Passpoint 6

When performing a physical assessment on an 18-month-old child, which measure would be best? Have a parent hold the toddler. Assess the ears and mouth first. Carry out the assessment from head to toe. Assess motor function by having the child run and walk.

Have a parent hold the toddler. Explanation: The best strategy for assessing a toddler is to have the parent hold the toddler. Doing so is comforting to the toddler. Assessment should begin with noninvasive assessments first while the child is quiet. Typically, these include assessments of the cardiac and respiratory systems. The ears and throat are typically examined last. Using a head-to-toe approach is more appropriate for an older child. For a toddler, assessment should begin with noninvasive assessments first while the child is quiet. Having a toddler run and be active may make it difficult to settle the child down after the physical exertion.

When developing a teaching plan for a client taking hormonal contraceptives, a nurse should ensure that the client knows she must have which vital sign monitored regularly? Pulse Respirations Temperature Blood pressure

Blood pressure Explanation: The incidence of hypertension is three to six times greater in clients using hormonal contraceptives than in women who don't use these drugs. Age and duration of the drug's use increase this incidence. Hormonal contraceptives don't directly affect pulse, respirations, or temperature.

A primiparous client planning to breastfeed her term neonate born vaginally asks, "When will my 'real' milk come in?" The nurse explains to the client that after childbirth, breasts begin to produce milk within what time period? 12 hours 24 hours 2 to 4 days 7 days

2 to 4 days Explanation: If the client begins breast-feeding early and often after childbirth, the breasts begin to fill with milk within 48 to 96 hours, or 2 to 4 days. The breasts secrete colostrum for the first 24 to 48 hours, which is beneficial to the neonate because of the immunoglobulins contained in colostrum.

Which client does the nurse determine has the highest risk for developing ovarian cancer? 35-year-old woman who breast fed one of her four children 45-year-old woman taking oral contraceptives for 5 years 50-year-old woman who has had multiple pregnancies 60-year-old obese woman who has never been pregnant

60-year-old obese woman who has never been pregnant Explanation: Risk factors for ovarian cancer include age over 55, body mass index over 30, and inherited gene mutations (BRCA I and II). Interrupting the menstrual cycle by means of oral contraceptives, pregnancy, and breast feeding are considered protective factors.

A nurse is caring for a client who's in labor. The health care professional still isn't present. After the neonate's head is delivered, which nursing intervention would be appropriate? Checking for the umbilical cord around the neonate's neck Placing antibiotic ointment in the neonate's eyes Turning the neonate's head to the side to drain secretions Assessing the neonate for respirations

A nurse is caring for a client who's in labor. The health care professional still isn't present. After the neonate's head is delivered, which nursing intervention would be appropriate? Checking for the umbilical cord around the neonate's neck Placing antibiotic ointment in the neonate's eyes Turning the neonate's head to the side to drain secretions Assessing the neonate for respirations

While assisting a primiparous client with her first breastfeeding session, the nurse should instruct the mother to perform which action in order to stimulate the neonate to open the mouth and grasp the nipple? Pull down gently on the neonate's chin and insert the nipple. Squeeze both of the neonate's cheeks simultaneously. Place the nipple into the neonate's mouth on top of the tongue. Brush the neonate's lips lightly with the nipple.

Brush the neonate's lips lightly with the nipple. Explanation: Lightly brushing the neonate's lips with the nipple causes the neonate to open the mouth and begin sucking. The neonate should be taught to open the mouth and grasp the nipple on his or her own. The neonate should not be forced to nurse.

A primiparous client who is bottle-feeding her neonate asks, "When should I start giving the baby solid foods?" The nurse instructs the client to introduce solid foods no sooner than at which age? 2 months 6 months 8 months 10 months

6 months Explanation: Pediatricians recommend that infants be given either breast milk or formula until at least 6 months of age because of the neonate's difficulty digesting solid foods. Giving solid foods too early can lead to food allergies. Because chewing movements do not begin until 7 to 9 months of age, foods requiring chewing should be delayed until this time.

Which question has been added to nursing admission assessment to screen for the Zika virus? Have you recently traveled to Japan? Have you recently traveled to Africa? Have you recently traveled to Canada? Have you recently traveled to South America?

Have you recently traveled to South America? Explanation: Central and South America are areas experiencing the transmission of the Zika virus.

A client is having elective surgery under general anesthesia. Who is responsible for obtaining the informed consent? the nurse the surgeon the anesthesiologist the social worker

the surgeon Explanation: It is the role of the surgeon or the person performing the procedure to obtain the informed consent. This consists of informing the client about the procedure, the risks of treatment, the side effects, other types of treatments available, and the effects without the procedure. Nurses, anesthesiologists, and social workers do not obtain informed consent.

Which client has the highest risk of ovarian cancer? 30-year-old woman taking hormonal contraceptives 36-year-old woman who had her first child at age 22 40-year-old woman with three children 45-year-old woman who has never been pregnant

45-year-old woman who has never been pregnant Explanation: The incidence of ovarian cancer increases in women who have never been pregnant, are older than age 40, are infertile, or have menstrual irregularities. Other risk factors include a family history of breast, bowel, or endometrial cancer. The risk of ovarian cancer is reduced in women who have taken hormonal contraceptives, have had multiple births, or have had a first child at a young age.

Which client should the nurse assess first? A client newly diagnosed with hypertension, with a blood pressure of 164/92 mm Hg who is having chest pain. A client with peripheral vascular disease with a blood pressure of 190/102 mm Hg who is due to receive a scheduled beta blocker. A client with a history of cerebral vascular attack, right sided weakness, blood pressure of 180/96 mm Hg who has a headache. A client with type 1 diabetes with a fasting blood glucose of 102 mg/dL, blood pressure of 172/90 mm Hg and whose urine shows microalbuminuria.

A client newly diagnosed with hypertension, with a blood pressure of 164/92 mm Hg who is having chest pain. Explanation: The client with chest pain may be experiencing acute myocardial infarction and is unpredictable. A rapid assessment and intervention are needed. The remaining clients are all stable and have expected symptoms associated with their diagnosis.

Which factors are major components of a client's general background history? Allergies and socioeconomic status Urine output and allergies Gastric reflex and the client's age Bowel habits and allergies

Allergies and socioeconomic status Explanation: General background data consist of such components as age, allergies, medical history, habits, socioeconomic status, lifestyle, beliefs, and sensory deficits. Urine output, gastric reflex, and bowel habits are significant only if a disease affecting these functions is present.

A multigravid client is admitted at 4-cm dilation and is requesting pain medication. The nurse gives the client an opioid agonist-antagonist. Within 5 minutes, the client tells the nurse she feels like she needs to have a bowel movement. What should the nurse do first? Have naloxone hydrochloride available in the birthing room. Complete a vaginal examination. Prepare for birth. Document the client's relief due to pain medication.

Complete a vaginal examination. Explanation: The feeling of needing to have a bowel movement is commonly caused by pressure on the receptors low in the perineum when the fetal head is creating pressure on them. This feeling usually indicates advances in fetal station and that the client may be close to birth. The nurse should respond initially to the client's signs and symptoms by completing a vaginal exam to validate current effacement, dilation, and station. If the fetus is ready to be born, having the room ready for the birth and having naloxone available are important. Naloxone completely or partially reverses the effects of natural and synthetic opioids, including respiratory depression. Documenting pain relief takes time away from the vaginal examination, preparing for birth, and obtaining naloxone. The birth may be occurring rapidly. Being prepared for the birth is a higher priority than documentation for this client.

As two toddlers play side by side, their parents note that they are not sharing their toys with each other and one cries when a toy is taken by the other child. The nurse hears the parents telling their children to share. Which is the nurse's best response? Do nothing as this is normal behavior for a toddler. Encourage the parents to teach their children to share. Separate the children so that they cannot fight. Sit between the children and encourage them to play together.

Do nothing as this is normal behavior for a toddler. Explanation: Toddlers participate in parallel play. They play beside each other but not together. They are not ready to "share" their toys. No intervention is needed for this normal developmental behavior.

The nurse is a assessing a newborn and notes the presence of strabismus. Which is the nurse's best action? Document the findings in the newborn's chart. Contact the pediatrician immediately. Expect the newborn to have an elevated bilirubin level. Ensure that the hearing screening exam is done immediately.

Document the findings in the newborn's chart. Explanation: Strabismus is a normal finding during the newborn stage and the finding should be documented. There is no association with bilirubin levels and hearing screenings with strabismus.

Which plane divides the body longitudinally into anterior and posterior regions? Frontal plane Sagittal plane Midsagittal plane Transverse plane

Frontal plane Explanation: A frontal or coronal plane, which runs longitudinally at a right angle to a sagittal plane, divides the body into anterior and posterior regions. A sagittal plane runs longitudinally, dividing the body into right and left regions; if exactly midline, it is called a midsagittal plane. A transverse plane runs horizontally at a right angle to the vertical axis, dividing the structure into superior and inferior regions.

The nurse finds a client lying on the floor next to the bed. After returning the client to bed, assessing for injury, and notifying the health care provider (HCP), the nurse fills out an incident report. What should the nurse do next? Give the incident report to the nurse-manager. Place the incident report on the medical record. Call the family to inform them. Omit mentioning the fall in the medical record documentation.

Give the incident report to the nurse-manager. Explanation: The incident report should be given to the nurse-manager. The incident report should not be placed on the medical record because it is considered a confidential communication and cannot be subpoenaed by a client or used as evidence in lawsuits. It is appropriate, ethical, and legally required that the fall be documented in the medical record. Unless there is a change in the client's condition reflecting an injury from the fall, there is no need to notify the family. If the family does need to be notified, the nurse-manager or the HCP should place the call.

After instructing a primiparous client about episiotomy care, which client statement indicates successful teaching? "I will use hot, sudsy water to clean the episiotomy area." "I wipe the area from front to back using a blotting motion." "Before bedtime, I will use a cold water sitz bath." "I can use ice packs for 3 to 4 days after childbirth."

I wipe the area from front to back using a blotting motion." Explanation: The nurse should instruct the client to cleanse the perineal area with warm water and to wipe from front to back with a blotting motion. Warm water is soothing to the tender tissue, and wiping from front to back reduces the risk of contamination. Hot, sudsy water may increase the client's discomfort and may even burn the client in a very tender area. After the first 24 hours, warm water sitz baths taken three or four times a day for 20 minutes can help increase circulation to the area. Ice packs are helpful for the first 24 hours.

A multiparous client who has been in labor for two hours states that she feels the urge to move her bowels. What would the nurse do first? Assist the client to get up to use the toilet Allow the client to use a bedpan Perform a pelvic examination Check the fetal heart rate (FHR)

Perform a pelvic examination Explanation: A report of rectal pressure usually indicates a low presenting fetal part, and imminent birth. The nurse should perform a pelvic examination to assess the dilation of the cervix and station of the presenting fetal part. Do not let the client use the toilet or a bedpan before she's examined because she could deliver on the toilet or in the bedpan. Checking the FHR is important but comes after the nurse evaluates the client's report.

A nurse is planning care for a 14-year-old client following an appendectomy. What is the most important intervention? Reduce conflict between the client and his parents Promote the development of an identity and independence Encourage the development of trust Confirm plans for the future

Promote the development of an identity and independence Explanation: Since adolescents are in Erikson's identity versus role confusion stage, planning care should include interventions that promote a sense of identity and independence. During adolescence, conflict is usually intensified, not reduced. Trust is a developmental task of infancy. Plans for the future aren't confirmed at age 14.

When implementing the planned care of a client with pneumonia, a nurse achieves proper placement of a tympanic thermometer probe in an adult's ear canal by which method? Pulling the ear pinna back, up, and out Pulling the ear pinna back, down, and out Pulling the ear pinna out Pulling the ear pinna down

Pulling the ear pinna back, up, and out Explanation: Pulling the pinna back, up, and out helps straighten an adult's ear canal so the nurse can properly place a tympanic thermometer probe. Pulling the ear pinna back, down, and out straightens a child's ear canal. Pulling the ear pinna only out or back does not straighten the ear canal for probe placement.

A multigravid client who stands for long periods while working in a factory visits the prenatal clinic at 35 weeks' gestation, stating, "The varicose veins in my legs have really been bothering me lately." Which instruction would be most helpful? Perform slow contraction and relaxation of the feet and ankles twice daily. Take frequent rest periods with the legs elevated above the hips. Avoid support hose that reach above the leg varicosities. Take a leave of absence from work to avoid prolonged standing.

Take frequent rest periods with the legs elevated above the hips. Explanation: The client with leg varicosities should take frequent rest periods with the legs elevated above the hips to promote venous circulation. The client should avoid constrictive clothing, but support hose that reach above the varicosities may help alleviate the pain. Contracting and relaxing the feet and ankles twice daily is not helpful because it does not promote circulation. Taking a leave of absence from work may not be possible because of economic reasons. The client should try to rest with her legs elevated or walk around for a few minutes every 2 hours while on the job.

Which of the following structures should be closed by the time the child is 2 months old?

The posterior fontanel should be closed by age 2 months. The anterior fontanel and sagittal and frontal sutures should be closed by age 18 months.

The parents of a 6-year-old child tell the nurse that they are concerned about the child's tonsils. On inspection, the nurse notes that the tonsils are large but not reddened or inflamed. How does the nurse interpret this finding? the need for tonsillectomy an acute viral infection of the tonsils a normal increase in lymphoid tissue the need for an antibiotic

a normal increase in lymphoid tissue Explanation: Because lymphoid tissue develops rapidly in relation to size until age 10 to 11 years, lymphoid hyperplasia in the form of enlarged tonsils is normal until age 6 to 7 years. After this time, the tissue slowly atrophies. Enlarged tonsils are not surgically removed unless they become abscessed or compromise physiologic functioning. An antibiotic would be needed if the evidence suggested a bacterial infection. However, the tonsils are only enlarged, not reddened or inflamed, suggesting no infection.

