the developing child. Erikson posited that infancy (from birth to age 12 months) is the stage of trust versus mistrust, during which the infant learns to deal with the environment through the emergence of trustfulness or mistrust. Initiative versus guilt corresponds to Freud's phallic stage. Autonomy versus shame and doubt corresponds to Freud's anal/sensory stage. Industry versus inferiority corresponds to Freud's latency period.

During a physical examination, a client who's 32 weeks pregnant becomes pale, dizzy, and light-headed while supine. Which action should the nurse immediately take?

Turn the client on her left side.

The nurse educator is preparing an in-service about urinary incontinence in the elderly. Which information should the nurse share with her colleagues describing urinary incontinence in the elderly?

Urinary incontinence is not a disease. - Urinary incontinence isn't a normal part of aging nor is it a disease. It may be caused by confusion, dehydration, fecal impaction, restricted mobility, or other causes. Certain medications, including diuretics, hypnotics, sedatives, anticholinergics, and antihypertensives, may trigger urinary incontinence. Most clients with urinary incontinence can be treated; some can be cured.

A client with advanced breast cancer is prescribed tamoxifen. When teaching the client about this drug, the nurse should emphasize the importance of reporting which adverse reaction immediately?

Vision changes - The client must report changes in visual acuity immediately because this adverse effect may be irreversible. Tamoxifen isn't associated with hearing loss. Although the drug may cause anorexia, headache, and hot flashes, the client need not report these adverse effects immediately because they don't warrant a change in therapy.

The nurse is preparing to change the perineal pad on a postpartum client. Which actions taken by nurse prevents postpartum infection? Select all that apply.

Wash hands before touching the client. Use gloves while changing pad. - Washing hands and using gloves during the examination prevents transmission of infection by preventing contact with body fluid and decreasing the germ colony through hand washing. Introduction, providing privacy, and auscultating before palpation are necessary steps during physical examination, but do nothing to prevent infection.

The nurse educator is preparing an in-service on antidiuretics. Which of the following functions of antidiuretic hormone (ADH) would the nurse include in the presentation?

Water reabsorption and urine concentration - ADH stimulates the renal tubules to reabsorb water, thereby concentrating urine. Aldosterone is responsible for sodium reabsorption and potassium excretion by the kidneys.

Which client would be most at risk for secondary Parkinson disease caused by pharmacotherapy?

a 30-year-old client with schizophrenia taking chlorpromazine - Phenothiazines, such as chlorpromazine, deplete dopamine, which may lead to tremor and rigidity (extrapyramidal effects). The other clients aren't at a greater risk for developing Parkinson disease caused by pharmacotherapy.

A nurse reviews the health history of four clients. Which client is at greatest risk for the development of colorectal cancer?

a 52-year-old client with a family history of polyposis - Familial polyposis is a strong risk factor for colorectal cancer. In addition, the risk of developing colorectal cancer increases after age 50. Certain cancers, such as genital and breast cancers, but not skin cancer, are also risk factors for colorectal cancer. Gastric ulcers rarely become malignant and are not associated with colorectal cancer. A high-fat, high-calorie diet also increases the risk of colorectal cancer. Other risk factors for colorectal cancer include inflammatory bowel disease and a previous history of colorectal cancer.

A nurse is caring for a client with renal failure who is reporting nausea. Which factor best explains how nausea is related to renal failure?

accumulation of metabolic wastes - Although a client with renal failure can develop stress ulcers, nausea is usually related to the poisons of metabolic wastes that accumulate when the kidneys cannot eliminate them. The client may have electrolyte imbalances and oliguria, but these conditions

A nurse is assisting with the care of a pregnant client experiencing mild active bleeding from placenta previa. The nurse suspects that an emergency cesarean birth may be necessary based on which finding?

fetal heart rate of 80 beats/minute - A fetal heart rate of 80 beats/minute indicates fetal distress, indicating the need for a cesarean birth. Maternal blood pressure and heart rate would be considered within normal parameters. Bleeding, especially if noted as pooling under the client, indicates active bleeding and an indication that cesarean birth may be necessary.

Which client is at the greatest risk for developing sensory overload?

an 80-year-old client in the intensive care unit (ICU) - Sensory overload is a condition in which the central nervous system receives much more auditory, visual, or other environmental stimuli than can be processed effectively. Because of the monitors, beeping sounds, lights, and constant activity in the ICU, an 80-year-old is most at risk for sensory overload. The pregnant client is experiencing symptoms that are not related to environmental stimuli. The 4-year-old receiving immunizations and the 72-year-old client having dressings changed are dealing with less overwhelming stimuli.

Following a kidney transplantation, a client is prescribed a combination of medications that includes steroids and cyclosporine. Which client education should the nurse reinforce?

avoid being in crowded places - The client should avoid situations in which infections can be transmitted because his ability to resist pathogens is diminished. Steroids impair the immune system and cyclosporine is given to suppress the immune response and decrease the chance of transplant organ rejection. Home-canned foods should be boiled for 20 minutes and inspected before being consumed, but generally pose no greater risk of infection than commercially canned foods. Steroids and cyclosporine aren't associated with bleeding tendencies and should never be stopped abruptly. Even mild febrile episodes should be reported immediately because the client's immune system is impaired, and taking medications such as acetaminophen could mask the presence of serious infections.

While gathering data about a child's skin integrity, the nurse observes a papular pruritic rash with some vesicles. The rash is profuse on the trunk and sparse on the distal limbs. What does the nurse correlate this finding with?

chickenpox - Chickenpox begins with a macule, rapidly progresses to a highly pruritic papule, then becomes a vesicle. All three stages are present in varying degrees at one time. Measles begin as an erythematous maculopapular eruption on the face and gradually spread downward. Mumps doesn't manifest a skin rash. Roseola rash is nonpruritic and appears as discrete rose-pink macules, first on the trunk and then spreading to the neck, face, and extremities.

The nurse is reviewing a pregnant client's nutritional status. To determine whether she has an adequate intake of vitamin A, the nurse should check her diet for consumption of:

dairy products. - Common food sources of vitamin A include dairy products, liver, egg yolks, fruits, and vegetables. Fish and meat are good sources of protein. Cereals, especially whole grains, are good sources of niacin, vitamin B1, and vitamin B6.

A nurse manager is appropriately using an autocratic method of leading the team. Which situation does the staff nurse determine demonstrates this form of leadership?

directing staff activities if a client has a cardiac arrest - In a crisis situation, the nurse-manager should take command for the benefit of the client. Planning vacation time and evaluating procedures and client resources require staff input characteristic of a democratic or participative manager.

During a prenatal visit, a pregnant client with cardiac disease and slight functional limitations reports increased fatigue. To help combat this problem, the nurse should advise her to:

divide daily food intake into five or six meals. - To combat fatigue, the nurse should advise the client to divide her daily food intake into five or six meals eaten throughout the day to minimize the energy expenditure associated with consuming three larger meals. Exercising before meals would increase fatigue, interfering with the client's nutritional intake. Vitamin and mineral supplements are appropriate for anyone, not specifically pregnant clients, and have little effect on fatigue.

A nurse is caring for a client with multiple myeloma. Which intervention should be stressed when reinforcing education to the client?

drinking 3 qt (2.8 L) of fluid daily - The client needs to drink 3 to 5 qt (2.8 to 4.7 L) of fluid each day to dilute calcium and uric acid and thereby reduce the risk of renal dysfunction. Walking is encouraged to prevent further bone demineralization. The lower extremities don't need to be elevated.

An LVN/LPN who works in an Alzheimer unit is administering medication to a group of clients. What should the nurse use to identify the right client for medication administration? Select all that apply.

first and last name medical record number date of birth - The three client identifiers are first and last name, date of birth, and medical record number. It will be difficult for two clients to have the same identical three identifiers. Clients who are confused can answer to another person's name or wander into another client's bed and room. Asking the nursing assistant to identify the client is not error proof and is not recommended.

A psychotic client reports to the evening nurse that the day nurse put something suspicious in his water with his medication. The nurse replies, "You're worried about your medication?" The nurse's communication is:

focusing on emotional content. - The nurse should help the client focus on the emotional content rather than the content of his delusions. Presenting reality isn't helpful because it can lead to confrontation and disengagement. Agreeing with the client and supporting his beliefs are reinforcing his delusions. Mind reading isn't therapeutic.

A client has a history of osteoarthritis. Which signs and symptoms would the nurse expect to find when gathering data on the client?

joint pain, crepitus, Heberden's nodes - Clinical findings for osteoarthritis include joint pain, crepitus, Heberden's nodes, Bouchard's nodes, and enlarged joints. The joint pain occurs with movement and is relieved by rest. As the disease progresses, pain may also occur at rest. Heberden's nodes are bony growths that occur at the distal interphalangeal joints. Bouchard's nodes involve the proximal interphalangeal joints. Tophi are deposits of sodium urate crystals that occur in chronic gout — not osteoarthritis. Hot, inflamed joints rarely occur in osteoarthritis. Swelling, joint pain, and tenderness on palpation occur with a sprain injury.

A nurse observes a client's vaginal discharge on the first postpartum day and describes it in the progress note (shown). Which term best identifies the discharge?

lochia rubra

A client with Guillain-Barré syndrome develops respiratory acidosis as a result of reduced alveolar ventilation. Which combination of arterial blood gas (ABG) values confirms respiratory acidosis?

pH, 7.25; PaCO2 50 mm Hg - In respiratory acidosis, ABG analysis reveals an arterial pH below 7.35 and partial pressure of arterial carbon dioxide (PaCO2) above 45 mm Hg. Therefore, the combination of a pH value of 7.25 and a PaCO2 value of 50 mm Hg confirms respiratory acidosis. A pH value of 5.0 with a PaCO2 value of 30 mm Hg indicates respiratory alkalosis. The other options represent normal ABG values and reflect normal gas exchange in the lungs.

Which symptom would indicate the neonate was adapting normally to extrauterine life without difficulty?

respiratory rate of 40 to 60 breaths/ minute - A respiratory rate of 40 to 60 breaths/minute is normal for a neonate during the transitional period. Nasal flaring, respiratory rate of more than 60 breaths/minute, and audible grunting are signs of respiratory distress.

A client has been diagnosed with lung cancer and is told that a wedge resection is required. The client asks the nurse for an explanation. What would be the nurse's best response?

"A small, localized area near the surface of the lung will be removed." - A very small area of tissue close to the surface of the lung is removed in a wedge resection. A segment of the lung is removed in a segmental resection, a lobe is removed in a lobectomy, and an entire lung is removed in a pneumonectomy.

A nurse is taking frequent blood pressure readings on a child diagnosed with acute glomerulonephritis. The parents ask the nurse why this is necessary. When implementing nursing care, which statement by the nurse is accurate?

"Acute hypertension must be anticipated and identified." - Regular measurement of vital signs, including blood pressure, body weight, and intake and output, is essential to monitor the progress of acute glomerulonephritis and to detect complications that may appear at any time during the course of the disease. Hypertension is more likely to occur with glomerulonephritis than hypotension and should be anticipated. Blood pressure fluctuations do not indicate that the condition has become chronic and are not common adverse reactions to antibiotic therapy.

A client comes to the clinic for right shoulder pain. The nurse observes bruises resembling fingerprints on several areas of the right arm and bruising on the back. The client has a history of similar injuries in the past. What questions would be important for the nurse to ask? Select all that apply.

"Are you in a relationship that makes you afraid or unsafe?" "People in relationships argue. What happens when you and your partner argue?" "If you are in danger now, would you like help in locating a shelter?" - Asking if the client feels unsafe or afraid, asking what it's like when the client argues with the partner, and asking if the client is in danger are questions that elicit further information from the client without placing blame. The client should in no way feel that the nurse is blaming them or being judgmental. The first priority for the client is their safety.

One hour before a client is to undergo abdominal surgery, the physician orders atropine, 0.3 mg I.M. Before administration of the medication, the nurse explains that the drug is given because of what reason?

"Atropine decreases salivation and gastric secretions." - When used as preanesthesia medications, atropine and other cholinergic-blocking agents reduce salivation and gastric secretions, thus helping to prevent aspiration of secretions during surgery. Atropine increases the heart rate and cardiac contractility, decreases bronchial secretions, and causes bronchodilation. No evidence indicates that the drug enhances the effect of anesthetic agents.

A nurse is reinforcing education for a client who has been prescribed allopurinol for the treatment of gout. Which instruction would the nurse give to the client?

"Avoid foods such as scallops, anchovies, and yeast breads." - Clients with gout should avoid foods that are high in purine. Alcohol should be avoided because it increases uric acid level. Because aspirin interferes with the action of allopurinol, it should be avoided. Because allopurinol can irritate the gastric lining, it should be taken with food or milk.

When providing discharge teaching for a client with multiple sclerosis (MS), the nurse should include which instruction?

"Avoid hot baths and showers." - A client with MS should avoid hot baths and showers because these may exacerbate the disease. The nurse should encourage daytime naps because fatigue is a common symptom of MS. A client with MS doesn't require food or fluid restrictions.

The nurse is talking with the parent of a 3-year-old child who has congenital heart disease. The parent reports feeling concerns that the child does not seem to be maturing emotionally in a manner that is at the same rate as the two older children in the family. Which response by the nurse is most appropriate?

"Children who have chronic health issues may experience developmental delays." - Chronic illnesses can impact a child's growth and development both emotionally and cognitively. The child with a cardiac disorder may experiences delays as a result of hypoxic episodes or because of repeated hospitalizations. Educating parents about these possibilities will be helpful in initiating the discussion about the child's level of maturity. Although children mature at different rates, this is not the best response. Children may act out in response to illness or other factors, but there is no information that supports this reason for the child's behavior. Encouraging parents to lower their expectations is not therapeutic.

A nurse is reinforcing home care instructions for a client who has recently had a skin graft. Which instruction is appropriate for the nurse to give the client?

"Cover the area when in direct sunlight." - To avoid burning and sloughing, the client who has recently had a skin graft must protect the graft from direct sunlight. The client should avoid applying cosmetics to the graft site. The client should follow the instructions given for the grafted area (care of the site, any dressings, or other interventions); therefore, washing with soap and water and applying lotion are not appropriate

The nurse is caring for a client on the orthopedic unit. When preparing the client for discharge, which instructions should the nurse reinforce after surgical repair of a hip fracture?

"Do not flex the hip more than 90°, do not cross your legs, and get help putting on your shoes." - Discharge instructions should include not flexing the hip more than 90°, not crossing the legs, and getting help to put on shoes. These restrictions prevent dislocation of the new prosthesis.

The physician prescribes an emollient for a client with pruritus of recent onset. The client asks why the emollient should be applied immediately after a bath or shower. How should the nurse respond?

"Doing so prevents evaporation of water from the hydrated epidermis." - Applying an emollient immediately after taking a bath or shower prevents evaporation of water from the hydrated epidermis, the skin's upper layer. Although emollients make the skin feel soft, this effect occurs whether or not the client has just bathed or showered. An emollient minimizes cracking of the epidermis, not the dermis (the layer beneath the epidermis). An emollient doesn't prevent skin inflammation.

The nurse is caring for a child that is undergoing cardiac surgery. Parents ask a nurse what the activity level for their child should be post-surgery. Which response would be best?

"Encourage a balance of rest and exercise."

A client has just expelled a hydatidiform mole. She's visibly upset over the loss and wants to know when she can try to become pregnant again. Which of the following would be the nurse's best response?

"I can see that you're upset; however, you must wait at least 1 year before becoming pregnant again." - Clients who develop a hydatidiform mole must be instructed to wait at least 1 year before attempting another pregnancy, despite testing that shows they have returned to normal. A hydatidiform mole is a precursor to cancer, so the client must be monitored carefully for 12 months by an experienced health care provider. Discussing this situation at a later time and checking with the health care provider to give the client something to relax ignore the client's immediate concerns. Telling her to wait until all tests are normal is vague and provides the client with little information.

While speaking with a client who was recently diagnosed with multiple myeloma, the nurse assesses the client's understanding of previous teaching. Which client statement suggests to the nurse that the client understood the teaching?

"I have a malignancy of plasma cells." - Tumors can be benign or malignant, and they are rooted in different types of tissue. The client who knows that multiple myeloma is a malignancy of the plasma cells has demonstrated an understanding of this disorder. The other responses require the nurse to intervene to provide clarity. A malignancy of the bone is an osteosarcoma. A benign adipose tissue tumor is a lipoma. A malignant tumor of the cartilage is a chrondrosarcoma.

A 54-year-old client who was admitted to the psychiatric unit during an acute phase of schizophrenia has hardly eaten and hasn't bathed or changed his clothes for 3 weeks. He undergoes 4 weeks of psychotherapy and medication adjustment. Which statement by the client indicates that he's ready for discharge?

"I know a sign of my disease is not bathing and maintaining my personal appearance."

A home health care nurse visits a client with chronic obstructive pulmonary disease who requires oxygen. Which statement by the client indicates the need for additional teaching about home oxygen use?

"I make sure my oxygen mask is on tightly, so it won't fall off while I nap." - Applying an oxygen mask too tightly can cause skin breakdown. The client should be cautioned against wearing it too tightly. Oxygen therapy is drying to the oral and nasal mucosa, so the client should be encouraged to apply a water-soluble lubricant, such as K-Y jelly, to prevent drying. Smoking is contraindicated wherever oxygen is in use. Posting of a "No Smoking" sign warns people against smoking in the client's house. Cleaning the mask with water 2 or 3 times a day removes secretions and decreases the risk for infection.

A client with type 1 diabetes is at 22 weeks' gestation after the first pregnancy ended in spontaneous abortion at 18 weeks' gestation. The nurse is reinforcing instructions with the client about exercise during her pregnancy. Which statement indicates that the client has an appropriate understanding of her exercise needs?

"I need to walk with a friend or family member." - A pregnant client with type 1 diabetes should walk with a friend or family member in case she becomes hypoglycemic while exercising. The client should exercise at the same time each day to ensure control of her blood glucose levels. The client should exercise after meals, when blood sugar is high. Fluids are important before, during and after exercising to prevent dehydration.

A client is diagnosed with a fungal infection of the scalp. The nurse knows the client understands the treatment plan when which statement is made? Select all that apply.

"I should throw away my combs and hats." "I will need to take all of my medication even if the rash gets better." - Tinea capitis is a fungal infection of the scalp. Tinea corporis describes fungal infections of the body. Tinea cruris describes fungal infections of the inner thigh and inguinal creases. Tinea pedis is the term for fungal infections of the foot. Over the counter steroid cream is not an appropriate treatment for fungal rashes. Fungal infections can be spread via a fomite transmission, so combs and hats should be discarded. Medications should be taken as ordered even if the rash is gone. Steroid cream will make fungal rashes worse.

A client admitted to the facility for treatment for tuberculosis receives instructions about the disease. Which statement made by the client indicates the need for further instruction?

"I will stay in isolation for at least 6 weeks." - The client needs to be in isolation for 2 weeks, not 6, while receiving antitubercular drug therapy. After 2 weeks of antitubercular therapy, the client is no longer considered contagious. The client needs to receive the drugs for 9 months to a year. He will be positive when tested, and if he's sick or under some stress he could have a relapse of the disease.

A 78-year-old client with type 2 diabetes needs a kidney transplant. The client's daughter volunteers to donate a kidney, but the client voices concerns about her daughter's health to the nurse. Which response by the nurse is appropriate?

"I'll notify your physician of your concerns and see if he can discuss the procedures with you." - The nurse should notify the physician of the client's concerns about the procedures. The client's daughter is willing to donate a kidney to help her mother, so the nurse should be supportive of her decision. There is no way to predict whether the daughter will have the same kidney disease as her mother when she is older. The comments about the sacrifice that the daughter is making and her compatibility as a donor are also inappropriate.

A client who has been taking imipramine, 125 mg P.O. daily, for 1 week wants to stop taking the medication because the client still feels depressed. Which response by the nurse would be mostappropriate at this time?

"Imipramine must build up to a therapeutic level; it may take 3 to 4 weeks to reduce depression." - Antidepressant agents such as imipramine do not produce antidepressant effects until they reach a therapeutic level in the blood, usually about 3 to 4 weeks after the initial dose. Therefore, the nurse should encourage the client to continue therapy at least until the drug reaches that level. After this time, if the client's depression does not begin to abate, another drug may be more effective.

A nurse is teaching the parents of an infant with clubfeet about cast care. Which statement by the father indicates the need for further teaching?

"Immunizations will have to be delayed until the casts come off." - The father's statement about delaying immunizations indicates the need for further teaching. Immunizations can be administered in the thighs because the casts cover only the lower legs and feet. The other responses are correct statements.

A nurse reinforces preoperative instructions for a client who is scheduled for a left above-the-knee amputation. Which statement made by the client indicates an understanding of the instructions?

"Isometric exercise will help me to maintain the muscle tone of my remaining limb." - Isometric exercise (static contraction of a muscle without any visible movement in the angle of the joint) is necessary to maintain muscle tone of the remaining limb. The exercises should begin the day after an above-the-knee amputation. Immediately after surgery, the client usually is not alert enough to get out of bed, even with assistance. Physical therapy begins in the hospital setting and continues in the rehabilitation or outpatient/community setting after discharge. A continuous passive motion machine is used to provide passive-range-of motion for the knee.

A newly hired graduate nurse is caring for a client prescribed a carminative enema. When discussing the plan of care with the nurse mentor, which appropriate information would the graduate state that provides an understanding of a carminative enema?

"It is given into the rectum to help expel flatus to relieve distention." - A carminative enema is given to help expel flatus to relieve bloating and distention. An oil-retention enema softens stool and lubricates the rectum. A medicated enema instills antibiotics or introduces anthelminthic agents. A nutritive enema administers fluids and nutrition through the rectum.

The night nurse reports that a postpartum client is homeless, has poor hygiene, and has tested positive for the human immunodeficiency virus (HIV). The nurse assigned to care for the client requests that the assignment be changed because she's pregnant and doesn't want to risk exposure. Which response by the charge nurse indicates an understanding of the ethical responsibilities of a professional nurse?

"It's inappropriate to refuse this assignment; all clients should be treated equally." - The charge nurse shouldn't change the nurse's assignment. According to the ethical principle of autonomy, all clients should be treated equally regardless of disease and social or economic status. Pregnancy shouldn't prevent the nurse from caring for an HIV-infected client. The nurse can adequately protect herself and her unborn child by following standard precautions. It isn't appropriate to recommend that the nurse take a leave of absence.

A nurse is reinforcing instruction for a client with a recent leg fracture and cast. Which statements by the client indicate that further education is needed? Select all that apply.

"It's normal to have some numbness or tingling following a fracture." "It's normal to have severe pain even after the cast is on." "It's normal to have swelling and for the cast to feel really tight." - Paresthesia (numbness or tingling) is the earliest sign, and severe pain is a later sign of compartment syndrome; they should be reported at once. Elevating the leg will help prevent venous stasis, edema, and impaired circulation. Circulation and limb sensation need to be monitored frequently.

A child with pauciarticular juvenile rheumatoid arthritis (JRA) is being seen for an annual physical examination. The child's parent reports not understanding why the child will need to have an annual eye examination if there are no visual problems. Which statement by the nurse is mostappropriate?

"Painless iritis (inflammation of the iris) is commonly seen with the disease." - Painless iritis may be found in up to 75% of children with pauciarticular JRA. If it's not detected and is left untreated, permanent scarring in the anterior chamber of the eye may occur, with loss of vision. Children should have annual slit-lamp examinations by an ophthalmologist. Detached retinas, glaucoma, and strabismus aren't commonly associated with pauciarticular JRA.

The X-rays of a client who was brought to the emergency department after falling on ice reveal a leg fracture. After a cast is applied and allowed to dry, the nurse teaches the client how to use crutches. Which instruction should the nurse provide about climbing stairs?