The following pediatric clients are in the triage area awaiting assessment. Which client will the nurse assess first? a crying 3-year-old whose parent is holding a cloth on the child's head covering a scalp laceration a lethargic 15-month-old with pink cheeks whose parent reported temperature of 38.4°C (101.2°F) a quiet 2-year-old with nasal flaring who is sitting in a tripod position a pale 6-month-old with a frequent cough and audible wheezing

a quiet 2-year-old with nasal flaring who is sitting in a tripod position Explanation: The nurse identifies the nasal flaring and particularly the tripod position as indications of respiratory distress. This pediatric client needs rapid assessment and intervention and will be seen first. The other pediatric clients are not in immediate danger and will be seen as soon as possible by a healthcare professional.

A nurse caring for a preterm neonate knows that positioning can benefit high-risk neonates. Which position is appropriate for a preterm neonate? hyperabduction and extension of the arms with external rotation of the hips neck extension and back arching with flattened shoulders adduction and flexion of the extremities with gently rounded shoulders abduction and flexion of the arms with flattened shoulders

adduction and flexion of the extremities with gently rounded shoulders Explanation: The goal of neonatal positioning is to gently round shoulders and flex elbows and to avoid abduction of the shoulders and hips. This positioning enhances physiologic stability and developmental progress. Hyperabduction and external rotation in a preterm neonate may result in contractures. Neck extension, back arching, flattened shoulders, and abduction should be avoided in neonates.

Which intervention would be least appropriate for a client who is in a double hip spica cast? encouraging the intake of cranberry juice advising the client to eat large amounts of cheese establishing regular times for elimination having the client dangle at the bedside

advising the client to eat large amounts of cheese Explanation: The client in a double hip spica cast should avoid eating foods that can be constipating, such as cheese. Rather, fresh fruits and vegetables should be encouraged, and the client should be encouraged to drink at least 2,500 mL/day. Drinking cranberry juice, which helps keep urine acidic, thereby avoiding the development of renal calculi, is encouraged. The client should be encouraged to establish regular times for elimination to promote regularity in bowel and bladder habits. The client will develop orthostatic hypotension unless the circulatory system is reconditioned slowly through dangling and standing exercises

Which risk factor would most likely contribute to the development of a client's hiatal hernia? having a sedentary desk job being 5 feet, 3 inches (160 cm) tall and weighing 190 lb (86.2 kg) using laxatives frequently being 40 years old

being 5 feet, 3 inches (160 cm) tall and weighing 190 lb (86.2 kg) Explanation: Any factor that increases intra-abdominal pressure, such as obesity, can contribute to the development of hiatal hernia. Other factors include abdominal straining, frequent heavy lifting, and pregnancy. Hiatal hernia is also associated with older age and occurs in women more frequently than in men. Having a sedentary desk job, using laxatives frequently, or being 40 years old is not likely to be a contributing factor in development of a hiatal hernia.

When teaching a preschool-age child how to perform coughing and deep-breathing exercises before corrective surgery for tetralogy of Fallot, which teaching and learning principle should the nurse address first? organizing information to be taught in a logical sequence arranging to use actual equipment for demonstrations building the teaching on the child's current level of knowledge presenting the information in order from simplest to most complex

building the teaching on the child's current level of knowledge Explanation: Before developing any teaching program for a child, the nurse's first step is to assess the child to determine what is already known. Most older preschool children have some understanding of a condition present since birth. However, the child's interest will soon be lost if familiar material is repeated too often. The nurse can then organize the information in a sequence because there are several steps to be demonstrated. These exercises do not require the use of equipment. The nurse should judge the amount and complexity of the information to be provided, based on the child's current knowledge and response to teaching.

What toy should the nurse included as part of a recreational therapy plan of care for a 3-year-old child hospitalized with pneumonia and cystic fibrosis? 100-piece jigsaw puzzle child's favorite doll fuzzy stuffed animal scissors, paper, and paste

child's favorite doll Explanation: The child's favorite doll would be a good choice of toys. The doll provides support and is familiar to the child. Although a 3-year-old may enjoy puzzles, a 100-piece jigsaw puzzle is too complicated for an ill 3-year-old child. In view of the child's lung pathology, a fuzzy stuffed animal would not be advised because of its potential as a reservoir for dust and bacteria, possibly predisposing the child to additional respiratory problems. Scissors, paper, and paste are not appropriate for a 3-year-old unless the child is supervised closely.

A mother is concerned about her 9-year-old child's compulsion for collecting things. The nurse's explanation is based on the understanding that this behavior is related to the cognitive ability to perform which functions? concrete operations formal operations coordination of secondary schemata tertiary circular reactions

concrete operations Explanation: The school-aged child (age 7 to 11 years) who has achieved the cognitive abilities required to master concrete operations commonly collects various objects when learning to manipulate and classify these objects. Formal operations do not emerge until later (age 11 to 15 years). Coordination of secondary schemata is part of the sensorimotor phase of cognitive development (up to age 2 years). Tertiary circular reactions are part of the sensorimotor phase of cognitive development (up to age 2 years).

Examination of a primigravid client having increased vaginal secretions since becoming pregnant reveals clear, highly acidic vaginal secretions. The client denies any perineal itching or burning. The nurse interprets these findings as a response related to which factor? a decrease in vaginal glycogen stores development of a sexually transmitted infection prevention of expulsion of the cervical mucus plug control of the growth of pathologic bacteria

control of the growth of pathologic bacteria Explanation: An increase in clear, highly acidic vaginal secretions is a normal finding during pregnancy that aids in controlling the growth of pathologic bacteria. Vaginal secretions increase because of the influence of estrogen secretion and increased vaginal and cervical vascularity. The highly acidic nature of the vaginal secretions is caused by the action of Lactobacillus acidophilus, which increases the lactic acid content of the secretions. The increased acidity helps to make the vagina resistant to bacterial growth. During pregnancy, estrogen secretion fosters a glycogen-rich environment. Unfortunately, this glycogen-rich, acidic environment fosters the development of yeast (Candida albicans) infections, manifested by itching, burning, and a cheese-like vaginal discharge. If the client had a sexually transmitted infection, most likely she would have additional symptoms, such as lesions in the genital area or changes in color, consistency, or odor of the vaginal secretions. An increase in vaginal secretions does not help prevent expulsion of the mucus plug. The mucus plug is held in place by the cervix until the cervix becomes ripe.

strabismus

crossed eyes

A nulliparous client tells the nurse that during her last pelvic examination, the health care provider (HCP) said that her uterus was in a severe retroverted position. The nurse determines that the client may experience: frequent vaginal infections. pain from endometriosis. severe menstrual cramping. difficulty conceiving a child.

difficulty conceiving a child. Explanation: Severe retroversion or anteversion may lead to infertility or difficulty conceiving a child because these positions can block the deposition or migration of sperm. The normal position of the uterus is tipped slightly forward. Frequent vaginal infections commonly are associated with diabetes or human immunodeficiency virus infection, not abnormal uterine positions. Pain from endometriosis (abnormal myometrial growth outside the uterus) is not associated with abnormal uterine positions. Severe menstrual cramping or dysmenorrhea (primary) is caused by increased prostaglandin production, not abnormal uterine positions. Secondary dysmenorrhea is associated with pelvic inflammatory disease or endometriosis.

While assessing a male neonate whose mother desires him to be circumcised, the nurse observes that the neonate's urinary meatus appears to be located on the ventral surface of the penis. The health care provider (HCP) is notified because the nurse suspects which complication? phimosis hydrocele epispadias hypospadias

hypospadias Explanation: The condition in which the urinary meatus is located on the ventral surface of the penis, termed hypospadias, occurs in 1 of every 500 male infants. Circumcision is delayed until the condition is corrected surgically, usually between 6 and 12 months of age. Phimosis is an inability to retract the prepuce at an age when it should be retractable or by age 3 years. Phimosis may necessitate circumcision or surgical intervention. Hydrocele is a painless swelling of the scrotum that is common in neonates. It is not a contraindication for circumcision. Epispadias occurs when the urinary meatus is located on the dorsal surface of the penis. It is extremely rare and is commonly associated with bladder extrophy.

Which statement would provide the best guide for activity during the rehabilitation period for a client who has been treated for retinal detachment? The activity level is: increased gradually; the client can resume usual activities in 5 to 6 weeks. determined by the client's tolerance; clients can be as active as they wish. restricted for several months; the client should plan on being sedentary. not restricted; clients can resume regular aerobic exercises.

increased gradually; the client can resume usual activities in 5 to 6 weeks. Explanation: The scarring of the retinal tear needs time to heal completely. Therefore, resumption of activity should be gradual; the client may resume usual activities in 5 to 6 weeks. Successful healing should allow the client to return to a previous level of functioning.

epididymitis

inflammation of the epididymis that is frequently caused by the spread of infection from the urethra or the bladder

hyperbaric oxygen therapy

involves breathing pure oxygen in a special chamber that allows air pressure to be raised up to three times higher than normal

The correct procedure for auscultating the client's abdomen for bowel sounds is to: palpate the abdomen first to determine correct stethoscope placement. encourage the client to cough to stimulate movement of fluid and air through the abdomen. place the client on the left side to aid auscultation. listen for 5 minutes in all four quadrants to confirm absence of bowel sounds.

listen for 5 minutes in all four quadrants to confirm absence of bowel sounds. Explanation: Because of the irregularity of bowel sounds, the nurse should listen for 5 minutes in each quadrant to confirm the absence of bowel sounds. Auscultation is performed before palpation because palpation may affect peristaltic activity. Coughing does not stimulate peristalsis. The client should be positioned supine to provide adequate access to the abdomen.

A nurse manager of the pediatric unit is responsible for making sure that each staff member reviews the unit policies annually. What policy should the nurse manager emphasize with the clerical support staff? proper documentation of a verbal order from a physician policy changes in the administration of opioids new education materials for the management of diabetes logging off a computer containing client information

logging off a computer containing client information Explanation: All members of the healthcare team are required to maintain strict client confidentiality, including securing electronic client information. Therefore, the clerical support staff should be instructed about the importance of logging off a computer containing client information immediately after use. Taking a verbal order, administering medications, and client education aren't within the scope of practice of the clerical support staff.

A parent reports that his 2-year-old child often falls when running. The nurse interprets this as indicating which normal aspect of a toddler's vision? nearsightedness farsightedness binocular vision strabismus

nearsightedness Explanation: Until age 7 years, children are normally myopic (nearsighted), meaning that they have difficulty seeing objects at a distance. Additionally, toddlers lack motor coordination, and their depth perception is not well developed. All these factors place them at risk for falling. Hyperopia, or farsightedness, is the inability to clearly see objects at close range. Binocular vision is the ability to focus on an object with both eyes, creating a single image; it assists with depth perception. Strabismus is misalignment of the eyes and can result from muscle weakness or trauma. It is not a normal finding in a toddler.

A 21-year-old primigravid client at 40 weeks' gestation is admitted to the hospital in active labor. The client's cervix is 8 cm and completely effaced at 0 station. During the transition phase of labor, which is a priority nursing problem? urinary retention hyperventilation ineffective coping pain

pain Explanation: During transition, contractions are increasing in frequency, duration, and intensity. The most appropriate nursing problem is pain related to strength and duration of the contractions. Insufficient information is provided in the scenario to support the other listed nursing diagnoses. Urinary retention would be appropriate if the client had a full bladder and was unable to void. Hyperventilation might apply if client was breathing too rapidly, but there is no evidence this is occurring. Ineffective coping might apply if the client said, "I can't do this" or something similar.

A multiparous client, 28 hours after cesarean birth, who is breastfeeding has severe cramps or afterpains. The nurse explains that these are caused by which factor? flatulence accumulation after a cesarean birth healing of the abdominal incision after cesarean birth adverse effects of the medications administered after birth release of oxytocin during the breastfeeding session

release of oxytocin during the breastfeeding session Explanation: Breastfeeding stimulates oxytocin secretion, which causes the uterine muscles to contract. These contractions account for the discomfort associated with afterpains. Flatulence may occur after a cesarean birth. However, the mother typically would have abdominal distention and a bloating feeling, not a "cramplike" feeling. Stretching of the tissues or healing may cause slight tenderness or itching, not cramping feelings of discomfort. Medications such as mild analgesics or stool softeners, commonly administered postpartum, typically do not cause cramping.

A 30-year-old client is being treated for epididymitis. What information should the nurse include in the teaching plan about the likely cause of epididymitis? virus parasite sexually transmitted infection protozoon

sexually transmitted infection Explanation: Among men younger than age 35, epididymitis is most frequently caused by a sexually transmitted infection. Causative organisms are usually chlamydia or Neisseria gonorrhoeae. The other major form of epididymitis is bacterial, caused by the Escherichia coli or Pseudomonas organisms. The nurse should always include safe sex teaching for a client with epididymitis. The client should also be advised against anogenital intercourse because this is a mode of transmission of gram-negative rods to the epididymis.

Which observation is expected when the nurse is assessing the gestational age of a neonate born at term? ear lying flat against the head absence of rugae in the scrotum sole creases covering the entire foot square window sign angle of 90 degrees

sole creases covering the entire foot Explanation: Sole creases covering the entire foot are indicative of a term neonate. If the neonate's ear is lying flat against the head, the neonate is most likely preterm. An absence of rugae in the scrotum typically suggests a preterm neonate. A square window sign angle of 0 degrees occurs in neonates of 40 to 42 weeks' gestation. A 90-degree square window angle suggests an immature neonate of approximately 28 to 30 weeks' gestation.

A student nurse inserts a nasogastric tube and begins a tube feeding without a radiological confirmation. The client develops pneumonia and is transferred to the intensive care unit. Which parties are liable for negligence? Select all that apply. the student nurse the nursing instructor the assigned nurse the physician the dietician

the student nurse the nursing instructor the assigned nurse Explanation: The student nurse, nursing instructor, and staff nurse are held to the same standard of care. The tube placement should be confirmed by radiology. The physician and dietician were not involved with the tube placement and following the standard of care with a radiology placement confirmation.

A nurse observes a play group of 2-year-old children. The nurse expects to see: four children playing dodgeball. three children playing tag. two children side by side in the sandbox building sand castles. one child playing with clay and another child using flash cards.

two children side by side in the sandbox building sand castles. Explanation: Two-year-olds exhibit parallel play; that is, they engage in similar activity, side by side. Playing dodgeball and tag are examples of interactive play, common to school-age children. Playing with clay and using flash cards are behaviors seen in preschool children.

A client tells a nurse that about a rash on his/her back and right flank. The nurse observes elevated, round, blisterlike lesions filled with clear fluid. When documenting the findings, what medical term would the nurse use to describe these lesions? pustules papules plaque vesicles

vesicles Explanation: Vesicles are raised, round, serous-filled lesions that are usually less than 1 cm in diameter. Examples of vesicles include chickenpox (varicella) and shingles (herpes zoster). A pustule is a raised, circumscribed lesion that's usually less than 3/8″ in diameter and contains purulent material that gives it a yellow-white color — for example, acne pustule and impetigo. A plaque is a circumscribed, solid, elevated lesion that's more than 3/8″, in diameter — for example, psoriasis. A papule is a firm, inflammatory, raised lesion that's as long as 1/4″ in diameter and that may be pigmented or the same color as the client's skin — for example, acne papule and lichen planus.

The mother of a 4-year-old child asks about dental care for her child. "I help brush her teeth every day, and her teeth look healthy," the mother states. "When should I take her to see a dentist?" Which response would be most appropriate? "Because you help brush her teeth, there is no need to see a dentist right now." "Ideally she should have seen a dentist already, but it is still not too late." "Your child does not need to see the dentist until she starts school." "A dental checkup is a good idea even if no problems are noticeable."

"A dental checkup is a good idea even if no problems are noticeable." Explanation: Routine dental examinations should begin when a child is young, with newer recommendations suggesting visits begin before a child's first birthday especially in at risk children. Even though the mother helps the child brush her teeth every day, this does not replace the need for preventative dental visits which can help reduce dental disease. Reprimanding the mother for not taking the child to the dentist is not therapeutic and may alienate the mother. Waiting until the child starts school may be too late because dental caries can occur before the age of 2 years.

A postpartum client requires teaching about breast-feeding. Which client statement indicates understanding of how to prevent breast engorgement? "I will use an electric breast pump." "I should apply warm, moist compresses to the breasts." "I will breast-feed as often as the infant is hungry — typically every 1 to 3 hours." "I must wear a brassiere 24 hours per day."

"I will breast-feed as often as the infant is hungry — typically every 1 to 3 hours." Explanation: The client demonstrates understanding of how to prevent breast engorgement when she states she will breast-feed as often as her baby wants. Frequent breast-feeding empties the breasts and increases circulation, helping to remove fluid that may lead to engorgement. If the neonate isn't ill or physically impaired and can breast-feed, the client shouldn't use an electric breast pump because doing so deprives the infant of optimal sucking and skin-to-skin contact with the mother. Applying warm, moist compresses stimulates the let-down reflex and causes the breasts to fill, which may lead to engorgement. A brassiere supports the breasts but doesn't prevent engorgement unless the client breast-feeds frequently.

A medical-surgical nurse is caring for a client with end stage kidney disease. The client asks the nurse, "Am I dying soon?" What is the best response(s) by the nurse? Select all that apply. "The health care provider will be in later and be able to discuss the prognosis with you". "We are doing everything medically possible and you will be fine". "You're in the final stage of illness so you may have little time remaining". "Do you want me to call the local clergy for you to obtain last rights?" "Do you want to talk about how you are feeling about your prognosis?"

"You're in the final stage of illness so you may have little time remaining". "Do you want to talk about how you are feeling about your prognosis?" Explanation: It is essential that nurses freely engage in dialogue concerning moral situations such as dying, even though such dialogue can be difficult for everyone involved. Since the client asked the nurse the question, the nurse should not wait and have the physician answer the question. Nurses should never give false reassurance to a client. Nothing says that the client is religious or asked for last rites in this scenario.

The nurse is caring for an 8-year-old with a life-threatening illness. The parents do not speak the native language and want the child discharged so they can pursue alternative therapies that they believe will be less expensive. What is the most important action taken by the nurse to help the family and the child? Have a social worker help the family with the financial burden. Contact a clergy member to administer last rites to the child. Arrange to have a translator present when talking with the parents. Notify the healthcare provider that treatment will no longer be necessary.

Arrange to have a translator present when talking with the parents. Explanation: A translator is an immediate priority. No effective health teaching or social intervention will be effective until there is an established means of communication with the family.

A client is receiving spironolactone for treatment of bilateral lower extremity edema. The nurse should instruct the client to make which nutritional modification to prevent an electrolyte imbalance? Increase intake of milk and milk products. Restrict fluid intake to 1,000 mL/day. Decrease foods high in potassium. Increase foods high in sodium.

Decrease foods high in potassium. Explanation: Aldactone is a potassium-sparing diuretic often used to counteract potassium loss caused by other diuretics. If foods or fluids are ingested that are high in potassium, hyperkalemia may result and lead to cardiac arrhythmias. Increasing the intake of milk or milk products does not affect the potassium level. Restricting fluid may elevate all electrolytes due to extracellular fluid volume depletion. By increasing foods high in sodium, water would tend to be retained and so would dilute all electrolytes in the extracellular fluid compartment.

A school nurse is teaching 4th graders about preventing injuries when riding bicycles, skateboarding, or using scooters. Indicate which is the best way for the nurse to motivate the children to use safety equipment? Tell the children that wearing helmets and knee pads are the law and that their parents will get into trouble. Show the children an animated movie about a child who has a traumatic brain injury. Ask the children what they know about bicycle safety. Present slides of famous athletes wearing protective gear.

Do nothing as this is normal behavior for a toddler. Explanation: Toddlers participate in parallel play. They play beside each other but not together. They are not ready to "share" their toys. No intervention is needed for this normal developmental behavior.Present slides of famous athletes wearing protective gear. Explanation: Children of this age will identify with peers and role models. "Scare tactics" do not appeal to the intellect of the child. Showing an animated movie may make a point but not necessarily gain compliance as it does not appeal to reality thinking of this age group. Asking children what they know is a good way to determine a starting point for teaching.

Which approach by a nurse is the best for trying to take a crying toddler's temperature? Ignore the crying and screaming. Tell the caregiver not to hold the client. Talk to the caregiver first and then to the client. Bring extra help so it can be done quickly.

Talk to the caregiver first and then to the client. Explanation: When dealing with a crying client, the best approach is to talk to the caregiver first then to the toddler. This approach helps the client get used to the nurse before attempting any procedures. It also gives the client an opportunity to see that the caregiver trusts the nurse. Ignoring the crying and screaming may be the second step. The nurse should encourage the caregiver to hold the client because it will likely help the situation. The last resort is to bring in assistance so the procedure can be completed quickly.

Four clients are assigned to a nurse. The nurse understands that the client with which condition would most benefit from ordered hyperbaric oxygen therapy? a compromised skin graft. a malignant tumor. pneumonia. hyperthermia.

a compromised skin graft. Explanation: A client with a compromised skin graft could benefit from hyperbaric oxygen therapy because increasing oxygenation at the wound site promotes wound healing. Hyperbaric oxygen therapy isn't indicated for malignant tumors, pneumonia, or hyperthermia.

A mother with a history of gestational hypertension gives birth to a neonate at 26 weeks' gestation. After the neonate receives surfactant through an endotracheal tube in the delivery room, a nurse takes the neonate to the neonatal intensive care unit (NICU), places the neonate on an overbed warmer, and provides mechanical ventilation. When the mother arrives in the NICU for the first time, the nurse's priority should be to explain the NICU visiting policy for the mother and family. enhance bonding by pointing out the neonate's features. obtain a family medical history. question the mother about her preterm labor.

enhance bonding by pointing out the neonate's features. Explanation: Pointing out neonate's features to the mother enables the mother to begin to bond with him. The nurse should encourage this important activity from the time of the neonate's admission to the NICU. Explaining the NICU visiting policy, obtaining a family medical history, and questioning the mother about her preterm labor don't take priority over enhancing maternal bonding.

The nurse is developing a primary disease prevention program for older adults. Which topic is the most appropriate? blood glucose screening for diabetes diet and exercise for people with heart disease immunizations for influenza range of motion exercises

immunizations for influenza Explanation: The three levels of prevention are primary, secondary, and tertiary. The most important topic to include in a program for older adults that is to emphasize primary prevention is the importance of receiving immunizations to prevent disease such as influenza, pneumonia, and shingles. The goal of primary prevention is to protect healthy people from developing a disease or injury. Immunization is an example of a primary prevention strategy. Secondary prevention involves taking action to slow or stop the progress of a disease. Monitoring blood glucose for clients with diabetes or initiating diet and exercise programs for people with heart disease are examples of secondary prevention. Tertiary preventions are treatments aimed to reduce the negative impact of established disease by restoring function and reducing disease-related complications. An example of tertiary prevention is performing passive and active range of motion exercises to prevent disability.

When developing a teaching plan for a group of parents with preschoolers about the most effective strategies for safety, the nurse should tell the parents to focus on: discussing the potential dangers to avoid with their child. modeling good examples of safe behavior. supervising the child when playing. using timeout when the child does something dangerous.

modeling good examples of safe behavior. Explanation: Young children tend to imitate what they see, and parents teach by example intentionally or not. Thus, role modeling examples of safe behavior is key. Discussing potential dangers is too abstract for preschoolers to understand, thereby making it harder for them to realize the cause and effect. Preschool children can be allowed some independence when playing as long as the parents have ensured the safety of the environment. While timeout has an important role in discipline, children may be repeating dangerous behaviors they have seen others model.

When developing a care plan for a hospitalized client, the nurse knows that children in which age-group are most likely to view illness as a punishment for misdeeds? infancy preschool age school age adolescence

preschool age Explanation: Preschool-age children are most likely to view illness as a punishment for misdeeds. Separation anxiety, although seen in all age-groups, is most common in older infants. Fear of death is typical of older school-age children and adolescents. Adolescents also fear mutilation.

An outbreak of lice has been reported in an elementary school. The nurse is training a group of parents and caregivers to assist in screening children for lice. Which findings should the nurse tell the parents and caregivers to report as evidence of lice? flaking of the scalp with pink, irritated exposed skin small white spots that adhere to the hair shaft, close to the scalp scaly, circumscribed patches on the scalp, with mild alopecia in these areas multiple tiny pustules on the scalp

small white spots that adhere to the hair shaft, close to the scalp Explanation: The small white spots that adhere to the hair shafts are the eggs, or nits, of lice. These are easy to see and cannot be brushed off like dandruff. Flaking of the scalp may indicate dandruff or a dry scalp. Scaly pustules, resulting from the scratching, may accompany a lice infestation, but nits would also be found on the hair shafts.

While assessing a neonate at age 24 hours, the nurse observes several irregularly shaped, red, flat patches on the back of the neonate's neck. The nurse interprets this as which finding? stork bite port-wine stain newborn rash café au lait spot

stork bite Explanation: Several irregularly shaped red patches, common skin variations in neonates, are termed stork bites. They eventually fade away as the neonate grows older. Port-wine stains are disfiguring darkish red or purplish skin discolorations on the scalp and face that may need laser therapy for removal. Newborn rash is typically generalized over the body, not localized to one body area, and is commonly raised. Café au lait spots are brown and typically found anywhere on the body. More than six spots or spots larger than 1.5 cm are associated with neurofibromatosis, a genetic condition of neural tissue.

The nurse is admitting a client to the hospital and fails to implement a turning and positioning schedule for the client identified as a high risk for impaired skin integrity. What are the legal actions that the nurse can be accountable for? Select all that apply. battery intentional tort unintentional tort defamation of character negligence

unintentional tort negligence Explanation: Negligence is an unintentional tort and applies because the nurse failed to implement proper skin care such as a turning schedule. Battery is an assault and did not occur with the failure to implement the turning schedule. Defamation of character is an intentional tort making derogatory remarks about the client which did not occur with this scenario.

Parents of a 2-year-old child with chronic otitis media are concerned that the disorder has affected their child's hearing. Which behavior suggests that the child has a hearing impairment? stuttering using gestures to express desires babbling continuously playing alongside rather than interacting with peers

using gestures to express desires Explanation: Using gestures instead of verbal communication to express desires — especially in a child older than age 15 months — may indicate a hearing or communication impairment. Stuttering is normal in children ages 2 to 4, especially boys. Continuous babbling is a normal phase of speech development in young children. In fact, its absence, not presence, would be cause for concern. Parallel play — playing alongside peers without interacting — is typical of toddlers. However, in an older child, difficulty interacting with peers or avoiding social situations may indicate a hearing deficit.

After the nurse instructs the parents of a 5-month-old infant about the purpose of the Denver Developmental Screening Test (DDST), which statement by the parents about what the test measures would indicate that the teaching was effective? "This test measures a child's IQ." "This test measures a child's emotional development." "This test measures a child's social and physical abilities." "This test measures a child's potential for future development."