"Place the unaffected leg on the first step, followed by the crutches and the injured leg, which should move together." - When climbing stairs with crutches, the client should lead with the unaffected leg, followed by the crutches and injured leg moving together. Any other method is incorrect and could increase the client's risk of falling.

A client with osteoarthritis uses a cane for assistance in walking. Which instruction should be reinforced when the client is using assistive devices for ambulation?

"The cane should be used on the unaffected side." - A cane should be used on the unaffected side. A client with osteoarthritis should be encouraged to ambulate with a cane, walker, or other assistive device as needed; such use takes weight and stress off joints.

A client, who is 11 weeks' pregnant and admitted to the facility with hyperemesis gravidarum, is being cared for by a nursing student. The nursing instructor asks the nursing student to discuss hyperemesis gravidarum. How does the student respond appropriately? Select all that apply.

"The cause is unknown." "It is characterized by severe nausea and vomiting during the first half of pregnancy." - The cause of hyperemesis gravidarum is not known. However, etiologic theories implicate hormonal alterations and allergic or psychosomatic conditions. The client has extreme nausea and vomiting associated with weight loss, which resolves by 20 weeks. No evidence suggests that hyperemesis gravidarum results from a neurologic disorder, inadequate nutrition, or hemolysis of fetal red blood cells (RBCs).

A child diagnosed with chickenpox is asked to stay home from school to avoid infecting other children. The caregiver of the child asks the nurse, "When is the infectious period?" What statement made by the nurse is most accurate?

"The client is infectious 1-2 days before the rash appears and until the blisters are crusted." - The client can transmit the disease a few days before the rash appears and until the blisters are dry and crusted.

A client who is 24 weeks pregnant is diagnosed with preeclampsia. She is prescribed bed rest at home and a referral for home health visits by a community health nurse. The nurse is reviewing the discharge instructions with the client. The nurse determines that the client understands the reasons for home health visits base on which client statement?

"The community health nurse will check me and my baby and talk with my health care provider." - Community health nurses provide skilled nursing care, such as evaluating and monitoring blood pressure, providing treatments and education, and communicating with health care providers. For the prenatal client with preeclampsia, this care may include assessing the therapeutic effects of antihypertensive medications, evaluating fetal heart tones, and providing nutrition counseling. The professional nurse does not fix meals in the home or do laundry; this service may be provided by a home health aide or housekeeper. The community health nurse educates the client about taking her own medications, including the proper time, dose, frequency, and adverse effects. The community health nurse does not replace the care provided by the client's health care provider.

An anesthesiologist prescribes atropine for a client who is scheduled to undergo cholecystectomy. The client asks the nurse why this drug is needed preoperatively. What is the best response by the nurse?

"The drug will dry up respiratory secretions and interrupt stimulation of the vagal nerve." - Because it is an anticholinergic agent, atropine is commonly prescribed preoperatively to reduce respiratory tract secretions and prevent the reflex slowing of the heart that occurs during anesthesia. Anxiolytic agents are used to relieve anxiety. Opioid analgesics are used to relieve pain and ease anesthesia induction. Antimicrobials are used to prevent infection resulting from contamination during surgery.

A client is receiving oxygen by way of a nasal cannula at a rate of 2 L/minute and will be discharged with home oxygen. The nurse is reinforcing teaching with the client about setting the appropriate oxygen flow rate. What is the best statement for the nurse to make?

"The line marked '2' should cut the ball in half." - The oxygen flow of the oxygen flow meter should be set by centering the indicator to the line marked "2" in a client receiving oxygen via a nasal cannula at a rate of 2 L/minute.

A client in the early stages of labor asks the nurse whether it's really necessary for her to purchase a car seat, noting that they're very expensive. Which response by the nurse is best?

"The only way to safely transport your baby in a car is to have him restrained securely in a car seat." - The nurse should emphasize car seat safety by reinforcing that restraining a baby securely in a car seat is the only way to transport him safely. Most likely, the client knows that the law mandates car seat use. It's inappropriate for the nurse to tell the client she can do whatever she wishes; doing so could cause harm to the infant. Social services shouldn't be consulted unless the client states that she can't afford a car seat.

A child is undergoing hypospadias repair. Which statement made by the child's parents about the principal objective of surgical correction implies a need for further education?

"The purpose is to decrease the chances of urinary tract infections." - A child with hypospadias is not at greater risk for urinary tract infections. The principal objectives of surgical corrections are to enhance the child's ability to void in the standing position with a straight stream, to improve the physical appearance of the genitalia for psychological reasons, and to preserve a sexually adequate organ.

The nurse is reinforcing education with parents about Wilms tumor. Which statement made by a parent would indicate the need for further education?

"This disease could have been a result of trauma to the baby in utero." - Wilms tumor is not a result of trauma to the fetus in utero. Wilms tumor can be genetically inherited and is associated with other congenital anomalies. There is, however, no method to identify gene carriers of Wilms tumor at this time.

A schizophrenic client with delusions tells the nurse, "There is a man wearing a red coat who's out to get me." The client exhibits increasing anxiety when focusing on the delusions. Which of the following would be an appropriate response?

"This subject seems to be troubling you. Let's walk to the activity room." - This remark distracts the client from the delusion by engaging the client in a less threatening or more comforting activity at the first sign of anxiety. The nurse should reinforce reality and discourage the false belief. The other options focus on the content of the delusion rather than the meaning, feeling, or intent that it provokes.

The nurse is obtaining data from a parent of a child suspected of having hypopituitarism. What comment made by the parent would be indicative of this disorder?

"Usually my child wears out clothes before the size changes." - Parents of children with hypopituitarism usually comment that the child wears out clothes before growing out of them or that, if the clothing fits the body, it is typically too long in the sleeves or legs.

A client who sustained a closed head injury in a motor vehicle accident is diagnosed as brain dead by a neurosurgeon. The physician has scheduled a meeting with the client's family about discontinuing life support. Before the meeting, a family member asks the nurse her opinion about life support. Which response by the nurse is appropriate?

"What has the physician explained about the client's prognosis?" - The nurse should ask the family what the physician has previously explained to them about the client's prognosis to gain insight into their understanding. Mentioning that others have recovered from comas would provide the family member with false hope because this client has been declared brain dead. The physician should make sure that the family is fully informed about the client's condition so that they can make an educated decision, but the nurse should not imply that the family ought to just follow the physician's suggestions. The nurse shouldn't close off communication by refusing to express her opinion. Instead, she should assess the family's knowledge of the client's condition and treatment options.

A client with type 1 diabetes tells a nurse in the clinic, "I sometimes skip my insulin dose in the morning so I won't gain back any of the weight I've lost." Which response would be appropriate for the nurse to make to this client?

"You are worried about your weight? There are safer ways to prevent weight gain." - The nurse needs to ask the client more questions about the client's weight and begin instructing the client in healthy ways to avoid gaining weight. Making references that connect withheld insulin to weight loss encourage the client not to take the prescribed medication, which would be dangerous to the client's health. The comment that there's "a good side to diabetes" is incorrect and shouldn't be made.

A pregnant client comes to the clinic after missing several scheduled prenatal appointments. During the initial assessment, the client states, "I haven't been coming to some of my appointments because I go to a homeopathic specialist who takes great care of me." Which response by the nurse is best?

"You should mention the homeopathic specialist to your health care provider so he can help devise the best care plan for you."

A 43-year-old black, male client, without a family history of prostate cancer, asks the nurse when he should have a prostate-specific antigen (PSA) test and a digital rectal examination (DRE) performed. Which response by the nurse is appropriate?

"You should start undergoing prostate cancer screening at age 45." - The American Cancer Society recommends that men at high risk for prostate cancer (which includes black men) begin testing at age 45. Otherwise, PSA and DRE testing should be offered yearly beginning at age 50.

A client with terminal cancer tells a nurse, "I've given up. I have no hope left. I'm ready to die." Which response is most therapeutic?

"You've given up hope?" - The use of reflection invites the client to talk more about his concerns. Deferring the conversation to a social worker or health care provider closes the conversation. Telling the client that cures for cancer are found every day gives false hope.

A child is admitted with a diagnosis of croup. Which characteristic signs would the nurse monitor in this client? Select all that apply.

"barking" cough severe respiratory distress increased heart rate - A resonant cough described as "barking" is the most characteristic sign of croup. Usually the heart rate is rapid. The child may present with a low-grade or high fever depending on whether the etiologic agent is viral or bacterial. The child may have varying degrees of respiratory distress related to swelling or obstruction.

A client is prescribed heparin 6,000 units subcutaneously every 12 hours for deep vein thrombosis prophylaxis. The pharmacy dispenses a vial containing 10,000 units/1 mL. How many milliliter(s) of heparin should the nurse administer? Record your answer using one decimal place.

0.6 - The dose dispensed by the pharmacy is 10,000 units/1 mL, and the desired dose is 6,000 units. The nurse should use the following equations to determine the amount of heparin to administer: Dose on hand/quantity on hand = dose desired/X 10,000 units/1 mL = 6,000 units/X 10,000 units X x X = 6,000 units X 1 mL X = 6,000 units X 1 mL/10,000 units X = 0.6 mL.

An older adult client is prescribed fluoxetine, 40 mg by mouth twice per day, for treatment of depression. The client has difficulty swallowing, so the pharmacy dispenses the oral solution containing 20 mg/5 mL. How many milliliters of solution should the nurse administer to achieve the prescribed dose? Record your answer using a whole number.

10 - To perform this calculation, use the following ratio: 20 mg/5 mL = 40 mg/X mL. X = 10 mL.

The nurse is assessing the puncture site of a client who has received a purified protein derivative test. Which finding indicates a need for further evaluation?

15-mm induration - A 10-mm induration strongly suggests a positive response in this tuberculosis screening test; a 15-mm induration clearly requires further evaluation. The other options aren't positive reactions to the test and require no further evaluation.

The health care provider prescribes bupropion 150 mg by mouth twice per day to treat the client's symptoms of depression. The nurse has 75-mg tablets on hand. How many tablets should the nurse administer with each dose? Record your answer using a whole number.

2 - The following formula is used to calculate the drug dosage: dose on hand/quantity on hand = dose desired/X. In this example, 75 mg/1 tablet = 150 mg/X. So X = 2 tablets.

A client experiencing opioid withdrawal syndrome is prescribed methadone, 120 mg by mouth daily. The pharmacy dispenses 40-mg tablets. How many tablets will the nurse administer with each dose? Record your answer using a whole number.

3 - To calculate the dose, set up the following ratio and solve for X: 40 mg/1 tablet = 120 mg/X tablets X = 3 tablets

The physician orders ampicillin, 500 mg by mouth every 6 hours. The nurse recognizes this as an example of which type of order?

A standard written order - A standard written order is an order that applies until the prescriber writes another order to alter or discontinue the first one. Many health care facilities have established policies dictating how long orders for certain classes of drugs, such as opioids or antibiotics, are to remain valid. A single order allows for a one-time dose only. An as-needed order allows for drug administration when the client needs it. A stat order includes such words as now, immediately, or stat.

The nurse assesses a neonate with esophageal atresia for signs of dehydration. Which finding should the nurse expect to see?

A sunken anterior fontanel

Which action takes priority for a client who is experiencing a hypersensitivity reaction to latex?

Administering supplemental oxygen - Airway, breathing, and circulation always take top priority. Therefore, the licensed practical nurse (LPN) should administer supplemental oxygen first. After doing so, the nurse should notify the charge nurse (or the nurse coassigned to the client) and the physician. After evaluating the client, the physician will most likely prescribe diphenhydramine. After the crisis abates, the LPN should obtain a supply cart that contains latex-free products to care for the client.

When drawing up a medication, the nurse notes there are small air bubbles adhering to the interior surface of the syringe. The nurse knows which effect the bubbles might have on parenteral administration?

Altered drug dose - Although not harmful to the client when injected, small air bubbles can change the dose of medication actually administered; therefore, the nurse should remove the air bubbles. The drug's onset of action, duration, and absorption won't be affected. Air bubbles may actually be helpful in some situations but should be added only after the dose of the drug has been withdrawn accurately. For example, with iron dextran, an air bubble and the Z-track method of injection help prevent permanent staining of the client's skin if the solution leaks into the subcutaneous tissue.

An elderly client who lives at home with her daughter is admitted with unexplained bruises on her arms and legs. Which action should the nurse take first?

Assess the client thoroughly and complete the health history. - The nurse should thoroughly assess the client first. After assessing the client, the nurse should inform the physician and follow facility policy for reporting suspected abuse. Speaking with the client alone about suspected abuse is inappropriate before performing the initial assessment.

A client who had a nephrectomy 2 days ago is reporting abdominal pressure and nausea. Which action should the nurse take first?

Auscultate bowel sounds. - If abdominal distention is accompanied by nausea in a client who had a nephrectomy 2 days prior, the nurse must first auscultate bowel sounds. If bowel sounds are absent, the nurse should suspect gastric or small intestine dilation, and these findings must be reported to the primary care provider. Palpation should be avoided postoperatively in cases of abdominal distention. If peristalsis is absent, measuring abdominal girth and inserting a rectal tube will not relieve the client's discomfort.

When caring for a toddler, the nurse should understand that a child in this age-group works to achieve which developmental task?

Autonomy - The toddler's developmental task is to achieve autonomy while overcoming shame and doubt. Developing initiative is the preschooler's task. Developing trust is the infant's task. Developing industry is the task of the school-age child.

A child with a Wilms tumor has had surgery to remove a kidney and has received chemotherapy. The nurse should include which instructions at discharge?

Avoid contact sports. - Because the child is left with only one kidney, certain precautions, such as avoiding contact sports, are recommended to prevent injury to the remaining kidney. Decreasing fluid intake is not indicated; fluid intake is essential for renal function. The child's sodium intake should not be reduced. Avoiding other children is unnecessary, will make the child feel self-conscious, and may lead to regressive behavior.

A nurse is working with the team to develop a neonate's plan of care. Which action would be the highest priority in regulating the neonate's temperature?

Block sources of radiant, convective, conductive, and evaporative losses. - Prevention of heat loss is always the first goal in thermoregulation to avoid hypothermia in the neonate by blocking the sources of loss. The second goal is to minimize the energy necessary for the neonate to produce heat. Adding extra heat sources is a means of correcting hypothermia. The ambient room temperature should be kept at approximately 100° F (37.8° C).

A nurse making morning rounds finds a client who has a history of myocardial infarction on the floor. The client is pale and responds to his or her name and tactile stimuli. Which action should the nurse take next?

Call for additional assistance. - The nurse should call for additional assistance to get the equipment needed for advanced care. Calling for additional assistance will provide access to an automated external defibrillator (AED)/cardiac monitor, additional team members, and equipment for advanced care. Checking the pulse helps to determine if compressions are needed and should be done, but calling for help takes priority over checking the pulse. The American Heart Association and the Canadian Heart and Stroke Foundation's Chain of Survival Links include: immediate recognition of cardiac arrest and activation of emergency medical services (EMS), early cardiopulmonary resuscitation (CPR) with an emphasis on chest compressions, and rapid defibrillation. The steps of CPR (adult unwitnessed) are as follows: establish unresponsiveness; call for assistance; check for a pulse while observing for signs of breathing; if no pulse, start chest compressions only; and if no pulse or breathing, start cycles of compressions and breathing.

A client is placed on oxygen therapy. Place the following steps in the correct order. All options must be used.

Check the health care provider's order. Explain procedure to client. Attach flow meter to wall outlet, fill humidifier with water, and attach the delivery system and tubing. Place the face mask or cannula on the client. Re-assess client and document the procedure. - Before placing a client on oxygen therapy, the first steps are to review the health care provider's order and to explain the procedure to the client. The next step is to attach the flow meter to a wall outlet, fill the humidifier with water, and attach the delivery system and tubing. The final steps are to place the mask or cannula on the client and to assess the client and document the procedure.

A school-age child with terminal leukemia is admitted to the pediatric unit. The nurse must discuss advance directives with the child's parents. The nurse should include which information?

Comfort care options - The nurse shouldn't give a positive appraisal of the child's prognosis because doing so gives the parents false hope. The nurse must be honest about the child's prognosis and provide them accurate information about treatment options, which include palliative care, comfort care, and pain management. The physician — not the nurse — should discuss such treatment options as chemotherapy or bone marrow transplantation, if indicated.

A nursing home resident is admitted to the hospital for evaluation and treatment of chronic diarrhea. The nurse plans to place the client on isolation precautions. Which type of isolation precautions should be observed with this client? Select all that apply.

Contact Standard - The purpose of isolation is to prevent the spread of infection to other clients. Contact isolation is normally used for GI infections and diarrhea as well as wound infections with drainage or draining abscesses. In addition to contact isolation, standard precautions should be observed with this client. Droplet precautions are used for clients with suspected or known infection caused by organisms transmitted by infectious droplets, as in pertussis. Airborne precautions should be instituted for clients suspected or known to be infected with tuberculosis. Neutropenic precautions are instituted to protect the client with a low white blood cell count from infection.

When preparing to give a client a prescribed drug, the nurse realizes that the drug is one the nurse has never administered before. No drug references on the nursing unit contain information about the drug in question. What is the nurse's best action?

Contact a pharmacist to obtain information about the drug. - Pharmacists are the best resources for drug information when print sources aren't available, and they can provide this information quickly and reliably. Pharmacists have more up-to-date and accurate drug information than do physicians and other nurses. The nurse should refuse to give a drug only if no information about the drug is available.

After undergoing a right lower lobectomy for treatment of lung cancer, a 75-year-old client returns to his room with a chest tube in place. Several hours later a nurse finds the client out of bed barely able to speak, with the chest tube removed. Which action should the nurse take immediately?

Cover the insertion site with an occlusive dressing, call for assistance, and remain with the client. - A chest tube facilitates lung re-expansion after surgical intervention in the pleural cavity. If the chest tube becomes dislodged before healing takes place, air enters the pleural cavity, causing the lung to collapse. In this case, the nurse should immediately call for assistance and cover the insertion site with an occlusive dressing. A gauze dressing shouldn't be used because gauze isn't occlusive. The physician should then be notified so that he can reinsert the tube. The nurse should remain with the client and continue to monitor vital signs until the chest tube has been reinserted, and its placement confirmed.

Family members would like to bring in a birthday cake for a client with nerve damage. What cranial nerve will the nurse assess to determine if it is functioning so the client can chew?

Cranial nerve V - Chewing is a function of cranial nerve V. Swallowing is a motor function of cranial nerves IX and X. Cranial nerve II doesn't have a motor function.

A 32-year-old multipara is admitted to the birthing room after her initial examination reveals her cervix to be at 8 cm, completely effaced (100%), and at 0 station. Which action taken by nurse promotes pain relief in the laboring client?

Direct pressure and massage to the sacral area. - Applying direct pressure and massage to the sacral area helps relieve pressure and eases the pain of labor. It is too late to administer an opioid analgesic as it can affect the newborn. Ambulation is not advised as delivery is imminent. A warm bath may be comforting but does not relieve the pressure that is causing the pain at this stage of labor.

During a routine assessment, a pregnant client tells the nurse that she hasn't had a bowel movement for "close to a week." What should the nurse do to help this client?

Discuss the client's diet, focusing on her fiber and water intake. - Many medications are not safe during pregnancy; therefore, the nurse should suggest that the client increase her consumption of water and fiber to facilitate a bowel movement.

A parent is discussing his or her 12-year old child with the nurse at the clinic and tells the nurse that the child is having trouble at school being bullied and coming home and picking on a younger sibling. What does the nurse recognize this ego defense mechanism as?

Displacement - Displacement is the ventilation of intense feelings toward a person or animal that is less threatening than the one who stimulated those feelings. Repression is the unconscious exclusion of painful thoughts and feelings. Regression is the moving to a previous developmental level. Dissociation is the dealing of an emotional crisis by an alteration in consciousness or identity.

A client presents with constipation. Which medication should the nurse expect to administer to this client?

Docusate sodium - Docusate sodium, a laxative, is used to treat constipation. It softens the stool by stimulating the secretion of intestinal fluid into the stool. Lorazepam, an antianxiety agent, has no laxative effect. Administering loperamide, an antidiarrheal agent, could cause the constipation to worsen. Flurbiprofen is a nonsteroidal anti-inflammatory agent with no laxative effect.

A pregnant client is prescribed an iron supplement. Which point should the nurse include when teaching the client about taking the supplement?

Eat a diet rich in vitamin C to promote iron absorption. - The nurse should teach the client that iron absorption is enhanced by a diet rich in vitamin C. Bran, milk, eggs, coffee, tea, and foods containing oxalate, such as spinach and Swiss chard, inhibit iron absorption when consumed at the same time. Iron supplements are best absorbed on an empty stomach; however, if taking the supplement on an empty stomach causes GI distress, the client may take it just before bedtime to lessen discomfort.

A child with a fractured left femur receives a cast. A short time later, the nurse notices that the toes on the child's left foot are edematous. Which nursing action would be most appropriate?

Elevate the foot of the bed. - To relieve edema of the toes, the nurse should raise the affected extremity above the heart level such as by elevating the foot of the bed. Contacting the orthopedic surgeon is not necessary at this time. Applying ice may be effective but raising the extremity will be more effective. Using traction is not indicated.

A severely depressed client rarely leaves the chair. To prevent physiologic complications associated with psychomotor retardation, which action is appropriate?

Encourage emptying the bladder on a schedule. - To prevent bladder infections associated with stasis of urine, the client should be encouraged to routinely empty her bladder. Neither calcium nor coffee intake are directly related to the psychological effects associated with this condition. Resting in bed is another form of psychomotor retardation.

After sustaining injuries in a motor vehicle accident, a client spends 10 days recovering in the intensive care unit. His condition stabilizes and he's transferred to the orthopedic unit. Upon arrival at the unit, his vital signs are stable, his temperature is 100° F (37.8° C), and he has an indwelling urinary catheter in place. He is currently on bed rest and able to consume a regular diet. Which independent nursing action should the nurse include in this client's plan of care?

Encourage the client to increase his intake of fluids. - Encouraging the client to increase his intake of fluids is an independent nursing action that the nurse can take to help reduce the client's fever, which might be caused by infection or dehydration. The nurse should first make sure that the client doesn't have another condition that might contraindicate increasing his fluid intake. Options 1 and 3 aren't independent nursing actions. The physician will most likely order a urine culture and sensitivity test before discontinuing the urinary catheter. The nurse can't encourage the client to ambulate without a physician's order to do so.

The nurse is caring for a child with a respiratory infection. Which precaution should the nurse take to adhere to infection control measures?

Enforce handwashing. - Handwashing helps prevent the spread of infections. Ill children should be placed in separate rooms if possible but don't need to be isolated. Educating children on the proper use of tissues is important, but the key is tissue disposal and handwashing after use.

Which action by the nurse displays client advocacy during a skin assessment?

Ensuring client privacy by pulling the curtain closed - Closing the client's curtain during a skin assessment demonstrates client advocacy. The nurse should inspect the client's skin for lesions and not rely on the client to inform her if any exist. Performing a visual inspection is part of the skin assessment process, but it doesn't demonstrate client advocacy. It isn't necessary to transfer the client in the other bed out of the room.

A nurse is caring for a 7-year-old child with Down syndrome. What action should the nurse take when assisting with the plan of care for this child?

Evaluate the child's current developmental level and plan care accordingly. - Nursing care should be planned at the developmental age of a child with Down syndrome, not the chronological age. Because children with Down syndrome can vary from mildly to severely mentally challenged, each child should be individually evaluated. A child with Down syndrome, especially one with mild limitations, is capable of learning as long as teaching is geared toward the appropriate developmental age.

A client with chronic renal failure is admitted with a heart rate of 122 beats/minute, a respiratory rate of 32 breaths/minute, a blood pressure of 190/110 mm Hg, neck vein distention, and bibasilar crackles. Which nursing diagnosis takes highest priority for this client?