"This test measures a child's social and physical abilities." Explanation: The Denver Developmental Screening Test (DDST) measures a child's social, language, and fine and gross motor skills by testing abilities that usually occur at a given age. The DDST is not designed to measure intelligence or emotional development nor does it necessarily predict future development.

A primiparous client diagnosed with cystitis at 48 hours postpartum who is receiving intravenous ampicillin asks the nurse, "Can I still continue to breastfeed my baby?" What should the nurse tell the client? "You can continue to breastfeed as long as you want to do so." "Alternate your breastfeeding with formula feeding to help you rest." "You'll need to discontinue breastfeeding until the antibiotic therapy is stopped." "You will need to modify your technique by manually pumping your breasts."

"You can continue to breastfeed as long as you want to do so." Explanation: The client can continue to breastfeed as often as she desires. Continuation of breastfeeding is limited only by the client's discomfort or malaise. Antibiotics for treatment are chosen carefully so that they avoid affecting the neonate through breast milk. Drugs such as sulfonamides, nitrofurantoin, and cephalosporins usually are not prescribed for breastfeeding mothers. Manual pumping of the breasts is not necessary.

A new nurse working on a mental health unit observes a senior nurse administer a parenteral dose of haloperidol to a client against the client's wishes. What should the new nurse do in response to this observation? Advise the nurse that he/she can be accused of battery. Inform the nurse that he/she can be accused of negligence. Ask the nurse if this is acceptable practice for this unit. Notify the licensing body of the nurse's behavior.

Advise the nurse that he/she can be accused of battery. Explanation: Battery is defined as an intentional and wrongful physical contact with a person that entails an injury or offensive touching. The other options are not correct because they do not describe the nurse's behavior.

Which intervention would be most appropriate to institute when a school-age child with burns becomes angry and combative when it is time to change the dressings and apply mafenide acetate? Ensure parental support during the dressing changes. Allow the child to assist in removing the dressings and applying the cream. Give the child permission to cry during the procedure. Allow the child to schedule the time for dressing changes.

Allow the child to assist in removing the dressings and applying the cream. Explanation: Expressions of anger and combativeness are often the result of loss of control and a feeling of powerlessness. Some control over the situation is regained by allowing the child to participate in care. Although having parental support during the dressing changes may be helpful, this action does nothing to allow the child control. Giving the child permission to cry may help with verbalizing feelings, but doing so does nothing to provide the child with control over the situation. Although allowing the child to determine the time for dressing changes may provide a sense of control over the situation, doing so is inappropriate because the dressing changes need to be performed as prescribed to ensure effectiveness and healing.

A client with intrauterine growth restriction is admitted to the labor and birth unit and started on an I.V. infusion of oxytocin. Which aspect of the client's care plan should the nurse revise? Carefully titrating the oxytocin based on the client's pattern of labor Monitoring vital signs, including assessment of fetal well-being, every 15 to 30 minutes Allowing the client to ambulate as tolerated Helping the client use breathing exercises to manage her contractions

Allowing the client to ambulate as tolerated Explanation: Because the fetus is at risk for complications, frequent and close monitoring is necessary. Therefore, the client shouldn't be allowed to ambulate. Carefully titrating the oxytocin, monitoring vital signs, including fetal well-being, and assisting with breathing exercises are appropriate actions to include in the care plan.

A parent brings her 6-year-old daughter to the pediatrician's office for evaluation. The child recently started wetting the bed and running a low-grade fever. A urinalysis is positive for bacteria and protein. A urinary tract infection (UTI) is diagnosed, and the child is prescribed antibiotics. Which nursing interventions are appropriate? Select all that apply. Limit fluids for the next few days to decrease the frequency of urination. Assess the parent's understanding of UTI and its causes. Instruct the parent to administer the antibiotic as prescribed, even if the symptoms diminish. Provide instructions only to the parent, not the child. Tell the parent to have the child wipe the back to the front after voiding and defecation.

Assess the parent's understanding of UTI and its causes. Instruct the parent to administer the antibiotic as prescribed, even if the symptoms diminish. Explanation: Assessing the parent's understanding of UTI and its causes provides the nurse with a baseline for teaching. The full course of antibiotics must be taken to eradicate the organism and prevent recurrence, even if the child's signs and symptoms decrease. Fluids should be encouraged, not limited, to prevent urinary stasis and help flush the organism from the urinary tract. Instructions should be given at the child's level of comprehension to help the child better understand the treatment and promote compliance. The child should wipe from the front to the back, not back to front, to minimize the risk of contamination after elimination.

A client, age 82, is admitted to an acute care facility for treatment of an acute flare-up of a chronic GI condition. In addition to assessing the client for complications of the current illness, the nurse monitors for age-related changes in the GI tract. Which age-related change increases the risk of anemia? Atrophy of the gastric mucosa Decrease in intestinal flora Increase in bile secretion Dulling of nerve impulses

Atrophy of the gastric mucosa Explanation: Atrophy of the gastric mucosa reduces hydrochloric acid secretion; this, in turn, impairs absorption of iron and vitamin B12, increasing the risk of anemia as a person ages. A decrease in hydrochloric acid increases, not decreases, intestinal flora; as a result, the client is at increased risk for infection, not anemia. A reduction, not increase, in bile secretion may lead to malabsorption of fats and fat-soluble vitamins. Dulling of nerve impulses associated with aging increases the risk of constipation, not anemia

A primigravid client admitted to the labor area in early labor tells the nurse that her brother was born with cystic fibrosis and she wonders if her baby will also have the disease. The nurse can tell the client that cystic fibrosis is: X-linked recessive and the disease will only occur if the baby is a boy. X-linked dominant and there is no likelihood of the baby having cystic fibrosis. Autosomal recessive and that unless the baby's father has the gene, the baby will not have the disease. Autosomal dominant and there is a 50 per cent chance of the baby having the disease.

Autosomal recessive and that unless the baby's father has the gene, the baby will not have the disease. Explanation: Cystic fibrosis and other inborn errors of metabolism are inherited as autosomal recessive traits. Such diseases do not occur unless there are two genes for the disease present. If one of the parents does not have the gene, the child will not have the disease. X-linked recessive genes can result in hemophilia A or color blindness. X-linked recessive genes are present only on the X chromosome and are typically manifested in the male child. X-linked dominant genes, which are located on and transmitted only by the female sex chromosome, can result in hypophosphatemia, an inborn error of metabolism marked by abnormally low serum alkaline phosphatase activity and excretion of phosphoethanolamine in the urine. This disorder is manifested as rickets in infants and children. Autosomal dominant gene disorders can result in muscular dystrophy, Marfan's syndrome, and osteogenesis imperfecta (brittle bone disease). Typically, a dominant gene for the disease trait is present along with a corresponding healthy recessive gene.

During a routine health assessment, a mother tells the nurse that her 2-year-old child is using a potty seat but is still having problems toilet training. Which suggestion would be most appropriate? Offer the child more praise each time. Use a potty chair instead of a potty seat. Focus on the "accidents" that occur during training. Defer training until the child is developmentally ready.

Defer training until the child is developmentally ready. Explanation: The most common reason for failed toilet training is that the child is simply not developmentally ready for training. Even with appropriate rewards and proper equipment, the child who is not ready for training will not be able to learn voluntary control. Offering praise is important and using a potty chair may help, but these measures are only effective when the child is developmentally ready. "Accidents" during training should be ignored. They are usually caused by the child's incomplete sphincter control and poor recognition of the impending need to defecate until it is too late to get to the potty chair.

To meet the developmental needs of an 8-year-old child who is confined to home with osteomyelitis, what goal should the nurse include in the care plan? Encourage the child to communicate with schoolmates. Encourage the parents to stay with the child. Allow siblings to visit freely throughout the day. Talk to the child about his interests twice daily.

Encourage the child to communicate with schoolmates. Explanation: Encouraging contact with schoolmates allows the school-age child to maintain and develop socialization with peers, an important developmental task of this age group. Although having family visits and interacting with the child are important, they do not meet the child's developmental needs. Talking to the child about his interests is important, but encouraging contact with schoolmates is crucial to maintain and develop socialization with peers.

When discussing spirituality with a mother of an 8-year-old child, the nurse instructs the mother that children of this age Enjoy lore and legends of religious groups. Are influenced by their peer groups. Are moved deeply by spirituality. May question religious authority.

Enjoy lore and legends of religious groups. Explanation: Childhood is the period when lore, legends, language, and symbols of a particular religious group are best presented.

The nurse is planning care with the parents of a 4-month-old infant with heart failure and congenital heart disease. The parents report that their child tires easily. Which intervention is a priority for this child? Increase the number of rest periods Prevent infection. Restrict the child's movements. Have more frequent health check ups.

Increase the number of rest periods Explanation: An infant with congenital heart disease and congestive heart failure usually tires easily due to lack of effective oxygenation. Nursing care needs to focus on allowing the infant to have frequent rest periods. Infants with congenital heart disease and heart failure are not necessarily at risk for more infections than other infants. An infant with congenital heart disease usually exhibits normal physical mobility, and the parents should encourage normal growth and development. The child's movements are not the cause of the fatigue. Unless there is a need for additional follow-up, this infant will not require more frequent health checkups.

The nurse is obtaining a health history from a client of Puerto Rican descent. Which of the following is most likely to be a health problem with a cultural connection for this client? Lactose enzyme deficiency. Tuberculosis. Sickle-cell anemia. Suicide.

Lactose enzyme deficiency. Explanation: Common health problems that may affect the Puerto Rican population include lactose enzyme deficiency and parasitic diseases. Tuberculosis is a common health problem for the Native American population. Sickle-cell anemia predominantly affects the African-American population, and suicide is a common health problem for the Native American and white middle-class populations.

Which nursing action would be most successful in gaining a preschooler's cooperation in preparing for surgery? Have the child take their own underwear. Encourage the child to use the hospital blanket as a transition object so the child's won't be lost. Let the child choose which parent can accompany the child to the preoperative waiting area. Let the child choose whether to ride to the preoperative area on a stretcher or in a wagon.

Let the child choose whether to ride to the preoperative area on a stretcher or in a wagon. Explanation: Giving the child a choice would promote cooperation, and children commonly prefer a nonthreatening method of travel such as a wagon. Having the child take off their own underwear isn't appropriate because preschoolers commonly have a fear of genital mutilation; the child would likely resist removing underwear. Children usually won't transfer feelings of security objects to another object such as a hospital blanket. Both parents are encouraged to accompany the child to the preoperative area, so having the child choose one parent isn't appropriate.

The nurse is asked to develop an in-service to explain documents guiding professional nursing practice on the obstetrical unit. One of the documents included is the Code of Ethics. The nurse correctly explains that the Code of Ethics asks nurses to demonstrate which behaviors? Select all that apply. Maintain integrity and shape social policy. Develop, maintain, and improve health care environments. Ask the hospital for fair compensation for work. Be responsible and accountable for individual practice. Increase professional competence and personal growth.

Maintain integrity and shape social policy. Develop, maintain, and improve health care environments. Be responsible and accountable for individual practice. Increase professional competence and personal growth. Explanation: The Code of Ethics describes those actions by the nurse that guide their practice. It is the responsibility of each nurse to be active in determining policy for health care for all citizens and assuring that the way nursing is practiced is of the highest caliber. Nursing needs to participate in the development of health care of the future, while caring for all members of society. In order to be productive in shaping policy, nurses need to be politically astute while growing personally and professionally to meet the needs of clients. The Code of Ethics does not address compensation for work.

A 15-month-old has just received routine immunizations, including DTaP, IPV, and MMR. What information would the nurse give to the parents before they leave the office? Select all that apply. Minor symptoms can be treated with acetaminophen. Analgesics for discomfort are suggested following arrival home. Call the office if the toddler develops a temperature above 103°F (39.4°C), seizures, or difficulty breathing. Discomfort at the immunization site and mild fever are common. The immunizations prevent the toddler from contracting associated diseases. The toddler should restrict activity for the remainder of the day.

Minor symptoms can be treated with acetaminophen. Call the office if the toddler develops a temperature above 103°F (39.4°C), seizures, or difficulty breathing. Discomfort at the immunization site and mild fever are common. Explanation: Minor symptoms, such as soreness at the immunization site and mild fever, can be treated with acetaminophen or ibuprofen. While some infants may experience discomfort, not all do; thus, analgesics are only given per healthcare provider guidelines and not routinely suggested to all. The parents would notify the clinic if serious complications (such as a fever above 103°F [39.4°C], seizures, or difficulty breathing) occur. Minor discomforts, such as soreness and mild fever, are common after immunizations. Immunizing the child decreases the health risks associated with contracting certain diseases; it does not prevent the toddler from acquiring them. Although the child may prefer to rest after immunizations, it is not necessary to restrict activity.

The nurse is caring for a hospitalized toddler who is having a temper tantrum. What is the most realistic approach for the nurse to use to manage the child's temper tantrum? Offer material or emotional bribes. Offer disapproval and then ignore the tantrum. Punish the child after the tantrum. Display anger at the child during the tantrum.

Offer disapproval and then ignore the tantrum. Explanation: Stating one's disapproval and then ignoring the tantrum generally results in a quick resolution of the tantrum. Offering material or emotional bribes may actually increase the frequency of tantrums. Punishing the child does not decrease the frequency of tantrums because the tantrums are generated by an inability to express feelings. Mirroring the tantrum behavior reinforces that style of communication.

A client, who underwent femoral-popliteal (fem-pop) bypass surgery, is scheduled to return from the post-anesthesia care unit. Which staff member should receive this client? Registered nurse with one year of experience Licensed practical nurse (LPN) with five years of experience Nursing assistant with 15 years of experience Charge nurse with 10 years of experience

Registered nurse with one year of experience Explanation: Because this client requires frequent neurovascular assessments, a registered nurse should receive him. Although experienced and able to collect data, an LPN doesn't have the education to assess this client. The nursing assistant lacks the necessary assessment skills. The charge nurse needs to be available to direct the care of other clients.

While caring for a mother and her 1-day-old neonate born vaginally at 30 weeks' gestation, the nurse explains about the neonate's need for gavage feeding at this time instead of the mother's plan for bottle feeding. What should the nurse include as the rationale for this feeding plan? The neonate has difficulty coordinating sucking, swallowing, and breathing. A high-calorie formula, presently needed at this time, is more easily delivered via gavage. Gavage feedings can minimize the neonate's increased risk of developing hypoglycemia. This type of feeding, easily given in the isolette, decreases the neonate's risk of cold stress.

The neonate has difficulty coordinating sucking, swallowing, and breathing. Explanation: Before 32 weeks' gestation, most neonates have difficulty coordinating sucking and swallowing reflexes along with breathing. Increased respiratory distress may occur with bottle-feeding. Bottle-feedings can be given after the neonate shows sucking and swallowing behaviors. High-calorie formulas can be given by bottle or by gavage feeding. Although frequent feeding prevents hypoglycemia, the feeding does not have to be given via a gavage tube. Although these neonates can be stressed by cold, they can be kept warm with blankets while being bottle-fed or fed while in the warm isolette environment.

A neonate with heart failure is being discharged home. When teaching the parents about the neonate's nutritional needs, what should the nurse explain? Fluids must be restricted. Decreased activity level should reduce the need for additional calories. The formula should be low in sodium. The neonate may need a more calorie-dense formula.

The neonate may need a more calorie-dense formula. Explanation: Neonates with heart failure may need calorie-dense formula to provide extra calories for growth. Fluids should not be restricted because the nutritional requirements are based on calories per ounce of formula. Decreasing fluid intake will decrease calories needed for growth. These neonates may have limited energy due to their heart condition but have a high caloric need to stimulate proper growth and development. The sodium level should be at a normal level to ensure adequate fluid and electrolyte balance unless prescribed by the health care provider (HCP) .

The nurse is caring for an infant diagnosed with nonorganic failure to thrive. Which action should be included in the plan of care for the infant? Suggesting to the infant's caregiver to continue to try to feed the infant even when the infant is crying. Weighing the unclothed infant at the same time every day. Reporting the caregiver to social services for suspected abuse. Requiring the caregiver to attend a community support group prior to discharge.

Weighing the unclothed infant at the same time every day. Explanation: Daily weights are an appropriate intervention for an infant with failure to thrive. It would be inappropriate for the nurse to encourage the caregiver to continue to try to feed the infant when crying because the infant may develop further aversion to eating. It is also inappropriate to assume that abuse has taken place; there is no information in the stem to suggest this. The caregiver would benefit from a community support group; however, the nurse cannot require the caregiver to attend a community support group prior to discharge.

The client asks the nurse, "How can I tell whether my baby is spitting up or vomiting?" The nurse explains that, in contrast to regurgitated material, vomited material is characterized by: one-time occurrence during feeding. a curdled appearance. a brownish color. usually occurring prior to a feeding.

a curdled appearance. Explanation: Vomited material has been digested and looks like curdled milk with a sour odor. Vomiting usually occurs between feedings and empties the stomach of its contents. It also tends to be forceful or projectile. In contrast, regurgitation is undigested material; it does not have a sour odor, and occurs during or immediately after feeding. Vomiting is unrelated to a feeding. Also, vomiting continues until the stomach is empty, while regurgitation is usually only about 5 to 10 mLs. Vomited material is typically white and curdled in appearance. A brownish color suggests old blood. Vomiting usually occurs between feedings, whereas regurgitation occurs during or immediately after feeding.

An apartment fire spreads to seven apartment units. Victims suffer burns, minor injuries, and broken bones from jumping from windows. Which client should be transported first? a woman who is 5 months pregnant with no apparent injuries a middle-aged man with no injuries who has rapid respirations and coughs a 10-year-old with a simple fracture of the humerus who is in severe pain a 20-year-old with first-degree burns on her hands and forearms

a middle-aged man with no injuries who has rapid respirations and coughs Explanation: The man with respiratory distress and coughing should be transported first because he is probably experiencing smoke inhalation. The pregnant woman is not in imminent danger or likely to have a precipitous childbirth. The 10-year-old is not at risk for infection and could be treated in an outpatient facility. First-degree burns are considered less urgent.

The nurse is working at the local family planning clinic completing family education. When devising a teaching plan, in which client group would the nurse stress the importance of an annual Papanicolaou test? clients with a history of recurrent candidiasis clients who were pregnant before age 20 clients infected with the human papillomavirus (HPV) clients with a long history of oral contraceptive use

clients infected with the human papillomavirus (HPV) Explanation: Annual Papanicolaou testing is a screening to detect potential precancerous and cancerous cells in the endocervical canal of the female reproductive system. HPV causes genital warts, which are associated with an increased incidence of cervical cancer. Recurrent candidiasis, pregnancy before age 20, and use of oral contraceptives do not increase the risk of cervical cancer.

Assessment of a primigravid client in active labor who has had no analgesia or anesthesia reveals complete cervical effacement, dilation of 8 cm, and the fetus at 0 station. The nurse should expect the client to exhibit which behavior during this phase of labor? excitement loss of control numbness of the legs feelings of relief

loss of control Explanation: Assessment findings indicate that the client is in the transition phase of labor. During this phase, it is not unusual for clients to exhibit a loss of control or irritability. Leg tremors, nausea, vomiting, and an urge to bear down also are common. Excitement is associated with the latent phase of labor. Numbness of the legs may occur when epidural anesthesia has been given; however, it is rare when no anesthesia is given. Feelings of relief generally occur during the second stage, when the client begins bearing-down efforts.

The nurse must be aware that adverse drug reactions in the elderly client may be underestimated because: adverse reactions rarely have an atypical presentation. cognitive impairment is an expected finding in the elderly client. physical or psychological symptoms are attributed to the effects of aging. excess sedation is difficult to assess in the elderly client.

physical or psychological symptoms are attributed to the effects of aging. Explanation: The elderly client commonly has vague or atypical responses to medications and diseases that are erroneously attributed to aging. A new cognitive change needs to be investigated and is not an expected change with aging. Changes in a client's behavior should be investigated to see whether there is a relation to excessive sedation. The nurse can interview the family members to obtain information.

The nurse is performing the initial assessment on a middle age woman recently diagnosed with Cushing's syndrome. The nurse reviews the history and physical (see chart). The nurse should develop a plan with the client to manage which effects? Select all that apply. low blood volume risk for injury slow healing changes in physical appearance risk for infection

risk for injury slow healing changes in physical appearance risk for infection Explanation: Cushing's syndrome results from excessive levels of cortisol. Some effects of excessive adrenocortical activity include musculoskeletal changes, and the client may be at risk for injury and falls. There is excessive protein catabolism causing muscle wasting, decreased inflammatory response, and potential for delayed healing and infection. The increased cortisol levels cause a moon-faced appearance to which clients must adjust. The skin becomes thin and fragile, and the client is also at risk for infection. Increased cortisol levels do not cause deficient fluid volume.

The nurse is assessing a 6-month-old and notices no pincer grasp on either hand. The parent asks the nurse if this is abnormal. The nurse correctly responds that: the infant may be at risk for developmental disabilities. the 6-month-old does not normally have a pincer grasp yet. the physician will be in to check the child and the parent can ask the physician. the physician will need to ask questions about the infant's siblings and their development.

the 6-month-old does not normally have a pincer grasp yet. Explanation: The nurse would be incorrect to inform the parent that the infant could be at risk for developmental disabilities, because the pincer grasp does not present itself until around 9 months of age. Deferring the question to the physician is ignoring the mother's concern, and the nurse can manage this question. There is no need to ask the physician about the infant's other sibilings.

A client is scheduled for bowel resection with anastomosis involving the large intestine. The nurse formulates the nursing diagnosis of Risk for infection. The nurse knows that the risk for infection is most likely related to: major surgery required by bowel resection. the presence of bacteria at the surgical site. malnutrition secondary to bowel resection with anastomosis. the presence of a nasogastric (NG) tube postoperatively.

the presence of bacteria at the surgical site. Explanation: The nurse should add "Related to the presence of bacteria at the surgical site" to the diagnosis of Risk for infection. The large intestine normally contains bacteria because its alkaline environment permits growth of organisms that putrefy and break down remaining proteins and indigestible residue. These organisms include Escherichia coli, Aerobacter aerogenes, Clostridium perfringens, and Lactobacillus. Although bowel resection with anastomosis is considered major surgery, it poses no greater risk of infection than any other type of major surgery. Malnutrition seldom follows bowel resection with anastomosis because nutritional absorption (except for some water, sodium, and chloride) is completed in the small intestine. An NG tube is placed through a natural opening, not a wound, and therefore does not increase the client's risk of infection.

The nurse is providing an education program to a group of adolescents on the importance of testicular self-examinations. One of the participants asks the nurse, "when is the best time to do the examination?" What is the best response by the nurse? when you first arise in the morning when you are in the shower or immediately after in the evening prior to going to bed prior to urinating in the morning

when you are in the shower or immediately after Explanation: Testicular cancer occurs most frequently between the ages of 15 and 34; therefore, boys should begin doing testicular self-examinations at age 12, which will help them become familiar with the normal contours and consistency of their genital structures.The nurse should inform the group that the best time to perform a testicular self-examination is in the shower or immediately afterward because the scrotum is relaxed. When the male first rises in the morning, in the evening, or prior to urinating, the scrotum is not in the optimal condition for the examination.

A registered nurse (RN) is assigning care on the oncology unit and assigns the client with Kaposi's sarcoma and human immunodeficiency virus (HIV) infection to the unlicensed assistive personnel (UAP). This person does not want to care for this client. How should the nurse respond? "I will assign this client to another nurse." "I will help you take care of this client so you are confident with his care." "You seem worried about this assignment." "I will review blood and body fluid precautions with you."

"You seem worried about this assignment." Explanation: The RN assigning care should first give the UAP the opportunity to explore concerns and fears about caring for a client with HIV infection. Reassigning care for this client, assisting with care, and reviewing precautions do not address the present concern or create an environment that will generate useful knowledge regarding future assignments for client care.

When documenting the care of a client, the nurse is aware of the need to use abbreviations conscientiously and safely. This includes: Limiting abbreviations to those approved for use by the institution. Using only abbreviations whose meaning is self-evident to an educated health professional. Ensuring the abbreviations are understandable to clients who may seek access to their health records. Using those abbreviations defined in full at another location in the client's chart.

Limiting abbreviations to those approved for use by the institution. Explanation: In addition to avoiding abbreviations prohibited by the Joint Commission, it is important to limit the use of abbreviations to those recognized and approved for use by the institution where care is being provided. The criterion of being "self-evident" is not an accurate or consistent basis for choosing abbreviations. Approved abbreviations need not be defined in full within the chart, and the client's potential understanding of abbreviations is not taken into account during the process of documentation. As a result, clients need the assistance of a member of the care team when reviewing their chart.

When witnessing an adult client's signature on a consent form for a procedure, the nurse verifies that the consent was obtained in an appropriate manner. What information should the nurse verify? Select all that apply. that there was adequate disclosure of information that the client understood the information that there was voluntary consent on the client's part that the client has full awareness of the potential complications that the client's relative, spouse or legal guardian was present

that there was adequate disclosure of information that the client understood the information that there was voluntary consent on the client's part that the client has full awareness of the potential complications Explanation: The role of the nurse in witnessing the signing of the consent is to witness that the client is informed of the procedure, understands the information, is aware of potential complications, and is signing of his or her own free will. It is not necessary for a spouse, relative, or guardian to be present.

After teaching a community class to new parents, the nurse evaluates client understanding of strategies to prevent sudden infant death syndrome (SIDS). Which statements indicates appropriate understanding? "I will place my baby in a supine position for sleep during the first year." "I will use a baby monitor so I can hear if my baby stops breathing." "I will avoid feeding my baby cereal for the first 6 months." "I will keep my baby's crib at our bedside when we sleep."

"I will place my baby in a supine position for sleep during the first year." Explanation: SIDS has no specific cause but occurs most often in male infants who were low birth weight, were placed on their stomachs for sleep, and had mothers who used tobacco or alcohol. Caucasian infants have a lower risk than children of color. SIDS can occur anytime between ages 1 week and 1 year. The incidence peaks at ages 2-4 months.

A client has sought care because she has recently returned from a trip to Central and South America and is concerned that she might have contracted the Zika virus. What question should the nurse prioritize during the client interview? "Is there any chance that you might be pregnant?" "Were you vaccinated against the Zika virus before you left on your trip?" "How would you describe your overall level of health before you left?" "Were you ever on a farm or ranch when you were on your trip?"

"Is there any chance that you might be pregnant?" Explanation: Infection with the Zika virus is associated with an increased risk of microcephaly. There is no vaccine, and it is spread by mosquitos; being on a farm or ranch is not a risk factor. The client's overall level of health is important during any assessment, but this is not directly related to the possibility of Zika virus infection.

A nurse is teaching parents about the nutritional needs of their full-term infant, age 2 months, who's breast-feeding. Which response shows that the parents understand their infant's dietary needs? "We won't start any new foods now." "We'll start the baby on skim milk." "We'll introduce cereal into the diet now." "We should add new fruits to the diet one at a time."

"We won't start any new foods now." Explanation: The parents show understanding of their infant's dietary needs by stating they won't start any new foods. Breast milk provides all the nutrients a full-term infant needs for the first 6 months. They shouldn't provide skim milk because it doesn't have sufficient fat for infant growth. The parents also shouldn't provide solid foods, such as cereal and fruit, before age 6 months because an infant's GI tract doesn't tolerate them well.