Excess fluid volume - A client with renal failure can't eliminate sufficient fluid, increasing the risk of fluid overload and consequent respiratory and electrolyte problems. This client has signs of excessive fluid volume and is acutely ill. Fear and a toileting self-care deficit may be problems, but they take lower priority because they aren't life-threatening. Urinary retention may cause renal failure but is a less urgent concern than fluid imbalance.

A client, now 37 weeks pregnant, calls the clinic because she's concerned about being short of breath and is unable to sleep unless she places three pillows under her head. After listening to her concerns, the nurse should take which action?

Explain that these are expected problems for the latter stages of pregnancy. - The nurse must distinguish between normal physiologic reports of the latter stages of pregnancy and those that need referral to the health care provider. In this case, the client indicates normal physiologic changes related to the growing uterus and pressure on the diaphragm. These signs aren't indicative of heart failure. The client does not need to be seen or admitted for delivery at this time.

A client who's 2 months pregnant reports urinary frequency and says she gets up several times at night to go to the bathroom. She does not have other urinary symptoms. What is the best nursing intervention?

Explain that urinary frequency is expected during the first trimester. - Urinary frequency is expected during the first trimester as the growing uterus exerts pressure on the client's bladder. Although the client should increase fluid intake during pregnancy, she should avoid drinking fluids after 6 p.m. (1800) to reduce the need to get up at night. Because urinary frequency is a normal discomfort of pregnancy and the client has no other signs or symptoms of UTI, referral to a urologist is unnecessary. Urinary frequency, dysuria, and voiding of small amounts of urine indicate UTI.

The client is receiving an infusion of cytarabine through a peripheral IV catheter when he reports burning at the insertion site. The nurse notes no blood return from the catheter, but she sees redness at the IV site. The client is most likely experiencing which complication?

Extravasation - The client is exhibiting signs of extravasation, which occurs when the medication leaks into surrounding tissues, causing swelling, burning, or pain at the injection site. Erythema is redness of the skin that results from skin irritation. Flare is a spreading area of redness that occurs as a result of drawing a pointed instrument across the skin. Thrombosis is the formation of a clot within the vascular system; it doesn't occur during drug infusion.

A 6-year-old child with a history of varicella and aspirin intake is brought to the emergency department. The nurse suspects Reye's syndrome. Which data collection findings are consistent with this syndrome?

Fever, decreased level of consciousness (LOC), and impaired liver function - Reye's syndrome occurs in children with a history of a viral infection, varicella, or influenza. It's often associated with the administration of aspirin. The child presents with fever and decreased LOC, which can lead to coma and death. As the disease progresses, the child also develops impaired liver function. A child with joint pain, a red macular rash with a clear center, and a low-grade fever probably has rheumatic fever. A child presenting with peripheral edema, fever for more than 5 days, and a "strawberry tongue" probably has Kawasaki disease. A child with a red, raised "bull's eye" rash, malaise, and joint pain should be tested for Lyme disease.

After a motor vehicle accident, a client is admitted to the medical-surgical unit with a cervical collar in place. The cervical spinal X-rays haven't been read, so the nurse doesn't know whether the client has a cervical spinal injury. Which position should the nurse restrict this client until such an injury is ruled out?

Flat, except for logrolling as needed - When caring for a client with a possible cervical spinal injury who's wearing a cervical collar, the nurse must keep the client flat to decrease mobilization and prevent further injury to the spinal column. The client can be logrolled, if necessary, with the cervical collar on.

An 18-month-old is admitted to the emergency department with a diagnosis of seizure. Upon evaluation, the child's vital signs are: temperature, 104° F (40° C); respiratory rate, 26 breaths/minute; pulse, 120 beats/minute; and blood pressure, 90/69 mm Hg. Which action should the nurse take first?

Give a tepid sponge bath. - The child's seizure was most likely caused by fever. Therefore, the nurse should try to lower the child's core body temperature by giving a tepid sponge bath. Phenytoin isn't prescribed for fever-related seizures. At this time, it isn't necessary to obtain a finger-stick glucose level or a blood specimen for electrolytes.

A nurse is caring for a client who has just delivered a neonate, and finds that the fundus is boggy and deviated to the right. Which action taken by the nurse helps with uterine involution?

Have the client void. - Having the client void can determine whether the boggy, deviated fundus results from a full bladder — the most common cause of these fundal findings. Vital sign assessment is unnecessary unless the nurse suspects hemorrhage from delayed involution. Evaluation of the lochia is done to detect possible hemorrhage. If the uterus remains boggy after the client voids, or if hemorrhage is suspected, the nurse should massage the fundus.

The nurse is caring for a 21 kg child with a urinary tract infection. The health care provider has ordered amoxicillin 750 mg by mouth every 8 hours. The recommended pediatric dosage is 40 to 90 mg/kg/day in two to three divided doses. Which action should the nurse take?

Hold the medication and notify the health care provider that the dose exceeds the recommended range. - The nurse should notify the health care provider that the ordered dosage exceeds the recommended range for this child, which is 280 to 630 mg/dose.40 mg/kg/day × (1 day)/(3 doses) × 21 kg = 840 mg/3 doses = 280 mg/dose90 mg/kg/day × (1 day)/(3 doses) × 21 kg = 1,890 mg/3 doses = 630 mg/dose

A nurse is preparing a lecture for a prenatal class. Which hormone would the nurse include in the presentation as being responsible for maintaining pregnancy during the first 3 months?

Human chorionic gonadotropin (hCG) - The hormone hCG is responsible for maintaining pregnancy until the placenta is in place and functioning. Serial hCG levels are used to determine the status of the pregnancy in clients with complications. Progesterone and estrogen are important hormones responsible for many of the body's changes during pregnancy. Relaxin is an ovarian hormone that causes the mother to feel tired, thus promoting her to seek rest.

A client with a history of Addison's disease and flulike symptoms accompanied by nausea and vomiting over the past week is brought to the facility. The client's wife reports that she noticed that he acted confused and was extremely weak when he woke up in the morning. The client's blood pressure is 90/58 mm Hg, his pulse is 116 beats/minute, and his temperature is 101° F (38.3° C). A diagnosis of acute adrenal insufficiency is made. Which of the following would the nurse expect to administer by I.V. infusion?

Hydrocortisone - Emergency treatment for acute adrenal insufficiency (Addisonian crisis) is I.V. infusion of hydrocortisone and saline solution. The client is usually given 100 mg of hydrocortisone in normal saline every 6 hours until his blood pressure returns to normal. Insulin isn't indicated in this situation because adrenal insufficiency is usually associated with hypoglycemia. Potassium isn't indicated because these clients are usually hyperkalemic. The client needs normal - not hypotonic - saline solution.

The nurse is monitoring a client receiving tranylcypromine sulfate. Which serious adverse reaction can occur with high dosages of this monoamine oxidase (MAO) inhibitor?

Hypertensive crisis - The most serious adverse reaction associated with high dosages of MAO inhibitors is hypertensive crisis, which can lead to death. Although not a crisis, orthostatic hypotension is also common and may lead to syncope with high dosages. Muscle spasticity (not flaccidity) is associated with MAO inhibitor therapy. Hypoglycemia isn't an adverse reaction of MAO inhibitors.-

During a well-child visit, the nurse is reinforcing education with the parents of a 2-year-old child. What is the best recommendation a nurse can give to the parents regarding frequent temper tantrums?

Ignore the behavior when it happens. - The nurse should instruct the parents of a 2-year-old to ignore the tantrums because paying attention to this undesirable behavior reinforces it. Changing the toddler's setting can increase the tantrum behavior. Allowing the toddler more choices may increase tantrum behavior if the toddler is unable to follow through with choices. The toddler should be offered only allowable and reasonable choices. Giving in to the toddler's demands is not recommended because doing so promotes tantrum behavior.

The nurse is deciding whether to report a suspected case of child abuse. Which criterion is the most important for the nurse to consider?

Incompatibility between the history and the injury - Incompatibility between the history and the injury is the most important criterion on which to base the decision to report suspected child abuse. The other criteria also may suggest child abuse but are less reliable indicators.

After collecting data on an adolescent with sickle cell anemia, the nurse assists with formulating a nursing diagnosis of Impaired skin integrity. Which finding best supports this nursing diagnosis?

Leg ulcers - In sickle cell anemia, sickling of red blood cells leads to increased blood viscosity and impaired circulation. Diminished peripheral circulation makes the adolescent or adult with sickle cell anemia susceptible to chronic leg ulcers. In children younger than age 2 who have sickle cell anemia, swelling of the hands and feet (hand-foot syndrome) commonly occurs during a vaso-occlusive crisis as a result of infarction of short tubular bones. Petechiae aren't associated specifically with sickle cell anemia. Hemangiomas, benign tumors of dilated blood vessels, aren't linked to sickle cell anemia.

he nurse is caring for a client in the diagnostic studies area of the hospital. Which information should a nurse provide to the parents of a child undergoing testing for muscular dystrophy?

Local anesthetic will be used for the test. - A muscle biopsy, used to confirm the diagnosis of muscular dystrophy, shows the degeneration of muscle fibers and infiltration of fatty tissue. It is typically performed using a local anesthetic. Genitals are covered by a lead apron during an X-ray examination, which is used to detect osseous, not muscular, problems. Electrode wires are attached to the scalp during an electroencephalography to observe brain wave activity; this test is not used to diagnose muscular dystrophy. Arthroscopy, also not used to test for muscular dystrophy, involves the insertion of a fiber-optic scope into a joint.

The nurse is planning to discharge a 24-year-old gravida 1, para 1, non-English-speaking Hispanic client. Which nursing intervention takes priority?

Locating a staff member who can interpret the discharge instructions. - Most health care institutions have a language bank. Therefore, it is appropriate to locate a staff member who can translate. Using a family member may compromise client confidentiality, and accurate interpretation is not always guaranteed. The client and family members may not recognize when a problem arises to call an information number.

A male client is receiving digoxin and furosemide to treat heart failure. He reports feeling weak and having muscle cramps. His apical pulse is 76 beats/minute; respirations, 16 breaths/minute; and blood pressure, 148/86 mm Hg. What action should the nurse take?

Look at the chart for his last potassium level and contact the physician. - Muscle weakness and cramping are signs of hypokalemia, which can be an adverse effect of furosemide. If the nurse doesn't follow up on his complaints, the client's hypokalemia will worsen. The client isn't exhibiting symptoms indicative of digoxin toxicity or heart failure, so there's no need to notify the physician.

A nurse is caring for a client with acute pancreatitis who is exhibiting deficient fluid volume. What is the most appropriate nursing intervention for a client with this disease?

Maintain IV fluids at 125 mL/hour. - The nurse should maintain IV fluids at 125 mL/hour because clients with acute pancreatitis commonly experience deficient fluid volume, which can lead to hypovolemic shock. The volume deficit may be caused by vomiting, hemorrhage (in hemorrhagic pancreatitis), or plasma leakage into the peritoneal cavity. Nausea may occur in acute pancreatitis, but it would not be the priority nursing diagnosis. Hypovolemic shock causes a decrease in cardiac output. Peripheral tissue perfusion can become altered if hypovolemic shock occurs, but this would not be the primary nursing diagnosis.

A 75-year-old client who was admitted to the hospital with a stroke informs the nurse that he doesn't want to be kept alive with machines. He wants to make sure that everyone knows his wishes. Which action should the nurse take?

Make arrangements for the client to receive information about advance directives. - The nurse should make arrangements for the client to receive information about advance directives, which are written or verbal instructions stating his wishes for medical treatment in the event he becomes incapacitated. Examples include living wills, durable powers of attorney for health care, and any document that states the client's wishes. The client isn't specifically asking for information about a living will; therefore, it's inappropriate for the nurse to contact social services about the document. It's also inappropriate to contact the physician about a do-not-resuscitate order without further exploring the client's wishes. Clients should receive information about advance directives when they request it, regardless of their condition.

A neonate weighs 7 lb, 3 oz at birth. When assessing the neonate 1 day later, the nurse obtains a weight of 7 lb and an axillary temperature of 98° F (36.7° C) and observes the sclerae are slightly yellow. The neonate has been breast-feeding once every 2 to 3 hours. Based on these findings, the nurse should provide what suggestions to the mother? Select all that apply.

Make sure that the newborn's temperature is maintained within normal range. Observe the stool for amount and characteristic. Encourage early and frequent feedings. - The newborn's skin temperature should be maintained within normal limits because cold stress causes an acidotic state, which can decrease available serum albumin-binding sites and can elevate bilirubin levels. Bilirubin is eliminated in the stool, and if stool is inadequately being eliminated, the bilirubin levels can rise. Early and frequent feedings promote bowel elimination and reduce colonization of intestinal bacteria. The newborn should not be switched to water or breastmilk.

A nurse is caring for a client during the fourth stage of labor. Which intervention by the nurse can prevent uterine atony?

Massage the fundus. - Massaging the fundus helps expel clots and improve uterine contraction. Assessing the fundal height will not aid in uterine contraction. Measuring blood loss and catheterizing the client are actions that can be taken during the fourth stage of labor, but it will not prevent uterine atony.

A client in the emergency department is diagnosed with a communicable disease. When complications of the disease are discovered, the client is admitted to the hospital and placed in respiratory isolation. Which infection warrants respiratory isolation?

Measles - Measles warrants respiratory isolation, which aims to prevent disease transmission primarily over short distances through the air (droplet transmission). Other infections necessitating respiratory isolation include epiglottitis or pneumonia caused by Haemophilus influenzae, erythema infectiosum, meningitis caused by H. influenzae or meningococci, meningococcal pneumonia, meningococcemia, mumps, and pertussis. Chickenpox calls for strict isolation; impetigo, contact isolation; and cholera, enteric isolation.

A client with decreased urine output refractory to fluid challenges is evaluated for renal failure. Which condition may cause the intrinsic (intrarenal) form of acute renal failure?

Nephrotoxic injury secondary to use of contrast media - Intrinsic renal failure results from damage to the kidney, such as that from nephrotoxic injury caused by contrast media, antibiotics, corticosteroids, or bacterial toxins. Poor perfusion to the kidneys may result in prerenal failure. Damage to the epithelial cells of the renal tubules results from nephrotoxic injury, not damage to the adrenal cortex. Obstruction of the urinary collecting system may cause postrenal failure.

Which of the following is the most numerous type of white blood cell (WBC)?

Neutrophil - Neutrophils are the most numerous of the WBCs, comprising about 65%. Lymphocytes are the second most abundant. Eosinophils account for about 2%, and basophils are the least abundant.

The physician prescribes acetaminophen elixir, 160 mg every 4 hours, for a 14- month-old child who weighs 20 lb (9.08 kg). This drug, supplied in a bottle labeled 160 mg/tsp, has a safe dosage of 10 mg/kg/dose. The nurse should administer how many milliliters?

None because this isn't a safe dose - For this client, the safe dose of this drug is 90.8 mg (9.08 kg × 10 mg/kg = 90.8 mg). Therefore, the prescribed dose isn't safe.

A client receiving IV therapy tells the nurse that the IV site is swollen and cool to touch. What priority intervention should the nurse implement?

Notify the charge nurse. - The LPN should notify the charge nurse (RN) because further assessment is needed to validate the client's observation. The nurse should not stop the IV and remove the venous access before assessment is completed. Infiltration requires a warm compress and not a cold compress. Decreasing the rate of infusion will not improve the infiltration; rather, it will increase extravasation of the fluid.

A client is receiving a blood transfusion. If this client experiences an acute hemolytic reaction, which nursing interventions are most important?

Notify the health care provider, immediately stop the transfusion, infuse normal saline solution, and notify the blood bank. - When a transfusion reaction occurs, the health care provider should be notified immediately, the transfusion should be stopped at once, and normal saline solution should be infused to maintain venous access. The blood bank should be notified right away. Other nursing actions include saving the blood bag and tubing, rechecking the blood type and identification numbers on the blood tags, monitoring vital signs, obtaining necessary laboratory blood and urine samples, providing proper documentation, and monitoring for and treating shock. Because dextrose solutions can cause red blood cell hemolysis, they shouldn't be infused with blood products. Antihistamines may be administered for a mild allergic reaction.

A nurse in a postpartum unit failed to document whether she administered a medication to aid uterine contractions during the shift. The nurse who's currently caring for the client is asked whether the medication has been successful. She explains that she hasn't been monitoring its effectiveness because she didn't know that the medication was administered. What should the nurse do next? Select all that apply.

Notify the nursing supervisor and report the nurse's documentation omission. Call the nurse at home to inquire whether she or he gave the medication, then ask the client about the contractions while the health care provider is present. - The nurse should call the nurse from the previous shift at home to inquire whether the medication was administered; the nurse shouldn't assume that the medication was given. After calling the nurse at home, the nurse on the current shift should ask the client about her contractions in the presence of the health care provider. It is necessary to notify the nursing supervisor in case an adverse effect results from the issue. Giving the medication without checking with the previous nurse can result in overdose.

A nurse is preparing to assist a client who underwent gastroplasty yesterday to ambulate. The client has an IV line in place, a nasogastric (NG) tube connected to suction, and oxygen running at 6 L/minute by way of a nasal cannula. The health care provider has ordered patient-controlled analgesia (PCA) with morphine sulfate. What is the best way to plan for this client's walking activity?

Obtain a portable oxygen tank to maintain oxygen delivery during the client's ambulation. - The oxygen demands of the client who underwent gastroplasty yesterday will increase with activity, and oxygen delivery must be maintained. Obtaining a portable oxygen tank is the best way to prepare for the client's walk. The client should ambulate as much as possible, regardless of physical therapy assistance. The client needs the morphine to relieve the pain to facilitate ambulation. The NG tube does not need to be connected to suction while the client is walking. It should be clamped to prevent drainage.

A client with an endotracheal tube has copious, brown-tinged secretions. Which intervention is a priority?

Obtain a sputum specimen. - Suspicious secretions should be obtained and sent for culture and sensitivity testing by using sterile technique. Saline would dilute the specimen. Swab culturettes are useful for wound cultures—not endotracheal cultures. Various liquefying agents are available to help break up secretions; respiratory therapists can usually recommend the right agent, but this isn't a priority.

A client chronically complains of being unappreciated and misunderstood by others. She is argumentative and sullen. She always blames others for her failure to complete work assignments. She expresses feelings of envy toward people she perceives as more fortunate. She voices exaggerated complaints of personal misfortune. The client most likely suffers from which personality disorder?

Passive-aggressive personality - The client with passive-aggressive personality disorder displays a pervasive pattern of negative attitudes, chronic complaints, and passive resistance to demands for adequate social and occupational performance. Regarding the other answer options, the client with a dependent personality is unable to make everyday decisions and allows others to make important decisions; in addition, he often volunteers to do things that are unpleasant so that others will like him. The obsessive-compulsive personality displays perfectionism and inflexibility. The avoidant personality displays a pervasive pattern of social discomfort, fear of negative evaluation, and timidity.

The nurse is caring for a 7-year-old child hospitalized with cystic fibrosis. To help the child manage secretions and avoid respiratory distress, which nursing intervention would be a priority?

Perform chest physiotherapy every 4 hours. - Chest physiotherapy must be performed in a child with cystic fibrosis because it aids in loosening secretions in the entire respiratory tract. Pancreatic enzymes aid in the absorption of necessary nutrients, not in managing secretions. Oxygen therapy does not aid in loosening secretions and can cause carbon dioxide retention and respiratory distress in children with cystic fibrosis. A high-calorie diet is appropriate but does not facilitate respiratory effort.

The nurse prepares to administer a client's morning medication. Which action should the nurse take first?

Perform hand hygiene. - The nurse's first action should be to perform hygiene before handling or administering medications. Nurses may use an alcohol-based hand sanitizer if the hands do not have visible soiling. The nurse should always follow the "rights of safe medication administration" (right patient, dose, route, medication, time, and documentation). The use of two patient identifiers and checking allergies should be completed before opening any medication packages.

A registered nurse (RN) asks a licensed practical nurse (LPN) to change the colostomy bag on a client. Although having received in-service training for this procedure, the LPN has never performed it on a client. What action should the LPN expect the RN to take?

Perform the procedure step by step with the LPN. - An RN must remember that even though a task may be assigned to someone else, the delegating nurse maintains accountability for the overall nursing care of the client. Therefore, the RN is responsible for ensuring that competent and accurate care is delivered to the client. Since this is a new procedure for this LPN, the RN should accompany the LPN, provide guidance, and answer questions after the procedure. Reviewing the procedure in the hospital manual or from in-service materials might not help the LPN feel comfortable with the procedure. Requesting that another LPN observe the procedure does not ensure that the procedure will be done correctly.

A client who is receiving cyclosporine must practice good oral hygiene, including regular brushing and flossing of the teeth, to minimize gingival hyperplasia. Good oral hygiene also is essential to minimize gingival hyperplasia during long-term therapy with certain drugs. Which of the following drugs falls into this category?

Phenytoin - Gingival hyperplasia may occur with long-term administration of phenytoin, an anticonvulsant. This adverse effect presumably is dose related. Frequent toothbrushing removes food particles and helps prevent infection; regular dental care and frequent gum massage also are recommended. Gingival hyperplasia isn't a reported adverse effect of procainamide, azathioprine, or allopurinol.

A nurse is caring for a neonate whose mother was abusing drugs. The nurse anticipates that the neonate may experience drug withdrawal. Which intervention would be the priority?

Place the Isolette in a quiet area of the nursery. - Neonates experiencing drug withdrawal commonly have sleep disturbance. The neonate should be moved to a quiet area of the nursery to minimize environmental stimuli. Medications, such as phenobarbital, methadone, and diazepam should be given as needed. The neonate should be swaddled to prevent him from flailing and stimulating himself.

A nurse is caring for a client with a history of falls. Which interventions take priority in this client's care? Select all that apply.

Place the call light within the client's reach. Keep the bed in the lowest possible position. Provide immediate response to the client's toileting needs. - Keeping the bed in the lowest possible position, placing the call light within reach, instructing the client not to get out of bed, and responding to the client toileting needs promptly are all fall reduction/prevention measures. Neurological checks and security personnel placed outside the door are not fall reduction/prevention measures.

A child has just returned to the pediatric unit following ventriculoperitoneal shunt placement for hydrocephalus. Which intervention would the nurse perform first?

Place the child on the side opposite the shunt. - Following shunt placement surgery, the child should be placed on the side opposite the surgical site to prevent pressure on the shunt valve. Intake and output will be monitored, but that isn't the priority nursing intervention. Many children are nauseated after a general anesthetic, and ice chips or clear liquids would be introduced if the nurse determines the child is nauseated. Pain medication should initially be administered by an IV route postoperatively.

A school-age child is admitted to the facility with a diagnosis of acute lymphoblastic leukemia (ALL). The nurse recognizes a nursing diagnosis of Risk for infection. What is the most effective way for the nurse to reduce the child's risk of infection?

Practicing thorough hand washing - Both ALL and its treatment cause immunosuppression. Thorough hand washing is the single most effective way to prevent infection in an immunosuppressed client. Reverse isolation doesn't significantly reduce the incidence of infection in immunosuppressed clients; furthermore, isolation may cause psychological stress. Standard precautions are intended mainly to protect caregivers from contact with infectious matter, not to reduce the client's risk of infection. Staff and others needn't wear masks when visiting because most infections are transmitted by direct contact. Instead of relying on masks and other barrier methods, the nurse should keep anyone with a known or suspected infection out of the client's room.

A client requests something to treat his constipation. The client's medication administration record contains an order for a laxative to be administered every other day as needed. Which assessment finding by the licensed practical nurse indicates the need to notify the registered nurse (RN) before administering the laxative?

Presence of blood in the client's stool - Blood in the stool isn't a common sign of constipation and could indicate a more serious condition. Complaints of abdominal fullness, liquid stool, and abdominal distension are all associated with constipation and don't require reporting to the RN.

A client is admitted to the labor and delivery area. How can the nurse most effectively determine the effectiveness of the contractions?

Progressive cervical dilatation and descent from station -4 to 0 - Uterine contraction helps propel the fetus through the birth canal. Therefore, effective contraction is characterized by progressive cervical dilation and descent of the presenting part. Sporadic contraction does not produce descent of the presenting part and therefore is not effective. Increasing fetal movement is a sign of fetal distress. Strong uterine contraction without cervical dilation is a sign of a nonprogressing labor.

The nurse is caring for a client who is in the panic level of anxiety. Which action is the nurse's highest priority?

Provide for the client's safety needs. - A client in the panic level of anxiety doesn't comprehend and can't follow instructions or care for basic needs. The client is unable to express feelings due to the level of anxiety. Decreased environmental stimulus is needed, but only after the client's safety needs and other basic needs are met. The nurse must enter the client's personal space to provide personal care because a client in panic can't do so.

A client's gestational diabetes is poorly controlled throughout her pregnancy. She goes into labor at 38 weeks and gives birth. Which priority intervention should be included in the plan of care for the neonate during the first 24 hours?

Provide frequent early feedings with formula. - The neonate of a mother with gestational diabetes may be slightly hyperglycemic immediately after birth because of the high glucose levels that cross the placenta from mother to fetus. During pregnancy, the fetal pancreas secretes increased levels of insulin in response to this increased glucose amount that crosses the placenta from the mother. However, during the first 24 hours of life, this combination of high insulin production in the neonate coupled with the loss of maternal glucose can cause severe hypoglycemia. Frequent, early feedings of formula given orally can prevent hypoglycemia. Insulin shouldn't be administered because the neonate of a mother with gestational diabetes is at risk for hypoglycemia. A bolus of dextrose given IV may cause rebound hypoglycemia. If dextrose is given IV, it should be administered as a continuous infusion.

The nurse cares for a client who is post-op bowel resection and has a nasogastric (NG) tube to low intermittent suction. Which care intervention should the nurse administer?

Provide meticulous mouth care as needed. - Provide mouth care for clients who are receiving enteral or parenteral feedings or NPO and are not able to perform it for themselves. The NG tube should not be flushed once per shift; the health care provider's orders will determine the frequency of flushing if ordered. A client who is on gastric suctioning will be NPO. Avoid securing the suction tubing to the bed rail; doing so may cause the NG tube to become inadvertently dislodged if the bedrail is let down.

A nurse is developing a plan of palliative care for a client with end-stage cardiomyopathy. Which action is appropriate to include in the care plan?

Provide nonpharmacological measures to reduce discomfort. - Providing both pharmacological and nonpharmacological measures to reduce discomfort should be included in a plan of palliative care. Family members shouldn't be discouraged from assisting with care of the client unless they are not comfortable with it. Pain medication should be administered on a regular schedule, not just when the client asks for it. Staff members should avoid whispering when near the client because doing so may increase the strain on the client as his hearing diminishes.

A client is scheduled for an endoscopy. On admission, the nurse asks the client if he has an advance directive, and the client states, "No." What should the nurse do next?

Provide the client with information about an advance directive. - As a client advocate, a nurse must ensure that a client has adequate information on the advance directive so that he can make an informed decision about this legal document. A client isn't required to sign an advance directive before a procedure. Living wills and durable powers of attorney are forms of advance directives, not substitutes. The nurse should be able to inform the client about the advance directive and not have to refer the client to the admissions office for the information.

A pregnant client in the second trimester reveals feeling very anxious because of a lack of knowledge about giving birth. Which intervention by the nurse is most appropriate for this client?

Provide the client with the information and teach the skills needed to understand and cope during birth. - Because the client is in the second trimester, the nurse has ample time to establish a trusting relationship and to teach in a style that fits the client's needs. Written information would be effective only in conjunction with teaching sessions. Introducing the client to another pregnant client may be helpful, but the nurse still needs to teach the client about giving birth. Hoping that the client will begin coping does not meet the client's needs.

After a physician explains the risks and benefits of a clinical trial to a client, the client agrees to participate. Later that day, the client requests clarification of the process involved in the clinical trial. As a member of the multidisciplinary team, how should the nurse respond?

Provide the information requested. - As part of the multidisciplinary team, the nurse is empowered to help the client better understand the process, as long as the nurse has an understanding of the treatment plan. The nurse shouldn't discourage the client from participating in the research study. Providing information about the clinical trial isn't beyond the scope of nursing practice. It isn't necessary for the information to come from the physician who originally presented it to the client.

A local celebrity is admitted to a drug and alcohol abuse unit for treatment. When leaving the unit for lunch, a nurse is approached by the media to give a statement about the client's condition. What should the nurse do?

Refer the media to the facility public relations department. - The best response by the nurse is to refer the media to the public relations department. A client admitted with a drug or alcohol problem has a right to privacy, and client confidentiality must be upheld. The nurse should not confirm that the celebrity is in the facility or describe the client's condition. The media has a right to be on facility grounds. Doing nothing is unethical.

A client is exhibiting anxiety, which is evidenced by muscle tension, distractibility, and increased heart rate and blood pressure. Which nursing intervention has priority?

Remain with the client and use a soft voice and reassuring approach. - The priority nursing intervention is to remain with the client and use a soft voice and reassuring approach. Remaining with the client provides for his safety and a soft voice is calming and reassuring, which will add to his feelings of safety and protection. Interventions such as identifying factors that contribute to anxiety, teaching relaxation techniques, and administering antianxiety medications are included in the client's care plan but should be addressed later.

A nurse observes that an alternate personality (a child) of an adult client with dissociative identity disorder (DID) is in control. The client is sitting in the dayroom, interacting with others. Which action would be most appropriate?

Remove the client from the dayroom and reorient in a safe place. - Removing the client forcibly is assault and the client is doing nothing to warrant removal at this time. Reorienting the client discourages dissociation and encourages integration. Asking to speak to an alter personality encourages dissociation. Allowing the client to play with toys would reinforce this behavior and encourage dissociation.

A nurse is reinforcing previous teaching to a caregiver of a paraplegic client with a stage II sacral pressure ulcer. What information should the nurse provide?

Reposition the client at least every 2 hours. - The most important intervention is to avoid prolonged pressure on bony prominences by frequent repositioning. The most important instruction is to change the client's position at least every 2 hours. A dry dressing may not be an appropriate choice for a stage II ulcer; the caregiver should not touch the ulcer daily for measurements because of increased risk of infection and the bed linens may need to be changed more frequently if they become wet or soiled.

An incarcerated client is admitted to the hospital after sustaining multiple contusions and a fractured femur in an assault. After surgical repair of the femur, the client develops paralytic ileus. A nasogastric (NG) tube and cleansing enemas are prescribed. The client has a prison guard assigned to his bedside. How should a nurse proceed to implement a physician's orders?

Request that the guard remain outside the client's door during the prescribed procedures. - The client has a right to privacy even though he's incarcerated. The guard should remain outside the client's room while care is given. The nurse shouldn't request assistance from the guard to render care. If the client becomes violent during the procedure, the nurse can call the guard into the room to ensure her safety.

A nurse is investigating the smell of smoke in the hallway of a long-term care unit. On entering a client's room, the nurse finds the wastebasket on fire. The nurse takes immediate action. Place the nurse's actions in proper order from first to last. All options must be used.

Rescue the client. Trigger the alarm. Confine the fire. Extinguish the fire. - Based on the RACE (Rescue, Alarm, Confine, Extinguish) mnemonic, the nurse's first priority is the client's safety. The second need is to summon help in the emergency. Next, the nurse can attempt to confine and then extinguish the fire.

A client states, "I'd feel so much better if I could just sleep!" What method to promote sleep can the nurse reinforce to the client?

Resist napping during the day. - Napping during the day can cause difficulty sleeping at night. Alcoholic beverages promote sleep initially but interfere with normal, rapid eye movement sleep, causing early wakening. Regular exercise helps with sleep, but exercise needs to be done early in the day. Exercising late in the evening can cause sleep disturbances. Sleeping pills, even over-the-counter medications, should never be taken unless prescribed or recommended by a physician.

A client has the following arterial blood gas values: pH, 7.30; PaO2, 89 mm Hg; PaCO2, 50 mm Hg; and HCO3-, 26 mEq/L. Which acid-base imbalance should the nurse anticipate based on these values?

Respiratory acidosis - This client has a below-normal (acidic) blood pH value and an above-normal partial pressure of arterial carbon dioxide (PaCO2) value, indicating respiratory acidosis. In respiratory alkalosis, the pH value is above normal and the PaCO2 value is below normal. In metabolic acidosis, the pH and bicarbonate (HCO3-) values are below normal. In metabolic alkalosis, the pH and HCO3- values are above normal.

A 6-week-old infant is brought to the clinic for a well-baby visit. To check the fontanels, how should the nurse position the infant?

Seated upright - For the most accurate results, the nurse should seat the infant upright to assess the fontanels and should perform this assessment when the infant is quiet. Pressure from postural changes or intense crying may cause the fontanels to bulge or seem abnormally tense. When the infant is in a recumbent position, the fontanel is less flat than it is normally, creating the false impression that intracranial pressure is increased.

A nurse would observe a client undergoing electroconvulsive therapy (ECT) for which common adverse effect?

Short-term memory loss - Short-term memory loss is the most common adverse effect of ECT. In most cases, memory returns within 3 months. There is no effect on the heart. A seizure is not an adverse effect; rather, it is intentionally induced. Brain damage has not been substantiated from ECT.

A client has a history of schizophrenia. Because she has a history of noncompliance with antipsychotic therapy, she'll receive fluphenazine decanoate injections every 4 weeks. Before discharge, what should the nurse include in her teaching plan?

Sitting up for a few minutes before standing to minimize orthostatic hypotension - The nurse should teach the client how to manage common adverse reactions, such as orthostatic hypotension and anticholinergic effects. The antipsychotic effects of the drug may take several weeks to appear. Droperidol increases the risk of extrapyramidal effects when given in conjunction with phenothiazines such as fluphenazine. Tardive dyskinesia is a possible adverse reaction and should be reported immediately.

A client is admitted to the emergency department with complaints of double vision, difficulty swallowing, dry mouth, and muscle weakness. A nurse also observes that the client has drooping eyelids and slurred speech. He states that he recently ate home-canned green beans. The nurse suspects exposure to botulism. What type of infection control precaution is necessary?

Standard precautions - Standard precautions are all that are required in caring for a client with a botulism infection. Botulism isn't transmitted by air, contact, or droplets.

A 5-year-old is admitted to the emergency department with a broken clavicle. The nurse notices bruises in various stages of healing on the torso and extremities. The parent enters the room and angrily demands to take the child home. Which action is most appropriate?

Step out of the room, notify the charge nurse, and then call security. - In order to ensure the nurse's safety as well as the safety of the child, the best course of action would be to leave the room and immediately notify the charge nurse, and then call security. The nurse wouldn't want to further anger the parent and create the potential for violence by taking the child out of the room. Asking for personal information and telling the parent the child cannot be taken is an inappropriate action.

The client with a peptic ulcer is prescribed an antacid. After administering the medication, the nurse assesses the pH of which organ contents to determine effectiveness?

Stomach - The action of an antacid occurs in the stomach. The anions of an antacid combine with the acidic hydrogen cations secreted by the stomach to form water, thereby increasing the pH of the stomach contents. Increasing the pH and decreasing the pepsin activity provide symptomatic relief from peptic ulcer disease. Antacids don't work in the large or small intestine or in the esophagus.

The nurse is caring for a client on an oncology unit who is refusing further chemotherapy treatment after the rationale for the treatment has been clearly explained. What is the nurse's best action?

Support the client's decision and hold all treatments. - Supporting the client's decision is in concert with the ethical principle of autonomy. The other options violate autonomy and privacy of the client.

The nurse is assisting with the development of the plan of care for a child with celiac disease. Which finding indicates that the child is meeting the priority goal of care?

The child's growth is appropriate for both height and weight. - Because celiac disease is a disease that involves protein and carbohydrate malabsorption, the child is at risk for failure to thrive. The main goal of care is to promote a normal growth pattern for the child. Stressing good health and meeting a peer with celiac disease are also important nursing considerations, but would come after maintaining normal growth patterns. Understanding the pathophysiology of the disease would likely be overwhelming for a child and is not the priority at this time.

The nurse is caring for four clients on a medical surgical unit. Which interaction between the nurse and a client is the best example of the nurse using the ethical principle of fidelity?

The client asked for information regarding a new medication. The nurse provided written instructions. - Fidelity refers to faithfulness to agreement. The nurse forgetting to return is not fidelity. Returning to the client with the said information, even in printed form, is fidelity. The nurse was faithful to the agreement between the nurse and the client. The client refusing pain medication and the nurse documenting it signifies autonomy. A client in a hospice facility is there to die with dignity and free of pain. The nurse saying no to the question about death is against the ethical principle of veracity. If the nurse did not know, the client should be told that.

A nurse is caring for a client with a diagnosis of dissociative identity disorder (DID). Which client behavior should the nurse identify as a safety risk?

The client expresses a desire to do self harm. - The nurse needs to initiate safety precautions to prevent self-harm. The sensation of lost periods of time is not a safety issue. Being glad to be in the unit indicates a feeling of security. The client with DID hearing voices does not indicate a psychotic episode.

A client with Alzheimer's disease is being treated for injuries from a recent fall and malnutrition. The nurse determines a need to place the client closer to the nurse's station based on which finding?

The client has a tendency to wander. - A client with Alzheimer's disease is at risk for injury because of the tendency to wander. Placing the client closer to the nurses' station makes it easier to monitor and ensure safety should the client begin to wander. Placing the client closer to the nurses' station will not help the client remember to eat, change position often, or change the agnosia (difficulty finding a word or naming an object).

A postpartum client recovering from spinal anesthesia with morphine reports that her nose itches. Which would the nurse suspect as the cause?

The client is experiencing a common effect due to a morphine-based anesthetic. - Morphine causes a relatively high incidence of itching when used in spinal anesthesia. The itching usually begins at the tip of the nose, possibly becoming more generalized. Antipruritics, such as diphenhydramine or hydroxyzine hydrochloride, may be prescribed after the use of morphine. Itching on the tip of the nose isn't typical of an allergic reaction nor is it caused by postpartum hormonal changes. The client is awake and speaking appropriately, so she is alert.

The nurse is caring for a client with schizophrenia. Which outcome should prompt a revision to the client's plan of care?

The client spends more time by himself. - The client with schizophrenia is commonly socially isolated and withdrawn. Having the client spend more time by himself isn't a desirable outcome. The client's plan of care should be revised to reflect the outcome of spending more time with other clients and staff on the unit. The other options are desirable outcomes that don't require revisions to the client's plan of care.

A client experiencing alcohol withdrawal is upset about going through detoxification. Which goal is the priority?

The client will work with the nurse to remain safe. - The most important goal is client safety. Although drinking enough fluids, identifying personal strengths, and committing to a drug-free lifestyle are important goals, promoting client safety must be the nurse's priority.

A client experiencing alcohol withdrawal is upset about going through detoxification. Which of the following goals should the nurse determine as priority?

The client will work with the nurse to remain safe. - The priority goal in alcohol withdrawal is maintaining the client's safety. Committing to a drug-free lifestyle, drinking plenty of fluids, and identifying personal strengths are important goals, but ensuring the client's safety is the nurse's top priority.

A nurse is monitoring a client's intracranial pressure (ICP) after a traumatic head injury. The physician calls and asks for a report on the client's condition. Based on the documentation, how should the nurse respond?

The client's ICP remains elevated." - A normal ICP is between 0 and 15 mm Hg. The documentation shows pressures greater than 15 mm Hg.

The nurse is preparing to administer penicillin VK to a 25 kg child with acute glomerulonephritis. The health care provider has ordered penicillin VK 500 mg by mouth every 8 hours. The recommended dose (from the drug literature) is 50 to 75 mg/kg/day by mouth every 6 to 8 hours. After reviewing the information, the nurse draws which conclusion?

The dose is safe to give and falls within the safe dose range for this child. - The calculated safe dosage range for this child is 1,250 to 1,875 mg per day. The child will be receiving 1,500 mg per day (500 mg x 3 doses/day) which is within the recommended range, so it is safe to administer.

The nurse should place a client with appendicitis in which position to help relieve pain?

The nurse should sit the client in the Fowler's position with a pillow at the knees. Lying still with the legs drawn up toward the chest helps relieve tension on the abdominal muscles, which helps to reduce the amount of discomfort felt. Lying flat or sitting may increase the amount of pain experienced.

A 10-year-old child is in the hospital for the first time. The nurse has provided support and teaching to help the family and child adjust and to reduce their anxiety related to the child's hospitalization. Which of the following would the nurse view as unexpected?

The parents choose to leave to let the child build a relationship with the staff. - The parents of an adolescent might leave to help the teen maintain a fragile identity, but a 10-year-old would prefer to have his parents with him. Expected outcomes for a child and parents new to the hospital would include the parents relating readily to the staff and calmly with the child, the child accepting and responding positively to comforting measures, and the child discussing procedures and activities without evidence of anxiety.

A client reports abdominal pain. When examining this client, when should the nurse collect data?

The symptomatic quadrant last - The nurse should systematically collect data on all areas of the abdomen, if time and the client's condition permit, concluding with the symptomatic area. Otherwise, the nurse may elicit pain in the symptomatic area, causing the muscles in other areas to tighten. This tightening would interfere with further data collection.

An unconscious client is admitted to the emergency department. The nurse suspects which source is the cause of airway obstruction in this client, as it is the most common source of airway obstruction in the unconscious victim?

The tongue - n many cases, the muscles controlling the tongue relax, causing the tongue to obstruct the airway. When this occurs, the nurse should use the head-tilt, chin-lift maneuver to cause the tongue to fall back in place. If a neck injury is suspected, the jaw-thrust maneuver must be performed. A foreign object, saliva or mucus, and edema are less common sources of airway obstruction in an unconscious adult.

A client comes to the clinic for an ophthalmologic screening, which will include measurement of intraocular pressure with a tonometer. When teaching the client about the test, the nurse should cover which point?

The tonometer will register the force required to indent or flatten the corneal apex. - The force required to indent (using Schiotz's tonometer) or flatten (using an applanation tonometer) the corneal apex varies with firmness of the eye, which fluctuates with intraocular pressure. Although the client does direct the gaze forward during tonometry, the tonometer rests on the surface of the cornea, not the sclera. Topical anesthetic drops are administered before, not after, the examination. The client may wear dark glasses after pupil dilation to protect his eyes from light.

To treat a client with acne vulgaris, the physician is most likely to prescribe which topical agent for nightly application?

Tretinoin (retinoic acid) - Tretinoin is a topical agent applied nightly to treat acne vulgaris. Minoxidil is used to promote hair growth. Zinc oxide gelatin is used for abrasions on the lower arms or legs; the affected area must be covered with a bandage for about 1 week. Fluorouracil is an antineoplastic topical agent used to treat superficial basal cell carcinoma.

A client comes to the emergency department reporting visual changes and a severe headache. The nurse measures the client's blood pressure at 210/120 mm Hg. However, the client denies having hypertension or any other disorder. After diagnosing malignant hypertension, a life-threatening disorder, the physician initiates emergency intervention. What is the most common cause of malignant hypertension?

Untreated hypertension - Untreated hypertension is the most common cause of malignant hypertension. Pyelonephritis, dissecting aortic aneurysm, and excessive catecholamine release (an effect of pheochromocytoma) are less common causes. Rarely, malignant hypertension results from eclampsia, ingestion of or exposure to drugs or toxic substances, and food and drug interactions (such as monoamine oxidase inhibitors with aged cheeses).

The nurse is teaching a client with chronic bronchitis about breathing exercises. Which of the following should the nurse include in the teaching?

Use diaphragmatic breathing. - In chronic bronchitis the diaphragm is flat and weak. Diaphragmatic breathing helps strengthen the diaphragm and maximizes ventilation. Exhalation should be longer than inhalation to prevent collapse of the bronchioles. The client with chronic bronchitis should exhale through pursed lips to prolong exhalation, keep the bronchioles from collapsing, and prevent air trapping. Diaphragmatic breathing — not chest breathing — increases lung expansion.

The nurse must administer a liquid medication to an infant. Which step should the nurse take first?

Verify the physician's order. - The nurse should first verify the physician's order. Next, the nurse should make sure she has the right drug, dose, route, and time. She should then make sure she has the right client by checking the infant's armband. Next, the nurse should hold the infant securely in the crook of her arm and raise the infant's head to about a 45-degree angle. Then, the nurse should place the dropper at the corner of the infant's mouth so the drug runs into the pocket between the infant's cheek and gum. Doing so keeps him from spitting out the drug and reduces the risk of aspiration.

A nurse is reinforcing education for a client with allergies about anaphylaxis. What should the nurse be sure to include in this discussion?

Wear a medical identification bracelet. - If the client were to become unconscious or could not report allergies, medical identification could provide information that health care providers would need to treat anaphylaxis. The client should wet-mop hardwood floors because dry mopping scatters dust that can trigger allergies. Pollen and animal dander might cause an allergic response, but they do not usually cause anaphylaxis.

A client with an indwelling urinary catheter is suspected of having a urinary tract infection. Which technique should the nurse use to collect a urine specimen for culture and sensitivity?

Wipe the self-sealing aspiration port with antiseptic solution, and aspirate urine with a sterile needle. - Most catheters have a self-sealing port for obtaining a urine specimen. Antiseptic solution is used to reduce the risk of introducing microorganisms into the catheter. Tubing should not be disconnected from the urinary catheter. Any break in the closed urine drainage system can allow the entry of microorganisms. Urine in urine drainage bags may not be fresh and may contain bacteria, giving false positive test results. When there is no urine in the tubing, the catheter may be clamped for no more than 30 minutes to allow urine to collect.

Which action is appropriate for the nurse to perform when administering digoxin to an infant?

Withhold the dose if the apical pulse rate is less than 90 beats/minute. - Digoxin is used to decrease heart rate; however, the apical pulse must be carefully monitored to detect a severe reduction. Administering digoxin to an infant with a heart rate of less than 90 beats/minute could further reduce the rate and compromise cardiac output. Mixing digoxin with other food may interfere with accurate dosing. Double-dosing should never be done. Antacids may decrease absorption of digoxin.

A nurse working in the triage area of an emergency department sees that several pediatric clients arrive simultaneously. Which child is treated first?

a 2-month-old infant with stridorous breath sounds, sitting up in his or her mother's arms and drooling - The 2-month-old infant with the airway emergency should be treated first because of the risk of epiglottitis. The 3-year-old with the barking cough and fever should be suspected of having croup and should be seen promptly, as should the child with the laceration. The nurse would need to gather more information about the child with Down syndrome to determine the priority of care.

A toddler is brought to the emergency department with sudden onset of abdominal pain, vomiting, and stools that look like red currant jelly. To confirm intussusception, the suspected cause of these findings, the nurse expects the physician to order:

a barium enema - A barium enema commonly is used to confirm and correct intussusception. Performing a suprapubic aspiration or inserting an NG tube or an indwelling urinary catheter wouldn't help diagnose or treat this disorder.

A client is admitted to the psychiatric unit with a tentative diagnosis of psychosis. Her physician prescribes the phenothiazine thioridazine, 50 mg by mouth three times per day. Phenothiazines differ from central nervous system (CNS) depressants in their sedative effects by producing:

a calming effect from which the client is easily aroused. - Shortly after phenothiazine administration, a quieting and calming effect occurs, but the client is easily aroused, alert, and responsive and has good motor coordination.

The nurse is caring for a client who required chest tube insertion for a pneumothorax. To assess a client for pneumothorax resolution after the procedure, the nurse can anticipate that he'll require:

a chest X-ray. - Chest X-ray confirms whether the chest tube has resolved the pneumothorax. If the chest tube hasn't resolved the pneumothorax, the chest X-ray will reveal air or fluid in the pleural space. SaO2values may initially decrease with a pneumothorax but typically return to normal in 24 hours. ABG levels may show hypoxemia, possibly with respiratory acidosis and hypercapnia not related to a pneumothorax. Chest auscultation will determine overall lung status, but it's difficult to determine if the chest is re-expanded sufficiently.