The nurse is caring for an eight-year-old child who arrived at the emergency department with chemical burns to both legs. What is the priority intervention for this child? Diluting the chemicals Applying sterile dressings Applying topical antibiotics Debriding and grafting the burns

Diluting the chemicals Explanation: Diluting the chemical is the priority. It will help remove the chemical and stop the burning process. The remaining treatments are initiated after dilution.

Using Nägele's rule for a client whose last normal menstrual period began on May 10, the nurse determines that the client's estimated date of birth is what date? January 13 January 17 February 13 February 17

February 17 Explanation: When using Nägele's rule to determine the estimated date of childbirth, the nurse would count back 3 calendar months from the first day of the last menstrual period and add 7 days. This means the client's estimated date is February 17.

A female client informs the nurse that her husband is concerned about her sexual response. The client reports that during stimulation, her husband has noticed her clitoris disappears, and he wonders if she is enjoying the experience despite her positive responses to his stimulation. The nurse explains that building excitement and retraction of the clitoris are normal characteristics of which stage of the sexual response cycle? Plateau phase. Excitement phase. Orgasm. Resolution phase.

Plateau phase. Explanation: During the plateau phase, the intensity of excitement increases but not enough to cause orgasm. The female clitoris retracts and disappears under the clitoral hood. This phase may last for 15 to 20 minutes. The excitement phase is initiated by erotic stimulation and arousal, and physiologic changes begin. Orgasm defines the climax and sexual explosion of the tension that has been building during the preceding phases. The resolution phase is the return to normal body function.

A nurse is obtaining a history from a new client in the cardiovascular clinic. When investigating for childhood diseases and disorders associated with structural heart disease, which finding should the nurse consider significant? Croup Rheumatic fever Severe staphylococcal infection Medullary sponge kidney

Rheumatic fever Explanation: Childhood diseases and disorders associated with structural heart disease include rheumatic fever and severe streptococcal (not staphylococcal) infections. Croup — a severe upper airway inflammation and obstruction that typically strikes children ages 3 months to 3 years — may cause latent complications, such as ear infection and pneumonia. However, it doesn't affect heart structures. Likewise, medullary sponge kidney, characterized by dilation of the renal pyramids and formation of cavities, clefts, and cysts in the renal medulla, may eventually lead to hypertension but doesn't damage heart structures.

The mother asks the nurse why peanuts are one of the worst things a child can aspirate. What should the nurse include in the explanation as the main reason for the problem associated with aspirating peanuts? They swell when wet. They contain a fixed oil. They decompose when wet. They contain sodium.

They swell when wet. Explanation: Peanuts swell and become soft when moistened with bronchial secretions, making them difficult to remove. Although peanuts contain a fixed oil that can cause lipoid pneumonia, begin to decompose when wet, and contain sodium, these factors do not make them particularly dangerous when aspirated.

Which teaching approach for the client with chronic renal failure who has difficulty concentrating due to high uremia levels would be most appropriate? Provide all needed teaching in one extended session. Validate the client's understanding of the material frequently. Conduct a one-on-one session with the client. Use video clips to reinforce the material as needed.

Validate the client's understanding of the material frequently. Explanation: Uremia can cause decreased alertness, so the nurse needs to validate the client's comprehension frequently. Because the client's ability to concentrate is limited, short lessons are most effective. If family members are present at the sessions, they can reinforce the material. Written materials that the client can review are superior to videos because the client may not be able to maintain alertness during the viewing of the videos.

A nurse is assessing a pregnant client in the second trimester. The nurse weighs the client, then compares the current and previous weights. During the second trimester, how much weight should the client gain per week? 0.5 lb (0.23 kg) 1 lb (0.45 kg) 1.5 lb (0.68 kg) 2 lb (0.91 kg)

1 lb (0.45 kg) Explanation: During the second and third trimesters, weight gain should average about 1 lb per week in a client with a single fetus. A client with a multiple-fetus pregnancy should gain about 1.5 lb per week, on average, during the second half of pregnancy.

When teaching a primaparous client about neonatal reflexes the nurse determines that teaching about the rooting reflex has been effective when the mother identifies what as the age at which the rooting reflex disappears? 2 weeks to 1 month 6 weeks to 2 months 3 to 4 months 5 to 6 months

3 to 4 months Explanation: The rooting reflex, stimulated by touching the upper lip or cheek before a feeding, disappears by the age of 3 to 4 months. A rooting reflex that disappears before 2 months of age or persists beyond 4 months of age requires further evaluation of neurologic capabilities.

The nurse is teaching a group of parents about the risk of airway obstruction in young children. What information is most appropriate for the nurse to share regarding the risk of airway obstruction? "A large tongue helps prevent objects from obstructing the airway." "A small airway makes it easier for foreign objects to cause obstruction." "A thin chest wall makes it easier to expel objects obstructing the airway." "A child's airway expands easily to help prevent airway obstruction."

"A small airway makes it easier for foreign objects to cause obstruction." Explanation: A child's small airway increases the risk of airway obstruction from small foreign objects. Relatively small amounts of mucus, blood, or edema can lead to respiratory failure. Likewise, small amounts of swelling may result in a great reduction in airway diameter.

During a routine physical examination on a 75-year-old female client, a nurse notes that the client is 5 feet, 3/8 inches (1.6 m) tall. The client states, "How is that possible? I was always 5 feet and 1/2 inches (1.7 m) tall." Which statement is the best response by the nurse? "After age 40, height may show a gradual decrease as a result of spinal compression" "After menopause, the body's bone density declines, resulting in a gradual loss of height." "There may be some slight discrepancy between the measuring tools used." "The posture begins to stoop after middle age."

"After menopause, the body's bone density declines, resulting in a gradual loss of height." Explanation: The nurse should tell the client that after menopause, the loss of estrogen leads to a loss in bone density, resulting in a loss of height. This client's history doesn't indicate spinal compression. Telling the client that measuring tools used to obtain the client's height may have a discrepancy or that the posture begins to stoop after middle age doesn't address the client's question.

A mother and grandmother bring a 2-month-old infant to the clinic for a routine checkup. As the nurse weighs the infant, the grandmother asks, "Shouldn't the baby start eating solid food? My kids started on cereal when they were 2 weeks old." Which response by the nurse would be appropriate? "The baby is gaining weight and doing well. There is no need for solid food yet." "Things have changed a lot since your children were born." "Babies can't digest solid food properly until they're 3 or 4 months old." "Introducing solid food early leads to eating disorders later in life."

"Babies can't digest solid food properly until they're 3 or 4 months old." Explanation: Stating that babies can't digest solid food properly is correct because infants younger than 3 or 4 months lack the enzymes needed to digest complex carbohydrates. Saying that there's no need for solid food doesn't address the grandmother's question directly. Saying that things have changed is a cliché that may block further communication with the grandmother. Stating that introducing solid food early leads to eating disorders is incorrect because no evidence suggests that this occurs.

When the nurse instructs a pregnant client with a history of varicose veins about strategies to promote comfort, which client statement indicates that the teaching has been successful? "Lying down with my feet elevated should help." "Support hose can be put on just before bedtime." "Restricting milk intake may provide some relief." "Wearing knee-high stockings is better than pantyhose."

"Lying down with my feet elevated should help." Explanation: The enlarging uterus exerts pressure on blood vessels carrying blood to and from the lower part of the body, especially the extremities, predisposing the client to varicosities. Prevention and management of varicosities includes lying down with feet elevated several times a day to promote venous return and avoiding anything that constricts the legs or thighs, such as round garters or knee-high hose. Supportive hose or elastic stockings may be helpful but should be applied as soon as the client awakens in the morning. Restriction of milk intake has no effect on varicosities. Knee-high stockings could cause constriction and should be avoided.

The nurse is instructing a client with chronic obstructive pulmonary disease how to do pursed-lip breathing. In which order from first to last should the nurse explain the steps to the client? All options must be used. 1 "Relax your neck and shoulder muscles." 2 "Breathe in normally through your nose for two counts (while counting to yourself, one, two)." 3 "Pucker your lips as if you were going to whistle." 4 "Breathe out slowly through pursed lips for four counts (while counting to yourself, one, two, three, four)."

"Relax your neck and shoulder muscles." "Breathe in normally through your nose for two counts (while counting to yourself, one, two)." "Pucker your lips as if you were going to whistle." "Breathe out slowly through pursed lips for four counts (while counting to yourself, one, two, three, four)." Explanation: The nurse should first instruct the client to relax the neck and the shoulders and then take several normal breaths. After taking a breath in, the client should pucker the lips, and finally breathe out through pursed lips.

The nurse is making assignments for the next shift. Which client can be assigned to a licensed practical nurse/licensed vocational nurse (LPN/LVN)? Select all that apply. A client who just had coronary artery bypass graft (CABG) A client who needs initial admission assessment A client who needs assistance with colostomy irrigation A client who is receiving glargine subcutaneously A client who has C3 to C5 spine injury

A client who needs assistance with colostomy irrigation A client who is receiving glargine subcutaneously Explanation: An LPN/LVN can perform colostomy irrigation and administer subcutaneous injections. A client who just had CABG is unstable and needs to be monitored by an RN. The initial admission assessment should also be performed by an RN. C3 to C5 injury may cause respiratory compromise. Possible paralysis of diaphragm due to phrenic nerve involvement may occur. This client is unstable and should be assigned to an RN.

A 19-year-old nulligravid client visiting the clinic for a routine examination asks the nurse about cervical mucus changes that occur during the menstrual cycle. Which information would the nurse expect to include in the client's teaching plan? About midway through the menstrual cycle, cervical mucus is thick and sticky. During ovulation, the cervix remains dry without any mucus production. As ovulation approaches, cervical mucus is abundant and clear. Cervical mucus disappears immediately after ovulation, resuming with menses.

As ovulation approaches, cervical mucus is abundant and clear. Explanation: As ovulation approaches, cervical mucus is abundant and clear, resembling raw egg white. Ovulation generally occurs 14 days (±2 days) before the beginning of menses. During the luteal phase of the cycle, which occurs after ovulation, the cervical mucus is thick and sticky, making it difficult for sperm to pass. Changes in the cervical mucus are related to the influences of estrogen and progesterone. Cervical mucus is always present.

The unlicensed assistive personnel (UAP) reports to the nurse that the client with an abdominal hysterectomy who returned from the recovery room 1 hour earlier has saturated the blue pad with bright red blood. What should the nurse do? Call the surgeon to report the bleeding. Ask the UAP to obtain vital signs while the nurse calls the surgeon. Ask the UAP to increase the flow of IV fluids to prevent shock. Assess the client again in 15 minutes before the nurse takes any further action.

Ask the UAP to obtain vital signs while the nurse calls the surgeon. Explanation: The surgeon should be notified when a client who has had an abdominal hysterectomy develops vaginal bleeding that saturates a blue pad in 1 hour, and care should be managed so that other personnel can obtain vital signs while the nurse contacts the surgeon. The client may need to have IV fluids increased, but the surgeon needs to be notified first. Waiting 15 minutes while the client is having bright-red bleeding is an unsafe nursing action; the client may lose a large amount of blood.

An unlicensed nursing personnel (UAP) recorded a client's 0600 blood glucose level as 126 mg/dL (7 mmol/L) instead of 216 mg/dL (12 mmol/L). The UAP did not recognize the error until 0900 but reported it to the nurse right away. What should the nurse do first? Complete an incident report. Wait and observe the client for symptoms of hyperglycemia. Reprimand the UAP for the error. Call the health care provider (HCP) and complete an incident report.

Call the health care provider (HCP) and complete an incident report. Explanation: The error should be reported to the HCP promptly; the HCP may write additional prescriptions. The nurse should complete an incident report because a potentially dangerous event happened during the client's care. The nurse should observe the client for symptoms of hyperglycemia but first must call the HCP and complete an incident report. The UAP does not need to be reassigned for this error. The nurse does not need to reprimand the UAP for the error because the UAP already knows an error was made and has reported it to the nurse.

A primigravid client at 16 weeks' gestation visits the clinic for a routine examination. The client tells the nurse that she knows someone whose baby was born with congenital toxoplasmosis. What should the nurse instruct the client to do to prevent transmission of the toxoplasmosis protozoan? Avoid contact with anyone diagnosed with this disease. Consider a course of prophylactic penicillin as prevention. Plan to be vaccinated for this condition at the next visit. Cook all meats, such as beef and pork, thoroughly.

Cook all meats, such as beef and pork, thoroughly. Explanation: Toxoplasmosis is a protozoal infection caused by Toxoplasma gondii, which is transmitted through ingestion of raw or undercooked meat, through contact with infected cat feces, or across the placental barrier from the mother to the fetus. The mother should be instructed to cook all meats thoroughly, avoid touching the mucous membranes when handling raw meat, thoroughly clean all kitchen surfaces that have come in contact with raw meat, avoid uncooked eggs, and avoid contact with cat litter boxes and cat feces. The disease is not spread by contact with an infected person. Although prophylactic penicillin may be used for pregnant clients who test positive for group B streptococcus, penicillin is not used to treat toxoplasmosis. Toxoplasmosis may be treated with a combination of pyrimethamine and sulfadiazine, accompanied by folic acid to reduce the toxicity of the other two drugs. However, controversy exists about whether to treat the mother. There is no vaccine for toxoplasmosis. Although a vaccine exists for rubella, this is given within 72 hours postpartum if the client is not immune.