A nurse is caring for several clients on a medical floor. Which client does the nurse identify to have the greatest chance of developing cardiogenic shock?

a client with acute myocardial infarction (MI) - Of all clients with an acute MI, 15% suffer cardiogenic shock secondary to the myocardial damage and decreased function. CAD causes MI. Hypotension is the result of a reduced cardiac output produced by the shock state. A decreased hemoglobin level is a result of bleeding.

The nurse evaluates a client who is 36-hours postoperative. Which sign or symptom indicates to the nurse that the client is experiencing a complication?

a warm, erythematous tender incision - Redness, warmth, and tenderness around the incision area would lead the nurse to suspect a postoperative infection. The presence of dark colored urine does not necessarily indicate infection or a complication. An oral temperature of 100° F is a normal expectation in a postoperative client because of the inflammatory process. A normal WBC count ranges from 4-10 x 103/μl

In assessing a postmastectomy client, the nurse determines that the client is in denial. The nurse can best respond by:

accepting the denial. - When a client is faced with body image alterations and, possibly, terminal illness and death, the nurse should allow the client to express her feelings. By accepting the initial denial, the nurse acknowledges the role that denial plays in the coping process. Interpreting the client's denial and then confronting her with it will increase her anxiety, hinder the development of a trusting relationship, and delay the client's acceptance of her condition. Accepting the client's denial doesn't imply that the nurse supports it.

A client, who is newly prescribed metoprolol, has a headache and asks the nurse what medication to take. The nurse should reinforce the health care provider's instructions to take which of the following medications?

acetaminophen - Acetaminophen is the drug of choice for a client taking beta-blocking drugs. Aspirin and other nonsteroidal anti-inflammatory drugs (NSAIDs) such as ibuprofen and indomethacin counteract the blood-pressure-reducing effects of beta blockers by reducing the effects of prostaglandins.

A client receiving haloperidol reports a stiff jaw and difficulty swallowing. The nurse's first action is to:

administer an as-needed dose of benztropine I.M. as ordered. - The client is most likely suffering from muscle rigidity caused by haloperidol. An I.M. injection of benztropine should be administered to prevent asphyxia or aspiration. Lorazepam treats anxiety, not extrapyramidal effects. Another dose of haloperidol would increase the severity of the reaction.

Which nursing intervention is most effective in maximizing tissue perfusion for a child in vaso-occlusive crisis?

administer oxygen as prescribed - Administering oxygen is the most effective way to maximize tissue perfusion. Short term oxygen therapy helps to prevent hypoxia, which leads to metabolic acidosis, causing sickling. Analgesics are used to control pain. Hydration is essential to promote hemodilution and maintain electrolyte balance. Bed rest should be promoted to reduce oxygen utilization.

A parent reports that their teenager is losing hair in small, round areas on the scalp. The nurse interprets this as suggesting which condition?

alopecia - Alopecia is the correct term for thinning hair loss. Amblyopia and exotropia are eye disorders. Seborrhea dermatitis is cradle cap and occurs in infants.

Which hormone deficiency should the nurse suspect as the underlying cause of diabetes insipidus in a postoperative craniotomy client?

antidiuretic hormone (ADH) - A client with diabetes insipidus has a deficiency of antidiuretic hormone. TSH, FSH, and LH hormone levels are not affected.

A nurse is assisting with the development of a plan of care for a client diagnosed with ringworm. Which medication should the nurse anticipate discussing with this client?

antifungal

A client comes to the emergency department reporting chest discomfort and tingling of the fingers. The electrocardiogram shows a heart rate of 136 beats/minute and no other changes; respirations are 28 and shallow. Which nursing intervention has the greatest priority?

apply O2 at 3 L via nasal cannula - The client is exhibiting anxiety and the nurse should assist the client to calm down. Feelings of panic and/or fear, cold or sweaty hands and/or feet, shortness of breath/hyperventilation, heart palpitations, numbness or tingling in the hands or feet, nausea, and dizziness are signs and symptoms of panic from anxiety. Anxiety can adversely affect the client's heart rate and rhythm by stimulating the autonomic nervous system. The threat of death is an immediate and real concern for the client. The other nursing interventions are valid, but they are not the priority in this situation.

The nurse is reviewing an arterial blood gas (ABG) from a client with a subdural hematoma and observes the PaCO2 is 30 mm Hg. Which response best describes this result?

appropriate; lowering carbon dioxide (CO2) reduces intracranial pressure (ICP) - A normal PaCO2 value is 35 to 45 mm Hg. CO2 has vasodilating properties; therefore, lowering PaCO2 through hyperventilation will lower ICP caused by dilated cerebral vessels. Alveolar hypoventilation would be reflected in an increased PaCO2. Oxygenation is evaluated through PaO2and oxygen saturation.

A client with Alzheimer's disease begins supplemental feedings through a gastrostomy tube to provide adequate calorie intake. What should the nurse be most concerned about with this client?

aspiration - Of the options listed, aspiration is the most serious potential complication of tube feedings. Dehydration, not fluid volume excess, is a concern because of decreased free water intake. Hyperglycemia, not hypoglycemia, is a complication secondary to carbohydrate load of enteral feeding solutions. Constipation is potentially a problem, but it usually is not a serious one, and the client would be more likely to experience diarrhea.

Which intervention should the nurse implement to promote adequate nutritional intake for a client with Alzheimer's disease?

assist the client with feeding - Because a client with Alzheimer disease can forget how to eat, the nurse should stay and assist the client with eating to ensure adequate food intake. Allowing privacy during meals, filling out the menu, and helping the client to complete the menu don't ensure that the client will eat.

An infant, diagnosed with bronchiolitis, is ordered a mist tent with oxygen. The parents question how a mist tent with oxygen can help their infant. The nurse is most correct to identify which? Select all that apply.

assists in decreasing bronchial edema assists in improving cough assists in improving oxygen saturation - The nurse is correct to identify that a mist tent with oxygen assists with decreasing bronchial edema by soothing the respiratory tract. The tent improves the mechanism of cough. Improving ventilator processes improves oxygen saturation. The mist tent with oxygen hydrates, not dries, secretions. The mist tent does not improve swallowing function.

A client arrives in the clinic reporting right-sided chest pain and shortness of breath which started suddenly. What should be the nurse's first action?

auscultation of breath sounds - Because he's short of breath, auscultation of the lungs will indicate normal or abnormal breath sounds. He may need a chest x-ray and an electrocardiogram, but they require a health care provider's order. An echocardiogram also requires a health care provider's order and may be necessary if a pulmonary embolus is suspected.

When caring for a 2-year-old child, the nurse should offer choices, when appropriate, about some aspects of care. According to Erikson, doing this helps the child achieve:

autonomy. - According to Erikson's theory of development, a 2-year-old child is at the stage of autonomy versus shame and doubt. An infant is at the stage of trust versus mistrust; a school-age child, industry versus inferiority; and a preschooler, initiative versus guilt.

A client diagnosed with lung cancer states to the nurse, "If my biopsy comes back with a better outcome than the original one, I will never smoke another cigarette for the rest of my life." What stage of grief does the nurse document that this client is exhibiting?

bargaining - The client is experiencing the bargaining stage of grief. When faced with a crisis or illness, the client attempts to bargain with a higher entity or themselves. Denial is the first stage of grief in which the client is unable to accept the initial problem. Anger is the second stage of grief. Acceptance is the final stage of grief when the client understands and can accept the problem.

The orthopedic nurse is providing discharge instruction to a surgical client. Which action, by the client, would demonstrate proper touchdown weight bearing?

bearing no weight on the extremity but allowing the extremity to touch the floor - Touchdown weight bearing involves bearing no weight on the extremity but allowing the affected extremity to touch the floor. Full weight bearing allows for full weight to be put on the affected extremity. Partial weight bearing allows for 30% to 50% weight bearing on the affected extremity. Non-weight bearing refers to bearing no weight on the affected extremity.

A pediatric nurse is providing discharge instructions for the family of a school-age child with idiopathic thrombocytopenia. Which activity should be restricted until further notice?

bicycle riding - When routine blood counts reveal the platelet level is 100,000/mm3 or less, the child should not engage in contact sports, bicycle or scooter riding, climbing, or other activities that could lead to injury (especially to the head). Swimming releases energy, builds muscle, and allows the child to compete without risking injury, as long as the child follows normal safety precautions. Computer games do not cause physical injury. It is not necessary for this child to avoid large crowds because idiopathic thrombocytopenia does not suppress the immune system.

A pregnant client is admitted to the labor unit in early labor. When reviewing the plan of care for the client, which laboratory test would the nurse identify as being critical to obtain?

blood type - Blood type is a critical laboratory test to be done because the risk of blood loss is always a potential complication during the labor and birth process. Approximately 40% of a woman's cardiac output is delivered to the uterus; therefore, blood loss can occur quite rapidly in the event of uncontrolled bleeding. Calcium, iron, and oxygen saturation are not critical tests.

A licensed practical nurse (LPN) is delegating responsibilities to a certified nursing assistant (CNA) on a busy postpartum unit. Which task would be appropriate for the LPN to delegate to the CNA?

bottle-feeding a 24-hour-old neonate - Most bottle-fed neonates have had several successful feedings by the time they are 24 hours old; therefore, the task of bottle-feeding a 24-hour-old neonate can be delegated to a CNA. An LPN should complete the initial bath to adequately collect data about the neonate's skin and to determine whether the neonate's temperature has stabilized. Neonates transitioning to extrauterine life require frequent data collection. A recently circumcised neonate must be examined carefully for evidence of abnormal bleeding. A CNA should not be given these duties because they require more advanced skill.

A nurse is caring for a client who is four weeks pregnant. When collecting data on this client, the nurse would most likely note which finding?

breast sensitivity - Breast sensitivity is expected within the first 4 weeks of pregnancy. Amenorrhea, or the absence of menstrual flow, is also expected during this time. The other findings of uterine enlargement and fetal heart tones do not occur until after the first 4 weeks of pregnancy.

A child with tetralogy of Fallot has clubbing of the fingers and toes. The nurse understands that this finding is related to which condition?

chronic hypoxia - Chronic hypoxia causes clubbing of the fingers and toes when untreated. Hypoxia varies with the degree of pulmonary stenosis. Polycythemia is an increased number of red blood cells as a result of chronic hypoxemia. A pansystolic murmur is heard at the middle to lower-left sternal border but has no impact on clubbing. Growth and development may appear normal.

A histamine (H2) receptor antagonist is prescribed for a client with recurrent gastrointestinal discomfort. The nurse is instructing the client from a medication pamphlet and highlights which medications in this classification? Select all that apply.

cimetidine ranitidine nizatidine famotidine - H2 receptor antagonists suppress secretion of gastric action, alleviate symptoms of heartburn, and help to prevent peptic ulcer disease. Esomeprazole is a proton pump inhibitor.

The nurse is caring for the four clients. Which client should the nurse see first?

client who needs pain medication for a pain level of 9 of 10 - The client with pain should be seen first (according to Maslow's hierarchy of needs). A client for a magnetic resonance imaging and surgery can be prepared in 2 hours after giving pain medication. The client that needs a stool specimen can be taught to obtain the stool specimen or the nurse may be able to obtain it later.

The physician orders a stool culture to help diagnose a client with prolonged diarrhea. The nurse who obtains the stool specimen should:

collect the specimen in a sterile container. - The nurse should collect the stool specimen using sterile technique and a sterile stool container. The stool may be collected for 3 consecutive days; no follow-up care is needed. Although a stool culture should be taken to the laboratory as soon as possible, it need not be delivered immediately (unlike stool being examined for ova and parasites). Applying a solution to a stool specimen would contaminate it and only is done when testing stool for occult blood, not organisms. The nurse shouldn't store a stool culture on ice because the abrupt temperature change could kill the organisms.

A client comes to the clinic seeking medical attention for a rash. The nurse gathers information about the rash and finds that the client's back and right side are covered with vesicles. A vesicular rash may be associated with which conditions? Select all that apply.

contact dermatitis herpes zoster smallpox - A vesicular rash is associated with contact dermatitis, herpes zoster, and the late stages of smallpox. Cutaneous anthrax and Kaposi's sarcoma are associated with a papular rash.

A nurse is caring for a client with pneumonia. When gathering data, which finding does the nurse anticipate?

crackles - When gathering data on a client with pneumonia, the nurse should anticipate crackle on auscultation, increased respiratory effort, and decreased oxygen saturations. Pleural rub on auscultation is typically heard in clients with pleurisy versus pneumonia.

A client is undergoing a diagnostic workup for suspected testicular cancer. When obtaining the client's history, the nurse checks for known risk factors for this type of cancer. Testicular cancer has been linked to:

cryptorchidism. - Cryptorchidism (failure of one or both testes to descend into the scrotum) appears to play a role in testicular cancer, even when corrected surgically. Other significant history findings for testicular cancer include mumps orchitis, inguinal hernia during childhood, and maternal use of diethylstilbestrol or other estrogen-progestin combinations during pregnancy. Testosterone therapy during childhood, sexually transmitted disease, and early onset of puberty aren't risk factors for testicular cancer.

The nurse is reviewing the teaching provided to the family of a client with a psychiatric disorder about traditional antipsychotic drugs and their effect on symptoms. The nurse understands that which symptom would be most responsive to these types of drugs?

delusions - Positive symptoms, such as delusions, hallucinations, thought disorder, and disorganized speech, respond to traditional antipsychotic drugs. Apathy, social withdrawal, and attention impairment are part of the category of negative symptoms, which also includes affective flattening, restricted thought and speech, and anhedonia. These symptoms are more responsive to the atypical antipsychotics, such as clozapine, risperidone, and olanzapine.

The nurse is teaching a client who has facial muscle weakness and has recently been diagnosed with myasthenia gravis. The nurse should teach the client that myasthenia gravis is caused by:

destruction of acetylcholine receptors. - Myasthenia gravis is characterized by a weakness of muscles, especially in the face and throat, caused by the destruction of acetylcholine receptors at the postsynaptic membrane of the neuromuscular junction. It isn't a genetic disorder. A combined upper and lower motor neuron lesion generally occurs as a result of spinal injuries. A lesion involving cranial nerves and their axons in the spinal cord would cause decreased conduction of impulses at an upper motor neuron.

A nurse is collecting data on a client who is suffering from stress and anxiety. When collecting data from the client, the nurse interprets what reported symptom as a common physiologic response to stress and anxiety?

diarrhea - Diarrhea is a common physiologic response to stress and anxiety. Although sedation, vertigo, and urticaria could also be related to stress and anxiety, they do not occur as commonly as diarrhea.

A nurse is providing care for a pregnant client in her second trimester. A 1-hour oral glucose tolerance test results show that the client has a blood glucose level of 160 mg/dL. Which intervention would the nurse anticipate as being included in the client's multidisciplinary plan of care?

dietary management - The client's elevated blood glucose level would be controlled initially by diet and exercise, rather than using insulin. The client will need to watch her overall intake to control her blood glucose level. Two oral agents, metformin and glyburide, have been used to treat gestational diabetes; however, these drugs do cross the placenta, and research substantiating their safety and effectiveness is lacking. Fingerstick blood glucose monitoring, not urine glucose monitoring, would be appropriate. Urine glucose levels are not an accurate indication of blood glucose levels.

A pregnant woman arrives at the emergency department with abruptio placentae at 34 weeks gestation. Which blood dyscrasia should the nurse closely monitor for?

disseminated intravascular coagulation (DIC) - Abruptio placentae is a cause of DIC because of activation of the clotting cascade after hemorrhage. Thrombocytopenia results from decreased bone marrow production. ITP can result in DIC, but not because of abruptio placentae. A client with abruptio placentae wouldn't receive heparin and, as a result, wouldn't be at risk for HATT.

A client is suspected of having developed an acute pulmonary embolism. Which symptom would a nurse most likely observe first?

dyspnea - Dyspnea is usually the first symptom of pulmonary embolus because the thrombus prevents gas exchange in the pulmonary arterial bed. If the embolus is large enough, the client may then develop right ventricular failure with symptoms such as distended jugular veins, tachycardia, and circulatory collapse. He may also have hemoptysis.

A child is admitted to the hospital for an asthma exacerbation. The nursing history reveals this client was exposed to chickenpox 1 week ago. When would this client require isolation if he or she were to remain hospitalized?

immediate isolation is required - The incubation period for chickenpox is 2 to 3 weeks, commonly 13 to 17 days. A client is commonly isolated 1 week after exposure to avoid the risk of an earlier breakout. A person is infectious from 1 day before eruption of lesions until after the vesicles have formed crusts.

A client is admitted to the emergency department with chest discomfort, diaphoresis, and nausea. Suspecting possible myocardial infarction (MI), the nurse would anticipate that the health care provider will prescribe which diagnostic test to quickly determine myocardial damage?

electrocardiogram - Electrocardiogram is the quickest, most accurate, and most widely used tool to diagnose MI. Cardiac enzymes also are used to diagnose MI, but the results can't be obtained as quickly. An echocardiogram is used most widely to view myocardial wall function after an MI has been diagnosed. Cardiac catheterization is an invasive study for determining coronary artery disease.

A 3-year-old boy is having surgery to repair severe hypospadias. He returns from surgery with dextrose 5% in water (D5W) infusing IV at 40 mL/hour, an indwelling urinary catheter in place, and a prescription for diet as tolerated and pain medication as needed. Which action would be best for the nurse to perform in order to prevent separation of the incision?

elevate the scrotal sac - Elevation of the scrotal sac on a Bellevue bridge or similar structure helps avert separation of the suture line by preventing dependent edema. Placing the child in semi-Fowler position increases the swelling. Staying with a 3-year-old is more appropriate than restraining him. Cleaning the affected area every 2 hours with saline solution has no effect on incision separation.

The nurse is assisting with the development of a care plan for a postpartum client who had an uncomplicated vaginal birth of an 8-lb, 2-oz (3,693-g) neonate over an intact perineum 24 hours ago. While planning care for this client, the registered nurse collaborates with the licensed practical nurse to achieve which priority outcome in the next 8 hours?

encouraging the client to demonstrate an ability to breast-feed the neonate - With an uncomplicated vaginal birth, the average client will be hospitalized for 48 hours or less. By 24 hours postpartum, it's important for the client to start demonstrating the ability to care for her neonate. The first bowel movement occurs on average 2 to 3 days postpartum. The rubella vaccine is given, when indicated, on the day of discharge. This client delivered over an intact perineum, so a sitz bath isn't a priority.

The nurse is gathering data from a client with prolonged, chronic alcohol use. Which finding does the nurse expect?

enlarged liver - A major effect of alcohol on the body is liver impairment, and an enlarged liver is a common physical finding. Other gastrointestinal findings such as increased flatus, spleen deterioration, and having a colostomy are not commonly associated with findings in clients with chronic alcohol use.

A parent brings their child to the emergency department reporting difficulty swallowing, increased drooling, restlessness, and stridor. The position of comfort is observed to be tripod-sitting position. What does the nurse suspect may be occurring?

epiglottitis - Epiglottitis is associated with difficult swallowing, increased drooling, restlessness, stridor, and tripod sitting position. Asthma is accompanied dyspnea, fatigue, wheezing, decreased breath sounds, and use of accessory muscles. Bronchiolitis normally is diagnosed by a cough, sternal retractions, thick mucous, and elevated temperature. Croup is identified by a barking cough, crackles and/or decreased breath sounds, increased dyspnea, and inspiratory stridor.

A client at 42 weeks' gestation is 3 cm dilated and 30% effaced with membranes intact and the fetus at +2 station. Fetal heart rate (FHR) is 140 to 150 beats/minute. After 2 hours, the nurse notes on the external fetal monitor that for the past 10 minutes, the FHR ranged from 160 to 190 beats/minute. The client states that her baby has been extremely active. Uterine contractions are strong, occurring every 3 to 4 minutes and lasting 40 to 60 seconds. The nurse suspects fetal hypoxia based on which finding?

excessive fetal activity and fetal tachycardia - Fetal tachycardia and excessive fetal activity are the first signs of fetal hypoxia. The duration of uterine contractions is within normal limits. Uterine intensity can be mild to strong and still be within normal limits. The frequency of contractions is within the normal limits for the active phase of labor.

A client is admitted to the hospital with signs and symptoms of diabetes mellitus. Which findings will the nurse most likely observe in this client?

excessive thirst excessive hunger Frequent, high-volume urination - Classic signs of diabetes mellitus include polydipsia (excessive thirst), polyphagia (excessive hunger), and polyuria (excessive urination). Because the body is starving from the lack of glucose that the cells are using for energy, the client has weight loss, not weight gain. Clients with diabetes mellitus usually do not present with constipation.

Which finding is common when gathering data from a child with a total anomalous pulmonary venous return defect?

frequent respiratory infections - Children with total anomalous pulmonary venous return defects are prone to repeated respiratory infections due to increased pulmonary blood flow. Hypertension usually occurs with coarctation of the aorta, an acyanotic defect with obstructive flow. Poor feeding and failure to thrive are also signs of a total anomalous pulmonary venous return defect, as is a thin, malnourished appearance in infants.

Which interventions should the nurse perform prior to administering an enema to a client? Select all that apply.

gather the supplies verify the health care provider's prescription provide for client privacy Explain the procedure to the client. - The nurse should verify the prescription, wash hands, gather the supplies, identify the client, explain the procedure, position the client left-lateral Sims' position and don nonsterile gloves. Left-lateral Sims' position facilitates flow of the enema into the descending colon by gravity. Only if this position is contraindicated should the nurse place the client on the back or the right side.

A client is admitted with hypoparathyroidism. When collecting data on the client, the nurse should expect to see which sign or symptom?

hand twitching - Tetany, which is manifested by muscle twitching or spasms, is the chief symptom of hypoparathyroidism. Chest pain and shortness of breath aren't usually symptoms of hypoparathyroidism. Exophthalmos, or bulging eyes, is a common symptom of hyperthyroidism.

While caring for a 2-day-old neonate, a nurse notices the left side of the neonate reddens for 2 to 3 minutes. What does this finding suggest?

harlequin color change - Harlequin color change is a benign disorder related to the immaturity of the hypothalamic centers that control the tone of peripheral blood vessels. A newborn who has been lying on its side may appear reddened on the dependent side. The color fades on position change. Contact dermatitis is not short-lived. Changes in environmental conditions can cause diffuse bilateral mottling of the skin. Tet spells are associated with tetralogy of Fallot and cause cyanotic changes.

When gathering data from a client admitted with hypertension, the nurse should expect the client to report which symptom?

headache - An occipital headache is typical of hypertension owing to increased pressure in the cerebral vasculature. Blurred vision (due to arteriolar changes in the eye) and epistaxis (nosebleed) are far less common than headache, but can also be diagnostic signs. Peripheral edema can occur from an increase in sodium and water retention, but it's usually a latent sign.

Which symptom should the nurse expect to find in a client with increased blood plasma levels of thyroxine?

heat intolerance - In patients with hyperthyroidism, excess serum thyroxine increases the metabolic rate, leading to heat intolerance. Weight loss, not gain, also results from the increased metabolic rate. Diastolic blood pressure decreases because of decreased peripheral resistance. Clients with hyperthyroidism may experience an increase in appetite, not anorexia.

A client was admitted with Pneumocystis jirovecii pneumonia (PJP). Which history would the nurse expect to see in the client's chart?

history of acquired immunodeficiency syndrome (AIDS) - Pneumocystis jirovecii pneumonia (PJP), formerly known as Pneumocystis carinii pneumonia (PCP) is a type of pneumonia caused by a fungus called Pneumocystis jirovecii. It is one of the opportunistic infections seen in clients who are immunocompromised, particularly in clients with HIV/AIDS.

Following a transsphenoidal hypophysectomy, the nurse should assess the client carefully for:

hypocortisolism. - The nurse should assess for hypocortisolism. Abrupt withdrawal of endogenous cortisol may lead to severe adrenal insufficiency. Steroids should be given during surgery to prevent hypocortisolism from occurring. Signs of hypocortisolism include vomiting, increased weakness, dehydration and hypotension. After the corticotropin- secreting tumor is removed, the client shouldn't be at risk for hyperglycemia. Calcium imbalance shouldn't occur in this situation.

A 4-year-old has a petechial rash. The platelet count is 20,000/L, and the hemoglobin level and white blood cell (WBC) count are normal. Which diagnosis would the nurse most likely suspect?

idiopathic thrombocytopenic purpura (ITP) - The onset of ITP typically occurs between ages 1 and 6. Children with ITP are asymptomatic, except for petechial rash. ALL is associated with a low platelet count, but an abnormal hemoglobin level and WBC count. DIC is secondary to a severe underlying disease. SLE is rare in a 4-year-old child.

The nurse is reinforcing educating the parents of a child with hemophilia. The nurse should prepare the parents to initiate which immediate treatment to prevent excessive blood loss?

immobilizing and elevating the affected area - Elevating the area above the level of the heart will decrease blood flow. Cold, not heat, should be applied to promote vasoconstriction. Factor replacement should not be delayed. Pressure should be applied to the area for at least 10 to 15 minutes to allow clot formation.

A nurse determines that a client with antisocial personality disorder is beginning to practice several socially acceptable behaviors in the group setting. Which behavior observed by the nurse would indicate this is taking place?

improved self-esteem - When clients with antisocial personality disorder begin to practice socially acceptable behaviors, they also commonly experience a more positive sense of self. Clients with antisocial personality disorder don't tend to have panic attacks, alteration in their perception of reality, or somatic manifestations of their illness.

The nurse is planning care for a client who is argumentative and demanding, calling the nurse frequently. What is the nurse's best intervention?

include the client in the decision-making process - Involving the client in the planning process individualizes care and promotes self-esteem and autonomy, which often prevents arguments and demanding behavior. Asking the client to be cooperative does not mean the client is going to be. Having a witness can escalate the situation because it indicates a defensive posture by the nurse. No disease process was identified in the question.

A client is scheduled to have a cholecystectomy. In the preoperative teaching, the nurse explains that incentive spirometry will be used after surgery. Which information will the nurse include when conducting the postoperative teaching? Select all that apply.

increase alveolar inflation promote lung expansion promote deep breathing - The high abdominal incision used in a cholecystectomy interferes with respirations postoperatively, increasing the risk of atelectasis. Therefore, incentive spirometry is used to promote lung expansion and deep breathing, increase alveolar inflation, and strengthen respiratory muscles. Incentive spirometry has no effect on intubation, nutrition, or analgesia.

A nurse is providing fluid replacement for a client with burns on 35% of the body that occurred 12 hours previously. The client's blood pressure is 85/60 mm Hg, pulse is 124 beats/minute, and urine output was 25 mL during the past hour. What prescription should the nurse expect to receive from the health care provider?

increase the IV fluid infusion rate - During the first 24 hours after a burn, interstitial and intracellular fluid shifts occur, and intravascular fluid volume decreases. Hypovolemia calls for fluid replacement therapy to maintain vital organ perfusion. Keeping IV fluids at the current rate would not correct the client's fluid deficit. A vasoconstrictor would be inappropriate because it does not correct fluid volume deficits. Vital signs should be reevaluated sooner than 30 minutes and immediately after the intervention to determine effectiveness. Urine output may take longer than 1 hour to correct and should be ongoing.

The nurse is working with a 2-year-old child who has been admitted with a new diagnosis of diabetes mellitus. Which signs would the nurse expect to observe in the child? Select all that apply.

increased appetite weight loss frequent urination - Polyphagia, polyuria, polydipsia, and weight loss are cardinal signs of diabetes. Other signs include irritability, shortened attention span, lowered frustration tolerance, fatigue, dry skin, blurred vision, sores that are slow to heal, and flushed skin. If on initial presentation the child was in diabetic ketoacidosis, signs and symptoms would include fruity odor to the breath, Kussmaul respirations, and stupor.

Which complications should the nurse be most concerned about in the first 12 hours of life for a neonate born with a myelomeningocele?

infection - All of these complications are a potential for a child with a myelomeningocele. However, during the first 12 hours of life, the most life-threatening event would be an infection. The other potential complications will be addressed as the child develops.

The nurse is caring for a toddler with right lower lobe pneumonia. In order to improve gas exchange, which position should the child be placed in?

left side-lying - The child with right lower lobe pneumonia should be placed on his left side. This places the unaffected left lung in a position that allows gravity to promote blood flow though the healthy lung tissue and improve gas exchange. Placing the child on his right side, back, or stomach doesn't promote circulation to the unaffected lung.

The physician prescribes lithium carbonate for a client who has just been diagnosed with bipolar disorder. Now the nurse is teaching the client about signs and symptoms of lithium toxicity, which include:

lethargy, vomiting, and diarrhea. - Lethargy is an early sign of lithium toxicity; if it goes undetected, vomiting and diarrhea soon develop. Lithium doesn't cause extrapyramidal effects, such as skeletal muscle contractions, cogwheel rigidity, and a thick tongue, or cholinergic effects, such as dry mouth, blurred vision, and urine retention. The drug also doesn't cause edema, orthostatic hypotension, or rash.

The nurse is caring for a client diagnosed with leukemia who is going to have a chemotherapy treatment. Which test would the nurse expect to be done to evaluate the client's ability to metabolize chemotherapeutic agents?

liver function studies - Liver and kidney function studies are done before initiation of chemotherapy to evaluate the client's ability to metabolize the chemotherapeutic agents. A lumbar puncture is performed to assess for central nervous system infiltration. A CBC is performed to assess for anemia. A peripheral blood smear is done to assess the level of immature white blood cells (blastocytes).

A client is undergoing a left modified radical mastectomy for breast cancer. Postoperatively, blood pressure should be obtained from the client's right arm, and the left arm and hand should be elevated as much as possible to prevent which condition?

lymphedema - Lymphedema is a common postoperative adverse effect of modified radical mastectomy and lymph node dissection. Elevation of the arm on the affected side will allow gravity to assist lymph drainage. Other preventive measures include exercises in which the arms are elevated. Trousseau sign is a sign of hypocalcemia and wouldn't be expected in this situation. Neither intravenous infusions nor venipunctures should be given in the left arm. Although muscle atrophy is a potential adverse effect if the client doesn't exercise her left arm, it wouldn't be prevented by elevating the arm.

A unit manager has four licensed practical nurses (LPN) and one registered nurse (RN) working on a unit. Which assignments would be appropriate for the LPNs? Select all that apply.

medication nurse wound care nurse - A charge nurse requires constant use of assessment skills, analysis, and evaluation, and should not be given to the LPN. An admissions nurse requires assessment, which is not within the scope of practice for the LPN. Initiating intravenous therapy is within the scope of practice for the RN. Medication administration and wound care are within the scope of practice for the LPN.

A nurse prepares to care for a client who has just transferred from the emergency department to the medical-surgical floor. Which is the most effective action that the nurse should take to prevent microbial transmission?

meticulous hand hygiene - Hand hygiene is the principal means of preventing the spread of organisms among clients. Wearing gloves when they are indicated, using aseptic technique, and disinfecting equipment between clients are all important measures to prevent spread of microbes; however, none of these techniques is more effective than hand washing.

The nurse is collecting data from a child who may have a seizure disorder. Which behaviors indicate to the nurse that the child may be having an absence seizure?

minimal or no alteration in muscle tone, with a brief loss of consciousness - Absence seizures are characterized as generalized seizures and consist of a brief loss of responsiveness with minimal or no alteration in muscle tone. They may go unrecognized because the child's behavior changes very little. A sudden loss of muscle tone describes atonic seizures. A frozen position describes the appearance of someone having akinetic seizures. A brief, sudden contraction of muscles describes a myoclonic seizure.

An older adult client with pneumonia has copious secretions but is having difficulty coughing them up. Which nursing action would be most appropriate?

monitoring the need for suctioning every hour - Suctioning should be performed only when necessary, based on the client's condition at the time of assessment. Suctioning is a nursing procedure and doesn't require a health care provider's order.

A parent brings a child to the health care provider's office for evaluation of chronic stomach pain stating, "The pain seems to go away when I keeps the child home from school." The health care provider diagnoses school phobia. Which other behaviors or symptoms may the child exhibit? Select all that apply.

nausea headaches dizziness - Children with school phobia commonly report vague symptoms, such as stomachaches, nausea, headaches, and dizziness, to avoid going to school. These symptoms typically do not occur on weekends. A careful history must be taken to identify a pattern of school avoidance. Weight loss and fever are more likely to have a physiological cause and are uncommon in children with school phobia.

A nurse in a family health clinic is caring for a client with anemia. What education does the nurse reinforce?

needs to have activities spaced to allow for rest periods - Clients with anemia become fatigued easily and need rest between activities to conserve energy. Activities do not need to be severely restricted for clients with anemia. The client needs to eat foods that are high in iron (not calcium), such as lean red meat and fortified breakfast cereals. The client does not need close supervision when walking.

A client reports an intermittent milky vaginal discharge. The client is not sexually active and does not report itching or burning. Which factor is the most likely cause of the milky discharge?

normal fluctuation in estrogen and progesterone levels - Vaginal fluid is clear, milky, or cloudy, depending on the fluctuating levels of estrogen and progesterone. A milky vaginal discharge is normal and is not associated with sensitivity, reaction to heat or moisture, or inadequate cleaning.

A multigravida client at 34 weeks' gestation is having a non-stress test performed and begins having vaginal bleeding. Which nursing action would be the priority?

obtaining fetal heart rate (FHR) and maternal blood pressure - FHR and maternal blood pressure provide important data on the conditions of the mother and fetus. An IV line should be started after the mother and fetus are evaluated. Preparing the client for a cesarean birth before determining the cause of the vaginal bleeding would be premature. Maternal heart rate and respiratory rate, although important, are not the best indicators of maternal health status and provide no information about fetal health.

The nurse is caring for a child who has just been diagnosed with sickle cell anemia. Which initial action will be most therapeutic?

offer emotional support - The nurse can be instrumental in providing support, encouragement, and correct information to the parents of a child newly diagnosed with sickle cell anemia. Selective birth methods, such as in vitro fertilization of an embryo without markers for sickle cell disease, are discussed, but parents make their own decisions. All heterozygous, or trait-positive, parents should be referred for genetic counseling. The risk of transmission of sickle cell anemia in subsequent pregnancies remains the same.

A client is in the manic phase of bipolar disorder. To help the client effectively maintain adequate nutrition, the nurse should plan to:

offer finger foods and sandwiches. - Finger foods and sandwiches help maintain adequate nutrition and provide calories for this client's high energy level. During the manic phase, the client can't sit still for the large meals specified in option 1. Option 3 is incorrect because a quiet mealtime environment is more beneficial than a stimulating one. Option 4 is inappropriate because this client has a short attention span and has trouble making choices.

A nurse is working with the multidisciplinary team providing care to a pregnant client with hyperemesis gravidarum who will need close monitoring at home. The nurse as part of the team would expect to assist in beginning discharge planning at which time?

on admission to the facility - Discharge planning should begin when a client is first admitted to the hospital. Initially, discharge planning requires collecting information about the client's home environment, support systems, functional abilities, and finances. This information is used to determine what support services will be needed. Notifying support services on the day of discharge will not be sufficient to ensure meeting the client's needs in a timely fashion. Waiting until the day of discharge to begin planning is also likely to cause the client to become overwhelmed and anxious. Factors such as when the client stops vomiting or expressing a readiness to learn should not influence when the nurse begins discharge planning.

Capillary glucose monitoring is being performed every 4 hours for a client diagnosed with diabetic ketoacidosis. Insulin is administered using a scale of regular insulin according to glucose results. At 2 p.m., the client has a capillary glucose level of 250 mg/dl for which he receives 8 units of regular insulin. The nurse should expect the dose's:

onset to be at 2:30 p.m. and its peak to be at 4 p.m. - Regular insulin, which is a short-acting insulin, has an onset of 30 to 60 minutes and a peak of 2 to 4 hours. Because the nurse gave the insulin at 2 p.m., the expected onset would be from 2:30 p.m. to 3 p.m. and the peak from 4 p.m. to 6 p.m.

The nurse is gathering data from a child with sickle cell anemia. Which bone-related complications should the nurse be alert for during the data collection?

osteoporosis - Sickle cell anemia causes hyperplasia and congestion of the bone marrow, resulting in osteoporosis. Arthritis doesn't cause secondary to sickle cell anemia; however, crisis can cause localized swelling over joints, resulting in arthralgia. Bones do weaken, but spontaneous fractures don't occur as a result. Osteogenic sarcoma is bone cancer; sickle cell anemia doesn't cause bone cancer.

Six months after the death of her infant son, a client is diagnosed with dysfunctional grieving. Which behavior would the nurse expect to find?

overactive without a sense of loss - One of the signs of dysfunctional grieving is overactivity without a sense of loss. Going to the grave, tears, and including the infant as a part of the family are all normal responses to the death of an infant son.

The nurse, who is providing care for four clients, receives a report on the clients. Which report is an outcome indicator?

pain level 3/10 one hour after administration of pain medication - An outcome indicator describes client status at a defined time following care interventions. Pain level 3 one hour after administration of pain medication meets the definition of outcome indicator. Potassium level, blood pressure, and creatinine levels did not describe a client's status after an intervention.

The nurse is admitting a client who states, "I was bit by a brown recluse spider." Which observations made by the nurse would indicate the client's report is accurate?

painful rash around a necrotic lesion - Necrotic, painful rashes are associated with the bite of a brown recluse spider. A bull's-eye rash located primarily at the site of the bite is a classic sign of Lyme disease. A herald patch—a slightly raised, oval lesion about 2 to 6 cm in diameter that appears anywhere on the body—is indicative of pityriasis rosea. A linear, papular, vesicular rash is characteristic of exposure to poison ivy.

Which additional health care provider order should a nurse anticipate for a client who has been prescribed corticosteroids?

perform blood glucose checks every six hours. - Corticosteroids cause elevated blood glucose levels; insulin may be necessary to maintain normal blood glucose levels. Corticosteroids can cause edema but fluid restrictions are generally unnecessary unless the client also has renal or cardiac disease. Lactulose is given for constipation and to treat hepatic encephalopathy. Hematologic studies, such as platelet counts, hemoglobin, and hematocrit levels, aren't usually necessary when monitoring clients undergoing corticosteroid therapy.

The parents of a 4-year-old report that their child has been scratching the rectum recently. About which infestation or condition will the nurse reinforce education?

pinworms - The clinical sign of pinworms is perianal itching that increases at night. Anal fissures are associated with rectal bleeding and pain with bowel movements. Lice are infestations of the hair. Scabies are associated with a pruritic rash characterized as linear burrows of the webs of the fingers and toes.

A client diagnosed with active tuberculosis is started on triple antibiotic therapy. Which signs and symptoms would indicate that the therapy is inadequate?

positive acid-fast bacilli in a sputum sample after 2 months of treatment - Continuing to have acid-fast bacilli in the sputum after 2 months indicates continued infection. The other choices indicate improvement.

The nurse is caring for a toddler admitted to the hospital with nephrotic syndrome. The nurse carefully monitors the toddler's fluid intake and output and checks urine specimens regularly with a reagent strip. Which finding is the nurse most likely to report?

proteinuria - In nephrotic syndrome, the glomerular membrane of the kidneys becomes permeable to proteins. This condition results in massive proteinuria, which the nurse can detect with a reagent strip. Nephrotic syndrome typically does not cause glucosuria or ketonuria. Because the syndrome causes fluids to shift from plasma to interstitial spaces, it is more likely to decrease urine output than to cause polyuria (excessive urine output).

A nurse is caring for a client diagnosed with late stage Alzheimer's disease (AD). What nursing intervention is priority?

providing supervision - Whenever client safety is at risk, careful observation and supervision are of ultimate importance in avoiding injury. Physical contact is implemented during basic care. Applying restraints may cause agitation and combativeness. A high level of sensory stimulation may be too stimulating and distracting.

The nurse is caring for a 20-month-old toddler. The toddler's adoptive parent asks what kind of toy is good to give this child based on the toddler's age. Which toy would the nurse suggest that the parent give based on the growth and development of toddlers?

push-pull toy - A push-pull toy is an appropriate toy for a toddler to aid in development. A nursery mobile aids in infant development, whereas large blocks aid in development of a 10-month-old infant. A musical instrument aids in the development of a school-age child.

he nurse is caring for a group of clients. Which activities by the nurse is the best example of the nurse as an interdisciplinary team member?

recommending a physical therapy consult because of altered mobility - A case manager advocates for options and services to meet the client's health needs through collaboration. Performing hygienic care for the client and administering medications are independent functions of the nurse that do not require collaboration. Assisting the client with ambulation does not require collaboration. Recommending physical therapy is the best option because it involves collaboration with the health care provider and the physical therapist.

Which finding indicates to the nurse that a client's peripherally placed intermittent infusion intravenous (IV) site is infected?

redness and drainage around the insertion site of the needle - Redness and drainage around the insertion site of a peripherally placed needle for intermittent infusion of antibiotics are cardinal signs of infection. Puffiness below the tip of the needle indicates infiltration of the IV. A painful red line running down the arm along the course of the vein indicates phlebitis. A lump located close to the tip of the needle may indicate a thrombus.

A nurse is caring for a client diagnosed with Alzheimer's disease. What is the priority intervention for the nurse when assisting the plan of care?

reviewing safeguards that will limit client wandering - Each of the activities listed would be beneficial to the client with Alzheimer's disease. Protection of the client is the priority.

A client with a tic disorder has tried to use stress reduction techniques without success. Which medication does the nurse anticipate the client may be prescribed for treatment?

risperidone - The atypical antipsychotic drug risperidone is effective in reducing the tics. The other medications are not effective for this disorder.

A nurse manager can appropriately delegate which task?

scheduling staff assignments for the next month - Scheduling tasks may be safely and appropriately delegated. Termination, disciplinary action, and salary increases shouldn't be delegated to staff that don't have the authority to make such decisions.

Which clinical manifestations should a nurse expect to see in a child in stage V of Reye syndrome?

seizures, flaccidity, and respiratory arrest - Staging criteria were developed to help evaluate the client's progress and to evaluate the efficacy of therapies. The clinical manifestations of stage V of Reye syndrome include seizures, loss of deep tendon reflexes, flaccidity, and respiratory arrest. Vomiting, lethargy, and drowsiness occur in stage I. Hyperventilation and coma occur in stage III. Disorientation and aggressive behavior occur in stage II of the disease.

A nurse is obtaining data from a client with the potential diagnosis of gender dysphoria. The nurse knows that the diagnostic criteria for this disorder in a male must include a persistent identification with femaleness and which other sign or symptom?

significant impairment in social, occupational, or other important areas of functioning - Diagnostic criteria for male gender dysphoria include a pervasive identification with femaleness and feelings of discomfort or inappropriateness with maleness. These feelings cause significant distress and disturbances in functioning and aren't simply a rejection of sex-role stereotypes. Gender dysphoria doesn't usually occur as a result of an intersex condition and rarely occurs along with a diagnosis of schizophrenia.

Which nursing data should be given the highest priority for a child with clinical findings related to tubercular meningitis?

signs of increased intracranial pressure (ICP) - Assessment of fever and evaluation of nuchal rigidity are important aspects of care, but assessment for signs of increasing ICP should be the highest priority due to the life-threatening implications. Urinary and fecal incontinence can occur in a child who's ill from nearly any cause but don't pose a great danger to life.

A nurse is caring for a client with glaucoma who has gradually lost eyesight. When assisting the client with ambulation, where should the nurse walk?

slightly in front of the client, offering an elbow for the client to hold - The nurse should use the sighted-guide technique to help a blind client ambulate. In this technique, the nurse walks slightly ahead of the client and offers an elbow for the client to grasp lightly. The nurse should not grasp the client's elbow or walk beside the client because these interventions are not the most effective.

A confused client is brought to the emergency room. The client's has a heart rate of 108/minute and blood pressure 102/68 mm Hg. The family states the client has been taking lithium for manic episodes. Which laboratory results would be most concerning to the nurse?

sodium 150 mEq/L (150 mmol/L), hemoglobin 19.2 g/dL (192 g/L), blood urea nitrogen (BUN) 38 mg/dL (13.57 mmol/L) - Lithium toxicity can occur if the client is dehydrated. It is important for the nurse to recognize the signs of dehydration such as a change in mental status, elevated heart rate, and deceased blood pressure. Elevated sodium level, hemoglobin, and BUN are all due to decease in fluid volume. The remaining labs are not a concern since they do not reflect a decrease in fluid volume status.

A child comes to the clinic with symptoms of TB. Which test should the nurse expect to perform on this client?

sputum culture - Skin tests may be false positive or false negative. Lesions in the lung may not be big enough to be seen on x-ray. The sputum culture for Mycobacterium tuberculosis is the only method of confirming the diagnosis.

A client taking antidepressants for major depression for about 3 weeks now states " I'm feeling better." Which complication should the client be monitored for?

suicidal ideation - After a client has been on antidepressants and is feeling better, he commonly then has the energy for self-harm. Manic depression isn't treated with antidepressants. Nothing in the client's history suggests a potential for violence. There are no signs or symptoms suggesting substance abuse.

A client with severe acute respiratory syndrome privately informs a nurse that he doesn't want to be placed on a ventilator if his condition worsens. The client's wife and children have repeatedly expressed their desire that everything be done for the client. The most appropriate action by the nurse would be to:

support the client's decision. - The nurse is obligated to act as a client advocate. The nurse shouldn't discuss the issue with the client's family unless the client gives permission. Options 2 and 4 oppose the client's wishes and don't demonstrate client advocacy.

A client arrives in the local clinic and reports a chronic cough and fatigue. The client admits to smoking two packs of cigarettes daily for 10 years and also informs the nurse of a 9 kg weight loss over the last 2 months. Which test, required for a definitive diagnosis of cancer, does the nurse prepare the client for?

surgical biopsy - Only surgical biopsy with cytologic examination of the cells can give a definitive diagnosis of the type of cancer. Bronchoscopy gives positive results in only 30% of the cases. Chest x-ray and computerized tomography can identify location but don't diagnose the type of cancer.

How should the nurse instruct the client with unstable angina to use sublingual nitroglycerin tablets when chest pain occurs? "Sit down and then:

take one tablet. If the pain persists after 5 minutes, call 911." - The nurse should instruct the client that correct protocol for using sublingual nitroglycerin involves immediate administration when chest pain occurs. Sublingual nitroglycerin appears in the bloodstream within 2 to 3 minutes and is metabolized within about 10 minutes. The client should sit down and place the tablet under the tongue. If the chest pain is not relieved within 5 minutes, the client should call 911. Although some health care providers (HCPs) may recommend taking a second or third tablet spaced 5 minutes apart and then calling for emergency assistance, it is not appropriate to take two tablets at once. Nitroglycerin acts within 2 to 3 minutes and the client should not wait 15 minutes to take further action. The client should call 911 to obtain emergency help rather than calling the HCP.

The nurse is collecting data on a client who has been experiencing black stools for the past month. The client suddenly reports chest and stomach pain. Which action should the nurse perform first?

take vital signs - The first step of nursing process is data collection. Taking vital signs would determine hemodynamic stability, and monitoring heart rhythm may be indicated based on data collected. Giving nasal oxygen and drawing blood require a health care provider's order and should not be part of a screening evaluation.