A nurse overhears a second nurse making plans to meet a hospitalized client for a drink after the client has been discharged. Which of the following is the best action for the first nurse to take? Tell the client not to meet the nurse socially. Report the conversation to the nurse manager. Encourage the interaction with the client after discharge. Discuss the conversation directly with the other nurse.

Discuss the conversation directly with the other nurse. Explanation: Planning to meet a client for a social event while the client is still hospitalized could blur the boundaries of the therapeutic relationship. This could result in an unhealthy outcome for the client. The nurse should take the second nurse aside and point out that the behavior is inappropriate and not in the client's best interest. The other options do not demonstrate behavior that is consistent with the therapeutic nurse-client relationship.

Assessment of a 6-week-old infant reveals weight and length in the 50th percentile for his age and a head circumference at the 95th percentile. What should the nurse do first? Assess motor and sensory function of the legs. Examine the fontanels and sutures. Advise the mother of the need for follow-up in 1 month. Obtain a written consent for transillumination.

Examine the fontanels and sutures. Explanation: Head circumference usually parallels the percentile for length. The discrepancy found requires close and immediate attention because it could indicate hydrocephalus with its potential for brain damage. Therefore, the nurse should examine the fontanels and sutures. In an infant, bulging fontanels and widening cranial sutures are signs of increasing intracranial pressure related to increased cerebrospinal fluid in the cranial space. Assessing motor and sensory function of the legs would be done if the fontanel or sutures were abnormal. Since the infant requires immediate attention, follow-up in 1 month is inadequate. Transillumination is a noninvasive procedure used to assess hydrocephalus. It does not require a written consent and would be performed after examining the fontanel and sutures.

A 7-year-old child is brought to the clinic by a parent for a school physical. When the child is prepared for examination, which interventions should the nurse provide to ensure the the child's comfort? Offer the option of the parent staying or remaining in the waiting room. Explain the purpose of the equipment being used during the examination. Have the child take off all of their clothing and put on a client gown. Distract the child with bright colors.

Explain the purpose of the equipment being used during the examination. Explanation: At this age in the early school-age years, the child is still comfortable with a parent's presence in the examination room and is not generally given the option. It is important for the child's comfort and to decrease anxiety to explain the use of each piece of equipment prior to using it. During the school-age years, the child should be allowed to keep their underpants on along with the gown. Gaining distraction with bright objects would be used for an infant.

A nurse is about to give a client with type 2 diabetes mellitus her insulin before breakfast on her first day postpartum. Which client statement indicates an understanding of insulin requirements immediately postpartum? "I will need less insulin now than during my pregnancy." "I will need more insulin now than during my pregnancy." "I will probably be able to control my diabetes with diet and exercise now." "I will need more insulin now than before I was pregnant."

I will need less insulin now than during my pregnancy." Explanation: Postpartum insulin requirements are usually significantly lower than requirements during pregnancy. Occasionally, clients may require little or no insulin during the first 24 to 48 hours postpartum. Management of type 2 diabetes includes: healthy eating, regular exercise, possibly diabetes medication or insulin therapy, and blood sugar monitoring. However, there is not way of knowing if the client will now be able to control her diabetes without insulin.

A community health nurse is planning to address the physical needs of older adults living in their homes. What primary areas would be included in this discussion? Importance of exercise, balanced nutrition, mobility and safety needs Assessment of mobility patterns and ways to prevent joint deterioration and falls Social support systems and ways to prevent hearing and visual deficits Importance of frequent physician visits and access to health care resources

Importance of exercise, balanced nutrition, mobility and safety needs Explanation: This choice provides teaching regarding health promotion and illness and injury prevention for elderly clients living in their homes. It is important to ensure that elderly clients are meeting their needs of exercise, nutrition, mobility, and safety to be able to manage in their own homes. These are the primary physical needs that could pose problems for elderly clients. Assessment of mobility patterns focuses only on mobility. Social support systems do not address physical ones. By this time, prevention of deficits is difficult; aids to support adequate hearing and seeing are more practical. Physician visits are important, but they focus on health problems more than on meeting physical needs.

A client requests his medication at 9 p.m. (2100) instead of 10 p.m. (2200) so that he can go to sleep earlier. Which type of nursing intervention is required? Intradependent Interdependent Dependent Independent

Independent Explanation: Nursing interventions are classified as independent, interdependent, or dependent. Altering the drug schedule to coincide with the client's daily routine represents an independent intervention, whereas consulting with the physician and pharmacist to change a client's medication because of adverse reactions represents an interdependent intervention. Administering an already ordered drug on time is a dependent intervention. There's no such thing as an intradependent nursing intervention.

A client in early labor tells the nurse that she has a thick, yellow discharge from both of her breasts. What is the nurse's most appropriate intervention? Tell her that her milk is starting to come in because she's in labor Complete a thorough breast examination and document the results in the chart Perform a culture on the discharge, and inform the client that she might have mastitis Inform the client that the discharge is colostrum, and a normal finding

Inform the client that the discharge is colostrum, and a normal finding Explanation: After the fourth month, colostrum may be expressed. The breasts normally produce colostrum for the first few days after birth. Milk production begins one to three days postpartum. A clinical breast examination isn't usually indicated in the intrapartum setting. Although a culture may be indicated, it requires advanced assessment as well as a medical order.

The nurse is helping the parents plan strategies that will allow their diabetic child to participate in an early morning tennis program at school. Which interventions are appropriate? Select all that apply. Inject the morning insulin dose in an area away from major muscles used in playing tennis. Have the child eat more calories for breakfast on tennis days. Have the child carry a source of quickly absorbed carbohydrate to the program. Request that the school nurse be available during tennis practice. Teach the other children in the class the signs and symptoms of hyperglycemia.

Inject the morning insulin dose in an area away from major muscles used in playing tennis. Have the child eat more calories for breakfast on tennis days. Have the child carry a source of quickly absorbed carbohydrate to the program. Explanation: Insulin uptake from the subcutaneous tissue is increased when the circulation in the area is increased. This occurs around large muscle groups used in strenuous exercise. The child should eat something before participating in a strenuous activity because exercise increases both the efficiency of insulin and the amount of energy required by the body. In this case, increasing caloric intake at breakfast would offset the increased need for energy and increased insulin efficiency. An easily absorbed carbohydrate should be available in case the child experiences hypoglycemia. It is not necessary that the other children be able to identify hyperglycemia in this child. Hyperglycemia is not life threatening, but hypoglycemia can be. The other children can be taught signs and symptoms of hypoglycemia and how to treat the condition. It is not necessary for a nurse to be available as long as the child understands how to manage glycemic changes.

A client with acute kidney failure is placed on fluid restriction of 1000 mL of fluid over a 24-hour period. What is the priority nursing action? Eliminate the liquids between meal times. Divide the fluids equally among the three 8-hour nursing shifts. Notify the dietary department of a clear fluids order. Offer the client proportioned fluids in the day and less during the night.

Offer the client proportioned fluids in the day and less during the night. Explanation: The client and nurse should make a fluid schedule that takes into consideration factors such as periods of wakefulness, number of meals, oral medications, and personal preferences. Avoiding night fluids will decrease risk for aspiration. Other answers do not provide the client with autonomy of care, and good sleep patterns are essential for overall heal

During chemotherapy, an oncology client has a nursing diagnosis of Impaired oral mucous membrane related to decreased nutrition and immunosuppression secondary to the cytotoxic effects of chemotherapy. Which nursing intervention is most likely to decrease the pain of stomatitis? Recommending that the client discontinue chemotherapy Providing a solution of viscous lidocaine for use as a mouth rinse Monitoring the client's platelet and leukocyte counts Checking regularly for signs and symptoms of stomatitis

Providing a solution of viscous lidocaine for use as a mouth rinse Explanation: To decrease the pain of stomatitis, the nurse should provide a solution of hydrogen viscous lidocaine for the client to use as a mouth rinse. (Commercially prepared mouthwashes contain alcohol and may cause dryness and irritation of the oral mucosa.) The nurse also may administer systemic analgesics as ordered. Stomatitis occurs 7 to 10 days after chemotherapy begins; thus, stopping chemotherapy wouldn't be helpful or practical. Instead, the nurse should stay alert for this potential problem to ensure prompt treatment. Monitoring platelet and leukocyte counts may help prevent bleeding and infection but wouldn't decrease pain in this highly susceptible client. Checking for signs and symptoms of stomatitis also wouldn't decrease the pain.

A nurse at the family clinic receives a call from the mother of a 5-week-old infant. The mother states that her child was diagnosed with colic at the last checkup. Unfortunately, the symptoms have remained the same. Which teaching instructions are appropriate? Select all that apply. Position the infant on the back after feedings. Soothe the child by humming and rocking. Immediately bring the infant to the emergency department. Burp the infant adequately after feedings. Provide small but frequent feedings to the infant. Offer a pacifier if it is not time for the infant to eat.

Soothe the child by humming and rocking. Burp the infant adequately after feedings. Provide small but frequent feedings to the infant. Offer a pacifier if it is not time for the infant to eat. Explanation: Colic consists of recurrent paroxysmal bouts of abdominal pain and is fairly common in infants. It usually disappears by age 3 months. Rocking, riding in a car, humming, and offering a pacifier may be used to comfort the infant. Decreasing gas formation by frequent burping, giving smaller feedings more frequently, and positioning the infant in an upright seat are also appropriate teaching. The infant should not be positioned on the back after feedings, because this increases gas formation. Colic is a manageable condition in the home. The infant does not need to be taken to the emergency department unless the symptoms worsen, a temperature accompanies the symptoms, or vomiting occurs with the symptoms.

A nurse is giving a presentation to retirement home residents on fall prevention and injury reduction. Which of the following would be the most important priority? Explanation of the importance of a health professional evaluating gait and assessing for motor deficits Discussion of instability and effective use of ambulatory aids to stabilize the base of support Teaching about adjusting to change of position by sitting for a few minutes before standing to lessen dizziness Discussion about decreasing activity and favoring the use of wheelchairs, rather than mobility aids, to reduce the incidence of falls

Teaching about adjusting to change of position by sitting for a few minutes before standing to lessen dizziness Explanation: Sitting for a few minutes is the most appropriate to discuss to help maintain safety and reduce falls. Reliance on wheelchairs rather than mobility aids will result in weakening of the muscles and less strength and stability. The remaining actions would be important factors but not the immediate

A pregnant client at 26 weeks gestation walks a moderate distance to get to her prenatal class. When she gets to the class, she starts experiencing uterine cramping with no backache or bloody show. She is quite concerned about the cramping and asks the nurse what is happening. The most appropriate response from the nurse would be to advise the client to rest and drink fluids. tell the client the pains could be lightening and to count the movements over the next hour. advise her to see her physician immediately for preterm labor. explain to the client she may be miscarrying.

advise the client to rest and drink fluids. Explanation: Braxton Hicks contractions are irregular, generally painless uterine cramping and occur intermittently throughout the pregnancy often beginning around 16 weeks gestation. The client should rest and drink fluids to alleviate Braxton Hicks contractions. Lightening describes the effects when the fetus settles into the pelvis and cramping is not a sign. The client does not have the symptoms of preterm labor or miscarriage.

A 42-year-old female is interested in making dietary changes to reduce her risk of colon cancer. What dietary selections should the nurse suggest? croissant, granola and peanut butter squares, whole milk bran muffin, skim milk, stir-fried broccoli granola, bagel with cream cheese, cauliflower salad oatmeal-raisin cookies, baked potato with sour cream, turkey sandwich

bran muffin, skim milk, stir-fried broccoli Explanation: High-fiber, low-fat diets are recommended to reduce the risk of colon cancer. Stir-frying, poaching, steaming, and broiling are all low-fat methods to prepare foods. Croissants are made of refined flour. They are also high in fat, as are peanut butter squares, whole milk, granola, cream cheese, and sour cream.

When instilling ear drops on a 2-year-old child, the nurse should pull the pinna in which directions? down and back down and slightly forward up and back up and forward

down and back Explanation: When instilling ear drops on child younger than age 3 years, the nurse should pull the pinna down and back. This helps open the ear canal to ensure drops reach the tympanic membrane. For an older child, the nurse should pull the pinna up and back.

A 2 1/2-year-old child and his 2-month-old sibling are brought to the clinic by their father, who explains that the older child says "no" whenever asked to do something. The nurse should explain that the negativism demonstrated by toddlers is frequently an expression of which characteristic? pursuit of autonomy need to expend excess energy separation anxiety sibling rivalry

pursuit of autonomy Explanation: According to Erikson, the developmental task of toddlerhood is acquiring a sense of autonomy while overcoming a sense of doubt and shame. Characteristics of negativism and ritualism are typical behaviors in this quest for autonomy. The toddler commonly does the opposite of what others request. Hyperactivity, or the need to expend excess energy, is a typical behavior that may be demonstrated by a toddler; separation anxiety and siblings rivalry may also be demonstrated by the toddler. However, none of these three behaviors is the basis for the toddler's negativism.

A parent says that her family will soon be traveling abroad and asks why the drinking water in many regions must be boiled. The nurse should explain that, in addition to various types of dysentery, contaminated drinking water is most commonly responsible for the transmission of which disease? yellow fever brucellosis poliomyelitis typhoid fever

typhoid fever Explanation: Water is the usual vehicle for spreading typhoid fever. Yellow fever is spread through insect bites. Brucellosis (undulant fever) is spread by contaminated cow's milk. Poliomyelitis is most probably spread through respiratory secretions.

A client who had a gastrectomy has been in the postanesthesia recovery room for 30 minutes when the vital signs suddenly change. The nurse checks the recovery room record (see chart). In addition to notifying the health care provider, what other action should the nurse take immediately? Administer dantrolene. Elevate the head of the bed 30 degrees. Administer a bolus of IV fluids. Insert an indwelling urinary catheter.