A nurse is caring for a 1-day postpartum client. The progress note above informs the nurse that the client is in which phase of the postpartum period?

taking in - The taking-in phase is normally the first postpartum phase. During this phase, the mother feels overwhelmed by the responsibilities of newborn care and is still fatigued from delivery. Taking hold is the next phase, when the client has rested and can learn mothering skills with confidence. Letting go is the final stage, when the client adapts to parenthood, her new role as a caregiver, and her new baby as a separate entity. Holding out is not a valid phase.

A hospitalized client became seriously ill after a nurse inadvertently gave the client another client's medication. The client contacts an attorney and files a lawsuit after recovering from the injury caused by the medication error. Which individuals would most likely be held liable? Select all that apply.

the hospital the nurse - Nurses are always responsible for their actions. In this situation, the nurse did not follow the rights of medication administration: the right patient, the right drug, the right dose, the right route, at the right time. The hospital is liable for negligent conduct of its employee within the scope of employment. Consequently, both the nurse and the hospital are liable. The health care provider, pharmacist, and drug company are not involved in this error.

The physician suspects myasthenia gravis in a client with chronic fatigue, muscle weakness, and ptosis. Myasthenia gravis is associated with:

thymus gland hyperplasia. - Myasthenia gravis, characterized by a failure in transmission of nerve impulses at the neuromuscular junction, has been linked with changes in the thymus gland, stress, and hormonal changes. It isn't associated with poor nutrition, chemotherapy, or viral infection.

A pregnant client arrives in the emergency department and states, "My baby is coming." The nurse sees a portion of the umbilical cord protruding from the vagina. Why should the nurse apply manual pressure to the baby's head?

to relieve pressure on the umbilical cord

A mother comes to the clinic with her 5-year-old son who's complaining of a fever and sore throat. The nurse documents the client's tonsils as 3+. This means they're:

touching the uvula. - Tonsils that touch the uvula are rated 3+. Tonsils barely visible outside the tonsillar pillar are rated 1+. Tonsils between the tonsillar pillar and the uvula are rated 2+. Tonsils that touch each other are given a 4+ rating.

A client has an prescription for 5,000 units of subcutaneous heparin every 12 hours. When injecting heparin subcutaneously, which action should the nurse take?

use a 45- to 90-degree angle - The nurse should inject at a 45- to 90-degree angle, depending on the site and the amount of subcutaneous tissue present. When injecting subcutaneously, the nurse should not aspirate after the injection and should rotate injection sites. The Z-track method is used for I.M. injections that may cause tissue irritation.

A 3-day-old neonate needs phototherapy for hyperbilirubinemia. The nurse is reviewing the plan of care for this neonate. Which interventions would the nurse most likely find?

use of eye patches to prevent retinal damage - The neonate's eyes must be covered with eye patches to prevent damage. The neonate can be removed from the lights and held for feeding. Tube feedings are not necessary. The neonate's temperature should be monitored at least every 2 to 4 hours because of the risk of hyperthermia with phototherapy.

The nurse is assigned to care for a client with amnesia. When preparing to deliver care, which action will best meet the needs of this client?

use short, simple commands when providing instruction - Disruptions in the ability to perform basic care, along with confusion and anxiety, are commonly apparent in clients with amnesia. Offering simple directions to promote daily functions and reduce confusion helps increase feelings of safety and security. Giving this client lots of space may make him or her feel insecure. There's no significant rationale for keeping the client busy all day with no rest periods; the client may become more tired and less functional at other basic tasks. Asking the client many questions that he or she won't be able to answer would just intensify the client's anxiety level.

A nurse is providing cardiopulmonary resuscitation (CPR) to a 4-year-old. What should the nurse do?

use the heel of one hand for sternal compressions - To perform CPR on a child, the nurse should use the heel of one hand and compress at least one-third of the anterior-posterior diameter of the chest. This corresponds to approximately 2 inches (5 cm) in most children. For an adult, the nurse should use the heels of both hands clasped together and compress the sternum at least 2 inches. Either one-person or two-person CPR can be provided to a child. For a child, the nurse should deliver 30 chest compressions followed by two breaths instead of 12 breaths/minute.

A postpartum client who had a cesarean birth reports right calf pain to the nurse. The nurse observes that the client has nonpitting edema from her right knee to her foot. Based on this finding, the nurse would anticipate which test as the priority?

venous duplex ultrasound of the right leg - Right calf pain and nonpitting edema may indicate deep vein thrombosis (DVT). Postpartum clients and clients who have had abdominal surgery are at increased risk for DVT. Venous duplex ultrasound is a noninvasive test that visualizes the veins and assesses blood flow patterns. A venogram is an invasive test that utilizes dye and radiation to create images of the veins; it wouldn't be the first test to perform. Transthoracic echocardiography looks at cardiac structures and isn't indicated at this time. Right calf pain and edema are symptoms of venous outflow obstruction, not arterial insufficiency.

A client with peptic ulcer disease is prescribed aluminum-magnesium complex. When teaching about this antacid preparation, the nurse should instruct the client to take it with:

water. - Water helps transport an antacid to the stomach. The client shouldn't take an antacid with fruit juice or a food rich in vitamins C or D because the antacid may impair absorption of important nutrients in the juice or food.

A nurse is caring for a client who underwent a nephrectomy. While gathering data about client's response to the surgery, the nurse should stay alert for which signs and symptoms of hemorrhage?

weak, irregular pulse; cool, moist skin; and hypotension - A weak, irregular pulse; cool, moist skin; and hypotension are all signs of hemorrhage in a client who underwent a nephrectomy. Hemorrhage may also cause cyanosis, nausea, vomiting, and dilated (not constricted) pupils. Although hemorrhage produces tachycardia and hemoptysis, it usually results in irregular, labored respirations rather than even, unlabored ones. Hemorrhage also results in restlessness and confusion, along with decreased urine output and skin that is cool and moist.

A nurse is preparing to reinforce education with a client who uses alcohol. What client data would be most important for the nurse to obtain?

willingness to learn - It's important to know if the client's current situation helps or hinders his potential to learn. Sleep patterns, decision making, and communication skills aren't factors that must be assessed before educating clients about addiction.

The nurse has auscultated the first heart sound. When does the nurse determine this sound is occurring?

with closure of the mitral and tricuspid valves - The first heart sound occurs during systole with closure of the mitral and tricuspid valves. The second heart sound occurs during diastole with closure of the aortic and pulmonic valves. The third heart sound is heard early in diastole. The fourth heart sound is heard late in diastole and may be a normal finding in children.

A client with a peptic ulcer is about to begin a therapeutic regimen that includes a bland diet, antacids, and ranitidine. Before the client is discharged, the nurse should provide which instruction?

"Avoid aspirin and products that contain aspirin." - Aspirin is a gastric irritant and should be avoided by clients with peptic ulcer to prevent further erosion of the stomach lining. The client should eat small, frequent meals rather than three large ones. Antacids and ranitidine prevent acid accumulation in the stomach; they should be taken even after symptoms subside. Caffeine should be avoided because it increases acid production in the stomach.

A nurse is caring for a client who is receiving spironolactone (Aldactone) to treat hypertension. Which instruction should the nurse give the client?

"Avoid salt substitutes." - Because spironolactone is a potassium-sparing diuretic, the client should be taught to avoid salt substitutes because they have high potassium contents. Foods high in potassium and potassium supplements should also be avoided. Sodium restrictions should continue to reduce fluid volume overload.

When the nurse is reinforcing education about fluid intake with the parents of a child with a urinary tract infection (UTI), which statement by a parent would indicate the need for further education?

"I should offer my child carbonated beverages about every 2 hours." - Carbonated or caffeinated beverages are avoided because of their potentially irritating effect on the bladder mucosa. Adequate fluid intake is always indicated during an acute UTI. It is recommended that a person drink approximately 50 mL/lb of body weight daily. The child should primarily drink clear liquids.

The nurse observes many cuts and bruises on the back, arms, and legs of a pregnant client. The client tells the nurse, "I was cleaning and a box of supplies fell on me." Which response by the nurse is most appropriate?

"It's our responsibility to maintain your confidentiality and ensure your safety." - The client's bruises suggest that she might be a victim of abuse. The nurse should further explore this possibility by informing the client that nursing responsibilities include ensuring client safety and confidentiality. Stating that it must have been a very big box is condescending and suggests that the client is lying. The nurse, not the client, should inform the health care provider of the accident since it was the nurse who observed the bruising. The statement about someone beating her up assumes that the client was abused without gather more information about the situation.

A client is having trouble sleeping. Which nursing intervention should the nurse suggest to the client?

"Maintain the same schedule for waking and sleeping." - Keeping the same sleep-wake schedule each day can help to maximize the ability of the client having trouble sleeping to sleep without disturbance. The client should take a warm bath in the evening before going to bed to help promote sleep, not in the morning. Exercising in the evening can cause difficulty sleeping; ideally, exercise should be performed earlier in the day. Naps should be limited to 1 or 2 hours and should be taken at the same time each day.

The nurse is obtaining information from a pregnant client who is at 38 weeks' gestation and believes that she is going into labor. Which statement made by the client should be immediately reported to the health care provider?

"My membrane ruptured 2 days ago." - The client who has a ruptured membrane more than 24 hours ago is at great risk for infection and should be placed on antibiotics. The results could be detrimental for the mother as well as the infant. Having a previous miscarriage does not generally affect the outcome of the labor. Indigestion does not affect labor and is not an indicator of complication. It is normal to expel a mucous plug up until the onset of labor.

A nurse is instructing a client about taking oral corticosteroids to control severe chronic asthma. Which statement indicates that the client understands the treatment plan?

"My other health care providers should be informed that I'm taking a corticosteroid." - The client's other health care providers need to know that the client is taking a corticosteroid to control asthma because this class of drugs can suppress inflammatory and immune responses. To reduce GI symptoms, the client should take the corticosteroid with food or milk, never on an empty stomach. Corticosteroids suppress, rather than build up, the immune system. To prevent an adrenal crisis, corticosteroid use must be discontinued by gradually reducing drug dosage, especially when the client has been on long-term corticosteroid therapy.

During a health fair, the nurse discusses breast self-examination with a group of young women. Which statement should the nurse include when reinforcing the importance of performing breast self-examination?

"Performing the examination will help you to become familiar with your breast so that changes from previous exams can be identified." - Women are instructed to perform breast self-examinations to discover changes that have occurred in the breast since the previous exam. Only a health care provider can diagnose lumps that are cancerous, areas of thickness or fullness that signal the presence of a malignancy, or masses that are fibrocystic as opposed to malignant.

A female client is scheduled to undergo abdominal surgery for possible ruptured tubal pregnancy. A nurse is witnessing the client's signature on a consent form. Which client statement would the nurse interpret as the best indicator of the client's informed consent?

"The health care provider may have to remove my fallopian tube if it has burst." - The nurse witnessing informed consent should evaluate the client's understanding of the surgical procedure by having her repeat what the health care provider told her. In this situation, the client should be able to tell the nurse what will occur during the procedure and the associated risks. The client stating that "the health care provider may have to remove my fallopian tube if it has burst" indicates the client has a sufficient understanding of the procedure to provide informed consent. The other comments do not indicate client understanding of the procedure. The statement about the health care provider having performed the procedure "a lot" says nothing about the client's understanding about what will happen during surgery. Pain is possible with any surgery. If the client's tube is removed, fertility may be affected.

A nurse is caring for a client after evacuation of a hydatidiform mole. Which discharge instruction would be most appropriate for the nurse to reinforce with the client?

"Use birth control for at least 1 year." - After experiencing a hydatidiform molar pregnancy, the client should be counseled to use a reliable method of birth control for at least 1 year. The client is at risk for choriocarcinoma, so her hCG levels need to be monitored weekly until negative values are obtained, and then monthly for 1 to 2 years. Sterilization is not necessary after hydatidiform mole. If hCG levels remain low, the client may try to become pregnant after 1 year. The risk of recurrence of a hydatidiform mole is low.

A client who sustained an L1 to L2 spinal cord injury in a construction accident asks a nurse if he'll ever be able to walk again. Which response by the nurse is appropriate?

"What has your physician told you about your ability to walk again?" - The nurse should respond by asking the client what he's already been told about his ability to walk again. After assessing the client's knowledge, she can better respond to the client's questioning. Option 1 provides the client with false hope, and option 2 may place the client on the defensive. Option 4 is an inappropriate response.

A 15-year-old girl visits the neighborhood clinic seeking information on how to prevent pregnancy. How should the nurse respond to her request?

"What precautions are you taking now when you have sex?" - An approach that requests only the information necessary to answer the teenager's question is nonthreatening, nonjudgmental, and may enhance the adolescent's willingness to talk about her experiences. This enables the nurse to better evaluate the teenager's needs. The nurse should ask only about the precautions currently being taken. Asking the adolescent what she would like to know assumes that she knows what she needs to know. The birth control precautions her friends are taking are irrelevant at this time. Asking the teen if her parents know she is having sex may make her defensive and fearful of seeking help.

A client with adrenal hypofunction has been asked to participate in a research study for a new medication. The client is unsure about participating in the study. What would be an appropriate response for the nurse to make to this client?

"You have the right to refuse to participate in the study." - The client has the right to refuse to participate in a research study. The nurse should not make the client feel guilty by stating that the client has a responsibility to other clients. The nurse may not know the details of the research study, such as whether the client will get paid or get free health care for participating. Making these statements wouldn't be appropriate.

A client with primary diabetes insipidus is prescribed desmopressin. Which instruction should the nurse provide before the client is discharged?

"You may not be able to use desmopressin nasally if you have nasal discharge or blockage." - Desmopressin may not be absorbed if the intranasal route is compromised. Although diabetes insipidus is treatable, the client should wear medical identification and carry medication at all times to alert medical personnel in an emergency and ensure proper treatment. The client must continue to monitor fluid intake and output and receive adequate fluid replacement.

A client with a history of colon cancer has a permanent colostomy. The nurse must irrigate the colostomy to prepare the client for diagnostic testing. When irrigating, how far into the stoma should the nurse insert the lubricated catheter?

2" to 4" - When irrigating a colostomy, the nurse should insert the catheter 2" to 4" into the stoma. Inserting it less than 2" may cause leakage. Inserting it more than 4" may cause trauma to the intestinal mucosa.

Which client situation requires the nurse to file an incident report?

A family member who is visiting a client was found on the floor in the client's room. - An incident report is a record of an accident or unusual events that occur in an agency. Giving oral medication via peg tube is not unusual. This is nursing judgment and does not warrant an incident report. Client on bed rest who is not ambulatory transferred to a recliner is not an unusual occurrence. There is no change in activity level with the move. A pureed diet is a step down from a chopped diet and can be done by a nurse. A family member found on the floor is an unusual occurrence and needs to be documented on an incident report form.

An unresponsive client has been diagnosed with a probable drug overdose complicated by alcohol ingestion. What should be the priority nursing intervention?

Administer I.V. naloxone. - If the client took opioids, giving naloxone could reverse the effects and awaken the client. I.V. fluids will most likely be administered, and he'll be closely monitored over a period of several hours to several days. A drug screen should be drawn in the emergency department, but results may not come back for several hours.

A nurse is preparing to reinforce education with a 13-year-old child with asthma on how to administer breathing treatments. Which principle should the nurse keep in mind when planning the education session?

Adolescents are worried about appearing different from their peers. - Adolescents have a strong need to belong, and they seek social approval from their peers. Knowing this will help the nurse construct an effective teaching plan. Adolescents are capable of following detailed instructions. According to Piaget, adolescents are at the formal operations stage and are capable of deductive, reflective, and hypothetical reasoning. Fine motor coordination is well developed by adolescence. According to Erikson's stages of psychosocial development, adolescence is the stage of identity versus role confusion. During this stage, the adolescent strives toward establishing a sense of identity.

The nurse is reinforcing instruction for a client on a 3-point gait using crutches. The client demonstrates an understanding when placing weight on what part of the body?

palms of the hands - To avoid damage to the brachial plexus nerves in the axilla, the palms of the hands should bear the client's weight. Minimal weight should be placed on the affected leg.

A client on long-term mechanical ventilation becomes frustrated when trying to communicate. Which nursing intervention should be performed to assist the client?

Ask the client to write, use a picture board, or spell words with an alphabet board. - Offering an alternative method of communication, such as writing or using a picture or alphabet board, helps the client on long-term mechanical ventilation to feel more in control, thereby relieving frustration. Assuring the client that everything will be all right offers false reassurance; telling the client not to be upset minimizes the client's feelings. Neither of these methods helps the client to communicate. The family members of a client with an endotracheal tube or tracheostomy tube are also likely to encounter difficulty interpreting the client's communications. Making them responsible for interpreting the client's attempts at communication may frustrate the family. The client may be weaned off a mechanical ventilator only when the physiologic parameters for weaning have been met.

A primigravid client is admitted to the labor and delivery area in the early first stage of labor. She is breathing with each contraction. Which action taken by the nurse helps the client deal with the pain of labor?

Assist the client in performing effleurage. - Effleurage, gentle massage of the abdomen and thigh, is soothing to the mother during labor. Kegel exercises tighten the pelvic floor muscles, needed after birth and not during labor. Pushing before the cervix is fully dilated can cause swelling and tearing of the cervix. Supine position can cause compression of the abdominal vessels, leading to hypotension.

While administering morning medications, a nurse enters the room of a client who recently had a thyroidectomy. She observes that the client is sitting up in bed but appears unresponsive. After confirming unresponsiveness, what should the nurse do next?

Call for help. - After determining unresponsiveness, the nurse's next step should be to call for help. This would summon needed assistance and possibly the cardiac arrest team. Any nurse can institute emergency resuscitation procedures; therefore, calling the nurse assigned to the client would not be appropriate and could waste valuable time. Repositioning the client flat in bed would be the next step after calling for help. After the nurse opens the airway and checks for breathing, she should check the client for a pulse.

A client who has experienced a stroke is unable to move without help. Which intervention should the nurse perform to reduce this client's risk for developing a common complication of immobility?

Change the client's position every 1 to 2 hours. - Pressure ulcers occur rapidly and the most important intervention to prevent pressure ulcers is frequent position changes, which relieves pressure on the skin and underlying tissues. The client should be turned every 1 to 2 hours. If pressure is not relieved, capillaries become occluded, reducing circulation and oxygenation of the tissues and resulting in cell death and ulcer formation. During passive ROM exercises, the nurse moves each joint through its range of movement, which improves joint mobility and circulation to the affected area but does not prevent pressure ulcers. Adequate hydration is necessary to maintain healthy skin and ensure tissue repair if skin breakdown does occur. A footboard prevents plantar flexion and foot drop by maintaining the foot in a dorsiflexed position.

A client has just undergone a bronchoscopy. Which priority nursing intervention will the nurse perform at this time?

Check airway patency. - After a bronchoscopy, checking the client's airway patency is the most important nursing intervention. After checking airway patency, the nurse should monitor the client's breathing and check vital signs every 15 minutes until the client is stable. After these initial interventions, the nurse should check the level of consciousness. Reviewing the client's medical record for any allergies should be completed prior to starting the procedure.

A nurse caring for a client during the fourth stage of labor observes that the client has changed pads four times in the past hour and is reporting dizziness. What initial actions should the nurse take? Select all that apply.

Check vital signs. Check the fundal height. Notify the RN. - Obtaining vital signs and checking the fundus are required actions to establish the problem. The nursing process requires assessment of the problem first before any other action. Initiating IV therapy is outside the scope of practice for an LPN, as is starting a blood transfusion.

Which foods are contraindicated for a client taking tranylcypromine?

Chicken livers, Chianti wine, and beer - A client taking a monoamine oxidase inhibitor antidepressant, such as tranylcypromine, shouldn't eat foods containing tyramine. Such foods include chicken livers, Chianti wine, beer, ale, aged game meats, broad beans, aged cheeses, sour cream, avocados, yogurt, pickled herring, yeast extract, chocolate, excessive caffeine, vanilla, and soy sauce. The client also must refrain from taking cold and hay fever preparations that contain vasoconstrictive agents.

When inspecting a client's skin, the nurse finds a vesicle on the client's arm. How will the nurse document his findings about this client's vesicle?

Circumscribed, elevated, and filled with serous fluid - A vesicle is a circumscribed skin elevation filled with serous fluid. A flat, nonpalpable, colored spot is a macule. A solid, elevated, circumscribed lesion is a papule. An elevated, pus-filled, circumscribed lesion is a pustule.

A 25-year-old client comes to the emergency department with her clothes torn. She has visible cuts, bruises, and profuse vaginal bleeding. A nurse suspects that this client has been raped. What should the nurse do?

Collect forensic evidence. - The nurse should notify a physician and collect forensic evidence before it's destroyed. After collecting evidence, she should assist the client with bathing and notify a rape intervention specialist or the psychiatrist who is on call. If ice packs have been prescribed, she can apply them to the bruised areas to reduce swelling.

A nurse on the orthopedic floor is caring for a group of clients who are in various stages of recovery after knee replacement surgery. One client is ready for discharge. How should the nurse proceed with discharge planning?

Complete the discharge instructions for the client who is being discharged, and allow time for him to ask questions. - The nurse should first provide for the needs of the client who is ready for discharge by completing the discharge instructions and allowing time for questions. She can continue teaching the other clients after she discharges the client who is prepared for discharge. Discharge teaching shouldn't be delayed until the day of discharge; it should occur throughout the course of hospitalization. The nurse can provide discharge teaching without a physician's order.

Hyperbaric oxygen therapy increases the blood's capacity to carry and deliver oxygen to compromised tissues. Which condition would benefit from hyperbaric oxygen therapy?

Compromised skin graft - A compromised skin graft could benefit from hyperbaric oxygen therapy, because increasing oxygenation at a wound site promotes healing. Hyperbaric oxygen therapy isn't indicated for malignant tumors, pneumonia, or hyperthermia.

After a 33-year-old male client displays violent behavior, he is placed in restraints. Which intervention by the nurse takes priority for this client?

Continuously monitoring the client - A client who is placed in behavioral restraints must be monitored continuously by a member of the health care team. The team member must provide full documentation of the monitoring that occurred during the restraint episode. The nurse should notify the case manager of the restraint episode; however, doing so doesn't take priority over continuously monitoring the client.

A client sees a dermatologist for a skin problem. Later, the nurse reviews the client's chart and notes that the chief concern was intertrigo. This term refers to which condition?

Irritation of opposing skin surfaces caused by friction - Intertrigo refers to irritation of opposing skin surfaces caused by friction. Spontaneously occurring wheals occur in hives. A fungus that enters the skin surface and causes infection is a dermatophyte. Inflammation of a hair follicle is called folliculitis.

Nurses are aware that older clients' physiological changes of aging can complicate drug therapy. Which statement that describes how elderly clients react to medications must nurses be cognizant of?

Elderly clients are at risk for increased adverse effects to medications. - As individuals become older, their livers metabolize drugs at a slower rate. Cumulative effects can occur and increase the risk of adverse effects. Elderly clients typically need lower dosages not higher. Level of activity typically doesn't affect a person's reaction to medication.

A nurse on the psychiatric unit realizes that she typically fails to administer medications according to schedule. What's the best way for the nurse to improve her medication administration practice?

Evaluate her current practice and devise an improvement plan. - The nurse should evaluate her current medication administration practice and then devise an improvement plan. The nurse shouldn't change administration times to accommodate client care schedules. Reviewing medication administration principles won't improve the efficiency of her current practice. Asking a colleague to track the amount of time it takes her to administer medications is inappropriate and may cause an administration error.

While assessing a home care client, the nurse notices a family member smoking near the client's oxygen. Which action by the nurse is best?

Explaining to the family member that oxygen is flammable and smoking must be avoided - The nurse should explain that oxygen is flammable and smoking must be avoided. Asking the family member to smoke outside isn't sufficient. Without an explanation, the family member might continue to smoke near the oxygen when the nurse isn't present. Failing to intervene might cause serious harm to the client. Posting a "No Smoking" sign on the delivery system isn't sufficient.

An 8-year-old client has tested positive for West Nile virus infection. The nurse suspects the client has the severe form of the disease when she recognizes which signs and symptoms?

Fever, muscle weakness, and change in mental status - Severe West Nile virus infection (also called West Nile encephalitis or West Nile meningitis) affects the central nervous system and may cause headache, neck stiffness, fever, muscle weakness or paralysis, changes in mental status, and seizures. Such signs and symptoms as fever, rash, malaise, anorexia, nausea and vomiting, and lymphadenopathy suggest the mild form of West Nile virus infection.

The nurse educator is teaching a group of nursing students about baclofen therapy. The nurse educator will include baclofen as an analogue of which neurotransmitter?

Gamma aminobutyric acid (GABA) - Baclofen is an analogue of the neurotransmitter GABA.

A baby undergoes surgery to correct an esophageal atresia and tracheoesophageal fistula. Which nursing diagnosis has the highest priority during the first 24 hours postoperatively?

Ineffective airway clearance - Ineffective airway clearance is the priority nursing diagnosis in the immediate postoperative period. The infant's airway must be carefully assessed and frequent suctioning may be necessary to remove mucus while taking care not to pass the catheter as far as the suture line. Assess breath sounds, respiratory rate, skin color, and ease of breathing. Because of the risk of edema and airway obstruction, keep a laryngoscope and endotracheal intubation equipment readily available. Imbalanced nutrition, Interrupted breast-feeding, and Hypothermia are important diagnoses during the postoperative period but only after a patent airway is ensured.

The nurse is administering medication to a 6-week-old infant. Which factor is the nurse most correct to identify as likely to decrease the infant's ability for drug metabolism?

Inefficient liver function - When administering medications to pediatric clients, the nurse must understand pharmacokinetics. Inefficient liver function potentially decreases drug metabolism in the infant. As the liver matures during the first year of life, drug metabolism improves. Decreased glomerular filtration and increased tubular secretion may affect drug excretion rather than metabolism. Reduced protein-binding ability may affect drug distribution but not metabolism.

A client in the third trimester has come to the clinic for a routine checkup. The nurse reinforces the importance of lying on the left side when resting or sleeping. Which rationale should the nurse give to the client for this position?

It will prevent compression of the vena cava. - The weight of the pregnant uterus is sufficiently heavy to compress the vena cava, which could impair blood flow to the uterus, and subsequently interfere with supplying sufficient oxygen to the fetus. The side-lying position, especially the left side-lying position, helps to prevent compression, thereby ensuring adequate blood flow and oxygenation to the fetus. The side-lying position has not been shown to prevent fetal anomalies, nor does it facilitate bladder emptying or heartburn.

The nurse caring for a primipara in late first stage of labor notes left occiput-anterior (LOA) position, 7 cm dilated, and at +2 station. Which finding should be reported to the health care provider?

Labor is progressing well. - Labor is progressing well. The head is below the ischial spines. The head has passed level 0, which is engagement; therefore, it is not too big and descent is not prevented. The client, a primipara, is not ready to deliver at 7 cm dilated. There is no indication for a cesarean section.

The nurse is caring for multiple clients that have been determined to be at risk for falls. Which intervention(s) should the nurse institute to prevent falls? Select all that apply.

Orient client to the nurse call system and encourage its use. Ensure the nurse call system is within reach. Keep hospital bed in low position. - Orienting the client to the call system, keeping the call system within reach, and keeping the bed at low position empowers the client to seek assistance and prevent fall. Keeping side rails up for ambulatory clients is a restraint and will complicate falls. Keeping the room dark does not filter noise; rather, it inhibits the client's ability to see clutter and will potentiate falls. The room needs to be adequately lighted.

A client is receiving oxygen by way of a nasal cannula at a rate of 2 L/minute. How can the nurse promote oxygenation in this client? Select all that apply.

Position client in Fowler's position. Decrease anxiety in the client. Set the line marked "2" so it cuts the ball in half. - Positioning client in Fowler's position will allow for maximum chest expansion that eases respirations. Decreasing anxiety in the client will also ease the respiratory effort. The oxygen flow rate is set by centering the indicator on the line marked "2." Having any part of the ball touching the line marked "2" is not the correct dose; giving a client an extra dose of narcotic is not safe and is considered to be a medication error.

A nurse is reviewing the plan of care for a neonate receiving phototherapy. Which action would be most important for the nurse to do?

Reposition the neonate frequently. - Phototherapy works by the chemical interaction between a light source and the bilirubin in the neonate's skin. Therefore, the larger the skin area exposed to light, the more effective the treatment. Changing the neonate's position frequently ensures maximum exposure. Because the neonate loses water through the skin as a result of evaporation, the amount of formula or water may need to be increased. The neonate is typically undressed to ensure maximum skin exposure. The eyes are covered to protect them from light, and an abbreviated diaper is used to prevent soiling. The skin should be clean and patted dry. Use of lotions would interfere with phototherapy.

A nurse is assisting with the education of a client who receives a dose of human Rho(D) immune globulin at 28 weeks' gestation to prevent Rh isoimmunization. What should the nurse inform the client regarding the reason for administering the medication?

Rh-positive fetal blood crosses into maternal blood, stimulating maternal antibodies. - Rh isoimmunization occurs when Rh-positive fetal blood cells cross into the maternal circulation and stimulate maternal antibody production. In subsequent pregnancies with Rh-positive fetuses, maternal antibodies may cross back into the fetal circulation and destroy the fetal blood cells.

A nurse walking down the hospital corridor hears a call for help from a client who was admitted with vascular insufficiency. She finds the client lying on the floor. The nurse assesses the client and notifies the health care provider of the incident. What information should the nurse chart on the incident report form?

The client was observed on the floor. - The incident report should contain a factual description of what the nurse observed. In this case, the nurse saw the client lying on the floor. Options 1, 3, and 4 are interpretations of the situation, not the facts as found by the nurse.

A client begins experiencing physical symptoms believed to be caused by psychological distress. This client is most likely experiencing which disorder?

Somatic symptom disorder - Somatization occurs when a psychological state causes or contributes to the development of physical symptoms. Depersonalization/derealization disorder is characterized by a profound sense of detachment from reality. Functional neurologic symptom disorder is marked by a loss of or change in voluntary motor or sensory functioning that has no physiologic cause. Body dysmorphic disorder is characterized by a preoccupation with an imagined or slight defect in physical appearance.

The care plan for an older adult client who has had a stroke and is paraplegic indicates that the client should be turned at least every 2 hours. What outcome does the nurse hope to achieve with this intervention?

The client will not develop skin breakdown, pneumonia, and urinary tract infections (UTIs). - Immobility can lead to severe physiological problems such as skin breakdown, pressure ulcers, pneumonia, and UTIs. Therefore, frequent turning helps to minimize the effects of immobility. Immobility doesn't necessarily mean there's lack of stimuli. Although venous stasis can occur with immobility, heart failure doesn't develop as a result of venous stasis. Turning the client may improve how the client feels, but this isn't the primary rationale for this intervention.

A newly graduated nurse is working with the team that sets up organ donation. What is the mostimportant concept this nurse must understand about organ or tissue donation before working with families?

The family is offered an opportunity to speak with an organ procurement coordinator. - The family should be offered an opportunity to speak with an organ procurement coordinator. An organ procurement coordinator is very knowledgeable about the organ donation process and dealing with grieving family members. Health care provider support in the process is desirable, but consent or written orders aren't necessary for a referral to the organ procurement organization. The individual requesting has to believe in the benefits of organ donation and support the process. Approaching the family should only occur when the family members are made aware of the client's condition and prognosis. Approaching a family member when he believes that there's still hope for recovery will only result in a negative outcome.

A client with a pulmonary embolism has received a thrombolytic medication. What is the mostimportant concept the nurse should reinforce with this client and his family at this time?

The medication was given to break apart the blood clot blocking the pulmonary artery. - A thrombolytic medication is given I.V. to break apart or dissolve blood clots. It isn't given orally, doesn't prevent future clots from forming, and has no effect on the bronchial tubes.

The nurse realizes she's 1 hour late in administering a dose of medication for her 4-year-old client. She gives the medication immediately and assesses the client. The client isn't harmed by the delay. Which action should the nurse take next?

The nurse should follow facility procedures for reporting an error. - Although no harm came to the client, this scenario is an example of a medication error. The nurse should follow the facility's procedure for reporting the error. Reporting the error allows the facility to assess the system's causes of medication errors, and isn't meant to place blame on any one person. The nurse, in this instance, doesn't need to notify the physician because there was no harm to the client. The nurse shouldn't document in the client's chart that an error took place; doing so may place her at risk in case of a lawsuit.

A 2-year-old child is diagnosed with bronchiolitis caused by respiratory syncytial virus (RSV). The client has an 8-year-old sibling. Which statement is correct?

The siblings should be separated to prevent the spread of the infection. - RSV is communicable among children and adults, so the siblings should be separated to prevent the spread of the infection. Older children and adults may have mild symptoms of the disorder. Hospitalization is indicated only for children who need oxygen and I.V. therapy.

After a client is admitted with an adrenal malfunction, the nurse demonstrates an understanding of the function of the adrenal gland by identifying which hormones as being released by the adrenal medulla?

epinephrine and norepinephrine - The medulla of the adrenal gland causes the release of epinephrine and norepinephrine. Glucocorticoids, mineralocorticoids, and androgens are released from the adrenal cortex. T4, T3, and calcitonin are secreted by the thyroid gland. The islet cells of the pancreas secrete insulin, glucagon, and somatostatin.

A nurse is preparing a client for a stress test. Which is an appropriate nursing intervention?

Verify that a consent form has been signed. - A stress test is a noninvasive test that consists of a client walking on a treadmill while an electrocardiogram recording is done. Because a consent form is required, verify that it is signed and in the client's chart. The client will not receive a sedative for this test, and shaving the inguinal area and removing metal objects are not required.

A client is admitted to the facility for investigation of balance and coordination problems, including possible Meniere disease. When reviewing this client's chart, the nurse expects to find which signs and symptoms?

Vertigo, tinnitus, and hearing loss - Meniere disease, an inner ear disease, is characterized by the symptom triad of vertigo, tinnitus, and hearing loss. The combination of vertigo, vomiting, and nystagmus suggests labyrinthitis. Meniere disease rarely causes pain, blurred vision, or fever.

A nurse is reinforcing education provided to a client about reducing risk factors for coronary artery disease. Which risk factor does the nurse inform the client is nonmodifiable?

age - Age is a risk factor that can't be changed. Hypertension, type A personality, and smoking factors can be controlled.

A client with anorexia nervosa is admitted to the emergency department. Which finding does the nurse anticipate?

amenorrhea for 1 year - Anorexia nervosa is an eating disorder characterized by self-imposed starvation with subsequent emaciation, nutritional deficiencies, and atrophic and metabolic changes. Typically, the client is hypotensive and dehydrated (e.g., dry mucous membranes). Clients with anorexia nervosa often cease to menstruate (amenorrhea). Depending on the severity of the disorder, anorexic clients are at risk for circulatory collapse (indicated by hypotension), dehydration, and death. Diaphoresis and hypertension would not be expected in this client. Bulimia nervosa is an eating disorder characterized by binge eating followed by self-induced vomiting (purging).

A client admitted to the mental health unit has exhibited physical behaviors that put the client and others at risk. The nurse applies four-point restraints on the client without obtaining a health care provider's order or the client's consent. What situation is the nurse at risk for due to these actions?

battery - Battery is intentional and wrongful physical contact with a person that entails an injury or offensive touching. Performing treatment without permission or receiving informed consent from the client might constitute both assault and battery. Judgments of battery suits have been based on the application of restraints to confused clients. The other options do not meet the definition described in the question.

A client in labor is receiving magnesium sulfate as an intravenous infusion. Which medication should the nurse ensure is at the bedside while the magnesium sulfate is being infused?

calcium gluconate - Calcium gluconate should be kept at the bedside while a client is receiving a magnesium infusion. If magnesium toxicity occurs, administering calcium gluconate is an antidote. Oxytocin is the synthetic form of the naturally occurring pituitary hormone used to initiate or augment uterine contractions. Terbutaline is a smooth muscle relaxant sometimes used to relax the uterus, especially for preterm labor and uterine hyperstimulation. Naloxone is an opiate antagonist administered to reverse the respiratory depression that sometimes follows doses of opiates.

The nurse is caring for a client that is suspected of having prerenal acute renal failure. Which finding in the client's history and physical would the nurse recognize as a potential cause?

decreased cardiac output - Prerenal acute renal failure refers to renal failure due to an interference with renal perfusion. Decreased cardiac output causes a decrease in renal perfusion, which leads to a lower glomerular filtration rate. Atherosclerosis and rhabdomyolysis are renal causes of acute renal failure. Prostatic hyperplasia would be an example of a postrenal cause of acute renal failure.

The red blood cell (RBC) production in a client with chronic renal failure (CRF) has decreased. The nurse should monitor this client for:

fatigue and weakness. - RBCs carry oxygen throughout the body. Decreased RBC production diminishes cellular oxygen, leading to fatigue and weakness. Diarrhea, nausea, and vomiting may occur in CRF but don't result from faulty RBC production. Thrush, which signals fungal infection, and circumoral pallor, which reflects decreased oxygenation, aren't signs of CRF. Clients with CRF commonly experience hyperkalemia, not hypokalemia.

A nurse is assisting with developing a care plan for a client with Hepatitis A. What is the main route of transmission of this virus?

feces - The hepatitis A virus is transmitted by the fecal-oral route, primarily through ingestion of contaminated food or liquids. It isn't transmitted via sputum, blood, or urine.

The nurse is reinforcing education with parents of a child with growth hormone deficiency. What sport should the nurse encourage?

gymnastics - Children with growth hormone deficiency can be just as active as other children if directed to size-appropriate sports, such as gymnastics, swimming, wrestling, or soccer.

A nurse is caring for a client with lower back pain who is scheduled for myelography using a water-soluble contrast dye. After the test, the nurse should place the client in which position?

head of the bed elevated 45 degrees - After a myelogram, positioning of the client depends on the dye injected. When a water-soluble dye such as metrizamide is injected, the head of the bed should be elevated to a 45-degree angle to slow the upward dispersion of the dye. The other positions are contraindicated when a water-soluble contrast dye is used.

A client injured in a train derailment is admitted to an acute care facility with a suspected dysfunction of the lower brain stem. The nurse should monitor this client closely for:

hypoxia. - Lower brain stem dysfunction alters bulbar functions, such as breathing, talking, swallowing, and coughing. Therefore, the nurse should monitor the client closely for hypoxia. Temperature control, vision, and gait aren't lower brain stem functions.

Immediately after giving an injection, a nurse is inadvertently stuck with the needle. When is the best time to test the nurse for human immunodeficiency virus (HIV) antibodies?

immediately, and then again in 3 months - The nurse should be tested immediately to determine whether a preexisting infection is present, and then again in 3 months to detect seroconversion as a result of the needlestick. Waiting 2 weeks to perform the first test is too late to detect preexisting infection. Retesting sooner than 3 months may yield false-negative results.

A nurse is caring for a client In the early stages of Alzheimer's disease (AD). Which client behavior will the nurse most likely observe?

inability to remember breakfast food - Significant recent memory impairment, indicated by the inability to verbalize remembrances after several minutes to an hour, can be observed in the early stages of Alzheimer's disease. Difficulty writing, inability to stay focused on the topic, and rambling speech are expected symptoms of delirium.

A client with endocarditis is preparing for discharge from the hospital. The client has had instruction about symptoms that may signal further cardiac complications. Which symptoms indicate potential cardiac complications? Select all that apply.

increasing fatigue swelling in the lower extremities - The client with endocarditis is at risk for the development of further cardiac complications. Increasing fatigue may signal cardiac insufficiency. Swelling and edema are associated with heart failure. The client with endocarditis will be discharged to home with continued antibiotic therapy. A skin rash, vomiting, and diarrhea signal possible reactions to the antibiotic therapy and are not likely cardiac in nature.

The student nurse describes how to position a client for a lumbar puncture to the primary care nurse. Which description indicates that the student nurse understands the correct positioning for the procedure?

lateral recumbent, with flexed knees - To maximize the space between the vertebrae, the client should be placed in a lateral recumbent position during a lumbar puncture, with the knees flexed toward the chin. The needle is inserted between L4 and L5. The other positions do not allow as much space between L4 and L5.

The nurse is caring for a child with acute rheumatic fever. Which data does the nurse anticipate in this child?

leukocytosis - Leukocytosis can be seen as an immune response triggered by colonization of the pharynx with group A streptococci. The electrocardiogram will show a prolonged PR interval as a result of carditis. A low-grade fever is a minor manifestation. There should be no change in red blood cell count. The inflammatory response will cause an elevated erythrocyte sedimentation rate.

While administering medications to a group of clients admitted with anxiety, a nurse hears someone call for help. The nurse should respond by:

locking the medication cart and responding to the call for help. - A call for help in the hospital typically means a life-threatening situation is occurring. Therefore, the nurse should ensure the safety of the other clients by locking the medication cart and should then respond to the call for help. The nurse shouldn't assume that someone else will respond. The nurse shouldn't leave the client to whom she's administering medications until his safety is ensured.

After a traumatic spinal cord injury, a client requires skeletal traction. When caring for this client, the nurse must:

maintain traction continuously to ensure its effectiveness. - The nurse must maintain skeletal traction continuously to ensure its effectiveness. The client should be repositioned every 2 hours to prevent skin breakdown. Traction weights must hang freely to be effective; they should never be supported. The nurse should increase, not restrict, the client's fluid and fiber intake (unless contraindicated by a concurrent illness) to prevent constipation associated with complete bed rest.

When collecting data on a neonate for signs of diabetes insipidus, a nurse should recognize which symptom as a sign of this disorder?

polyuria and polydipsia - The cardinal signs of diabetes insipidus are polyuria and polydipsia. Hypernatremia, not hyponatremia, occurs with diabetes insipidus. Jaundice occurs because of abnormal bilirubin metabolism, not diabetes insipidus. Hyperchloremia, not hypochloremia, occurs with diabetes insipidus.

The nurse is caring for a client with quadriplegia. Which nursing intervention takes priority?

preventing atelectasis - Clients with quadriplegia have paralysis or weakness of the diaphragm, abdominal, or intercostal muscles. Maintenance of airway and breathing takes top priority. Although forcing fluids, maintaining skin integrity, and obtaining adaptive devices for more independence are all important interventions, preventing atelectasis has greater priority.

A client whose gestational diabetes is poorly controlled throughout her pregnancy goes into labor at 38 weeks' gestation and gives birth. When assisting with implementing the plan of care for this neonate, which intervention would be the priority during the neonate's first 24 hours?

providing frequent early feedings with formula - The neonate of a client with diabetes may be slightly hyperglycemic immediately after birth because of the glucose that crosses the placenta from mother to fetus. During pregnancy, the fetal pancreas secretes increased levels of insulin in response to this increased glucose amount. However, during the first 24 hours of life, the combination of this high insulin production in the neonate and the loss of maternal glucose can cause severe hypoglycemia. Frequent, early feedings with formula can prevent hypoglycemia. Insulin should not be administered because the neonate of a client with diabetes is at risk for hypoglycemia. A bolus of glucose given IV may cause rebound hypoglycemia. If glucose is given IV, it should be administered as a continuous infusion. Oral feedings should not be avoided because early, frequent feedings can help prevent hypoglycemia.

A client who has a deep vein thrombosis (DVT) reports dyspnea and chest pain and has diminished breath sounds. Which condition does the nurse prepare treatment for?

pulmonary embolism - The most common complication of a DVT is a pulmonary embolus. A pulmonary embolism is a thrombus that forms in a vein, travels to the lungs, and lodges in the pulmonary vasculature. Hemothorax refers to blood in the pleural space. Pneumothorax is caused by an opening in the pleura. Pulmonary hypertension is an increase in pulmonary artery pressure, which increases the workload of the right ventricle.

A nurse is caring for 10-year-old child with sickle cell anemia admitted for vaso-occlusive crisis. Which would be the most appropriate activity for the nurse to provide for the child?

reading - During a vaso-occlusive crisis, the child needs to minimize oxygen consumption by resting. Reading is a quiet, age-appropriate activity. Walking in the hallway and exercising in the physical therapy department are too strenuous for a child in vaso-occlusive crisis. Finger painting is not an appropriate activity for a 10-year-old.

A client was sexually assaulted when returning home from the store late one evening. The client arrives, tearful, to the emergency department. What is the priority intervention for this client?

remaining with the client and assisting the client through the crisis - Sexual assault is treated as a medical emergency, and the client requires constant attention and assistance during the crisis. Filing a police report doesn't take precedence over a medical emergency. Comforting the client by contacting family should be carried out after injuries are treated. Encouraging the client to enroll in a self-defense class isn't appropriate during crisis.

A nurse is assisting with the development of a plan of care for a client who has undergone electroconvulsive therapy (ECT). Which intervention would most likely be included?

reorienting the client to time and place - Confusion and temporary memory loss are the most common adverse effects of ECT. The nurse should continually reorient the client to time and place when waking up from the procedure. The nurse should also monitor the client's vital signs every 15 minutes for the first hour and position the client on the side after the procedure to reduce the risk of aspiration. The client should remain on bed rest until fully awake and oriented.

A client has developed a right torticollis with side bending to the right and rotation to the left. Which exercises may assist in reduction of the torticollis?

rotation exercises to the right - Performing rotation exercises to the right will help increase the length of the shortened right sternocleidomastoid. Rotation to the left will exacerbate the torticollis, as the head is already rotated in that direction. Cervical extension exercises won't lengthen tightened muscles. Cervical flexion will shorten the muscles further.

The nurse is meeting with a client who has recently been diagnosed with human immunodeficiency virus (HIV). The client is concerned about the impact of sharing the recent diagnosis with friends and family. What information can the nurse provide to the client?

sharing the diagnosis with friends and family members will provide a needed source of support - Studies support the benefit of sharing an HIV positive status with friends and family. This provides a source of support for the individual. Feelings of isolation may be heightened when the individual feels forced to live a double life and hide the truth of his HIV status. While the diagnosis of HIV may be difficult for friends and family to hear, it will allow them the opportunity of having increased openness and honesty in the relationship.

A client is admitted to the labor unit in early labor. The nurse would encourage the client to assume which position to promote tissue perfusion?

side-lying - In the side-lying position, cardiac output increases, stroke volume increases, and the pulse rate decreases, thereby promoting tissue perfusion. In the supine position, the blood pressure can drop severely due to the pressure of the fetus on the vena cava, resulting in supine hypotensive syndrome or vena cava syndrome. Neither the sitting nor semi-Fowler's position increases cardiac output or stroke volume.

The health care provider has ordered sulfasalazine for a child with juvenile rheumatoid arthritis. The nurse questions the order when reading that the client has an allergy to what medication?

sulfamethoxazole-trimethoprim - Sulfamethoxazole-trimethoprim is a sulfa drug as is sulfasalazine. If a person has a reaction to one sulfa drug, it is highly probable they would have a reaction to another. Alprazolam, naproxen, and penicillin will not make the nurse question the health care provider's order.

The nurse observes the unlicensed assistive personnel (UAP) delivering a food tray to the client prescribed a clear liquid diet. The nurse would intervene when which food product is seen on the food tray?

vanilla yogurt - Yogurt is found in full liquid diets. A clear liquid diet includes clear juices, such as cranberry juice, coffee, tea, water, and broth.

The nurse is gathering data regarding the physical development of a 33-month-old who is playing. Which of the following activities would the nurse anticipate the toddler being able to complete with minimal assistance? Select all that apply.

washing and drying hands removing his or her jacket using a spoon for eating - Normal growth and development for children entering the preschool years is to be able to follow directions on hand washing, remove one article of clothing, and feed themselves with a spoon. Riding a bicycle (two wheels) typically requires more coordination; coloring a detailed picture requires more fine motor ability.