Administer dantrolene. Explanation: The client is demonstrating signs of malignant hyperthermia. Unless the body is cooled and the influx of calcium into the muscle cells is reversed, lethal cardiac arrhythmia and hypermetabolism occur. The client's body temperature can rise as high as 109° F (42.8° C) as body muscles contract. Dantrolene, an IV skeletal muscle relaxant, is used to reverse muscle rigidity. Elevating the head of the bed will not reverse the hyperthermia. Adding fluids and inserting an indwelling urinary catheter are not immediately beneficial steps in reversing the progression of malignant hyperthermia.

A nurse-manager has decided to delegate responsibility for the review and revision of the surgical unit's client-education materials. Which statement illustrates the best method of delegation? Tell the nursing staff they're responsible for the review and revision and welcome their recommendations for improving the materials. Ask the two most proficient staff nurses to form a task force to review and revise client-education materials within the next 6 weeks. Have these nurses solicit input from clients and staff members. Tell the nursing staff that the client education materials need revision. Ask the staff to select people to review the materials and make suggestions for change. Ask the assistant manager to develop a plan for the review and revision of client-education materials.

Ask the two most proficient staff nurses to form a task force to review and revise client-education materials within the next 6 weeks. Have these nurses solicit input from clients and staff members. Explanation: Delegation must be clear and precise. The nurse-manager must assign responsibility, identify the task to be accomplished, explain the necessary outcomes, and define the time frame available to complete the work. The remaining options don't clearly define the work to be done, don't clearly assign responsibility or specify desired outcomes, or establish a time frame for completion of the task.

The nurse is receiving results of a blood glucose level from the laboratory over the telephone. What should the nurse do? Write down the results, read back the results to the caller from the laboratory, and receive confirmation from the caller. Repeat the results to the caller from the laboratory, write the results on scrap paper, and then transfer the results to the medical record. Indicate to the caller that the nurse cannot receive results from lab tests over the telephone and ask the lab to bring the written results to the nurses' station. Request that the laboratory send the results by e-mail to transfer to the client's medical record.

Write down the results, read back the results to the caller from the laboratory, and receive confirmation from the caller. Explanation: To assure client safety, the nurse first writes the results on the chart, then reads them back to the caller and waits for the caller to confirm that the nurse has understood the results. The nurse may receive results by telephone; and although electronic transfer to the client's medical record is appropriate, the nurse can also accept the telephone results if the laboratory has called the results to the nurses station.

The nurse managers of a home healthcare office wish to maximize nurses' freedom to characterize and record client conditions and situations in the nurses' own terms. Which of the following documentation formats is most likely to promote this goal? Narrative notes. SOAP notes. Focus charting. Charting by exception.

Narrative notes. Explanation: One of the advantages of a narrative notes model of documentation is that it allows nurses to describe clinical encounters in their own terms, as they understand them. Other documentation formats, such as SOAP notes, focus charting, and charting by exception, are more rigidly delineated and allow nurses less latitude in their documentation.

A client who's a member of Jehovah's Witnesses refuses a blood transfusion based on his religious beliefs and practices. His decision must be followed based on which ethical principle? The right to die Advance directive Autonomy of the client Substituted judgment

Autonomy of the client Explanation: The right to refuse treatment is grounded in the ethical principle of respect for the autonomy of the individual. The client has the right to refuse treatment as long as he's competent and aware of the risks and complications associated with that refusal. The right to die is a difficult decision involving whether to initiate or withhold life-sustaining treatment for a client who is irreversibly comatose, vegetative, or suffering with end-stage terminal illness. The client may have signed an advance directive, making his wishes known. An advance directive is a document that provides guidelines for starting or continuing life-sustaining medical care, generally for a client who has a terminal disease or disability and can't indicate his own wishes. Substituted judgment is an ethical principle used when a nurse makes a decision based on what's best for an incapacitated client.

A hospital uses the SOAP method of charting. Within this model, which of the nurse's following statements would appear at the beginning of a charting entry? "Client reporting abdominal pain rated at 8/10." "Client is guarding her abdomen and occasionally moaning." "Client has a history of recent abdominal pain." "2 mg hydromorphone PO administered with good effect."

"Client reporting abdominal pain rated at 8/10." Explanation: The SOAP method of charting (Subjective data, Objective data, Assessment, Plan) begins with the information provided by the client, such as a report of pain. The nurse's objective observations and assessments follow, with interventions, actions, and plans later in the charting entry.

Which client's response should the nurse address first? "My life is over if I gain weight." "I feel dizzy and light-headed when I get up." "I cannot eat because my teeth hurt." "I do not have the same energy that I used to have."

"I feel dizzy and light-headed when I get up." Explanation: The priority intervention, by the nurse, would be to assess the client's vital signs to note any alterations. Answer one is an example of catastrophizing. Dental erosion and caries are commonly found in a client with an eating disorder. Muscle weakness is also commonly found in a client with an eating disorder.

An elderly client becomes confused and combative. The client's nurse receives an order for soft wrist restraints. When the client's family insists that he not be restrained, the nurse informs the family that the family must provide an around-the-clock attendant for the client to avoid use of restraints. The family spokesman replies, "You find the attendant; that is your responsibility." Which of the following would be the best response by the nurse? "It is your responsibility, as I have already stated to you." "The hospital cannot be responsible for the client's safety if you won't let us use restraints." "You are making the situation more difficult than it really is." "I recommend family members arrange to stay with the client."

"I recommend family members arrange to stay with the client." Explanation: Offering the family a solution to the situation is therapeutic and can advance rapport with the family. It can also facilitate the problem-solving process, which involves the client, family, and staff. Restating that finding an attendant is the family's responsibility and saying that family members are making the situation more difficult are confrontational approaches. Such statements don't increase rapport with the family or enhance problem-solving. The staff cannot renounce responsibility for the client if the family will not allow restraints.

A postpartum client is ready for discharge. Which client statement reflects an understanding of the teaching session? "I will call my physician if my episiotomy hurts." "I should notify my physician if the vaginal discharge changes to a whitish color after 2 weeks." "I will call my physician if I notice redness, warmth, and pain in my breasts." "I should call my physician if I have a temperature of 99.2° F (37.3° C) for 24 hours or more."

"I will call my physician if I notice redness, warmth, and pain in my breasts." Explanation: Redness, warmth, and pain in the breasts indicate mastitis. Typically accompanied by fever, headache, and flulike symptoms, mastitis usually occurs 2 to 3 weeks after childbirth. The client should contact the physician if these symptoms occur. Episiotomy discomfort may persist for up to 6 weeks, depending on the extent of trauma. Lochia alba is normal at 2 weeks' postpartum. A temperature of 99.2° F (37.3° C) isn't significant. The client doesn't need to contact the physician if these signs or symptoms occur.

A female client is admitted to a mental health unit with a diagnosis of depression and is participating in group sessions. She asks a male nurse if he is married or has a girlfriend. What is the best response by the nurse to maintain a therapeutic relationship? "Group therapy is not the appropriate time to discuss my relationships." "It sounds as though you are interested in developing a relationship with me." "Tell me how you knew that I was not married or had a girlfriend." "I'm curious about your question, but I want to know how you are feeling today."

"I'm curious about your question, but I want to know how you are feeling today." Explanation: Nurses must practice in a manner that is consistent with providing safe, competent, and ethical care. If the nurse shared personal information with the client, the nurse would have crossed the boundary of a therapeutic relationship and changed the focus of the discussion from a client focus to a social focus. It is very important in all areas of care, but especially in the mental health setting, that the relationship between the nurse and the client has very clear boundaries and is client focused. The other options are incorrect because they do not follow the principles of a therapeutic nurse-client relationship.

A client on short-term mental health disability leave undergoes required psychiatric evaluation and counseling. He requests that his evaluation and counseling records be e-mailed to his Human Resources representative. How should the nurse respond? "We need to review our administrative policy with the agency director before we can release records." "It's best not to e-mail your personal records because doing so might jeopardize your right to privacy." "Think about whether you want us to release your entire counseling record to the company that employs you." "The treatment team must review disability-related records before we release them."

"It's best not to e-mail your personal records because doing so might jeopardize your right to privacy." Explanation: E-mailing personal health records to a client's place of employment increases the risk of breach of confidentiality. The nurse should make the client aware of this fact. Every health care agency has a policy and procedure related to release of client records; staff must be informed about the policy upon employment. Therefore, the nurse doesn't need to review the policy with the agency director when a client asks for his records to be released. It's inappropriate for a nurse to ask a client to think about his decision to release his records; doing so could make the client apprehensive. Review of a client's treatment goals and progress is an ongoing process; it isn't initiated when release of client records is requested.

A nurse is discussing wound care with a client. The client insists on taking a short video of the instruction by using the client's smart phone. What is the nurse's best response to the client? "After you record the video, are you going to post it to the internet?" "Let me check with the hospital policy regarding making a video." "I think we can find a video for you to view." "Let us make sure your name and face is in the video."

"Let me check with the hospital policy regarding making a video." Explanation: Use of technology and use of social media should be reviewed with the client. The institution may have a policy regarding what can and cannot be used.

A client is scheduled for a right lower lobectomy for lung cancer. During the admission assessment, the client asks for information about a living will and advance directive. The nurse knows that the client understands teaching about the living will and advanced directive when he says: "If I appoint a health care power of attorney, that person can override my wishes even if I'm still competent." "The advance directive allows me to state my health care wishes while I'm still able to do so." "The living will allows me to identify a person who can make health care decisions for me if I become too ill to make them myself." "I understand that in some states (provinces) a living will and health care power of attorney are the same."

"The advance directive allows me to state my health care wishes while I'm still able to do so." Explanation: The advance directive is a document that allows the client to give directions about future medical care or to designate another person to make medical decisions if and when the client loses decision-making capacity. The health care power of attorney is a legal document that enables the client to designate another person to act on the client's behalf if the client becomes disabled or incapacitated. The living will is a witnessed document indicating the client's desire to be allowed to die a natural death, rather than be kept alive by heroic life-sustaining measures. The living will applies to decisions that will be made after a terminally ill client is incompetent and has no reasonable possibility of recovery. The living will and health care power of attorney aren't the same.

A nurse has been assigned to four clients. Which client should the nurse see first? A client with systemic lupus erythematosus (SLE) with malar rash on the face A client with rheumatoid arthritis who is receiving adalimumab for inflammation A client with Hodgkin's lymphoma complaining of fatigue and night sweats A client with hemophilia who is receiving acetylsalisylic acid (ASA) for joint pain

A client with hemophilia who is receiving acetylsalisylic acid (ASA) for joint pain Explanation: A client with hemophilia should be seen first because ASA will increase bleeding. It should not be given to a client with hemophilia. Malar rash or "butterfly" rash is usually seen in clients with SLE. Adalimumab is a tumor necrosis factor (TNF) inhibiting anti-inflammatory drug given to clients with rheumatoid arthritis. A client with Hodgkin's lymphoma is expected to have fatigue and night sweats.

A young client has been arrested for assault and battery. The client has been admitted to the forensic psychiatric facility for a pretrial evaluation. Which of the following client goals is most appropriate for the client? Accept responsibility for personal behavior. Participate in group therapy. Verbalize ways to express anger, such as playing age-appropriate video games. Avoid contact with others on the psychiatric forensic unit.

Accept responsibility for personal behavior. Explanation: Accepting responsibility indicates an insight into the reasons for his/her hospitalization. This client is not hospitalized to receive treatment but for an evaluation, so group therapies would not be a goal. Verbalizing ways to express anger, such as playing age-appropriate video games is not indicated, as video games could be a further stimulus for violent behavior. The client should be assessed before a treatment plan is begun. Avoiding contact with others on the psychiatric forensic unit is not indicated, and interaction would be useful for assessment. Further, the client has the right to interact with other clients on the unit.

The nurse is reviewing the interventions listed in the plan of care for a child in vaso-occlusive crisis. Which intervention should the nurse implement first? Administering analgesics Monitoring fluid intake Encouraging activity as tolerated Administering antibiotics as prescribed

Administering analgesics Explanation: Pain management is a priority intervention when a client is in crisis. 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. Antibiotics will not be effective in resolving the vaso-occlusive crisis.

A client with a history of alcohol abuse comes to the emergency department and complains of abdominal pain. Laboratory studies help confirm a diagnosis of acute pancreatitis. The client's vital signs are stable, but the client's pain is worsening and radiating to his back. Which intervention takes priority for this client? Placing the client in a semi-Fowler's position Maintaining nothing-by-mouth (NPO) status Administering morphine I.V. as ordered Providing mouth care

Administering morphine I.V. as ordered Explanation: The nurse should address the client's pain issues first by administering morphine I.V. as ordered. Placing the client in a Semi-Fowler's position, maintaining NPO status, and providing mouth care don't take priority over addressing the client's pain issues.

A 16-year-old primigravida at 36 weeks' gestation who has had no prenatal care experienced a seizure at work and is being transported to the hospital by ambulance. What should the nurse do upon the client's arrival? Position the client in a supine position. Auscultate breath sounds every 4 hours. Monitor the vital signs every 4 hours. Admit the client to a quiet, darkened room.

Admit the client to a quiet, darkened room. Explanation: Because of her age and report of a seizure, the client is probably experiencing eclampsia, a condition in which convulsions occur in the absence of any underlying cause. Although the actual cause is unknown, adolescents and women older than 35 years are at higher risk. The client's environment should be kept as free of stimuli as possible. Thus, the nurse should admit the client to a quiet, darkened room. Clients experiencing eclampsia should be kept on the left side to promote placental perfusion. In some cases, edema of the lungs develops after seizures and is a sign of cardiovascular failure. Because the client is at risk for pulmonary edema, breath sounds should be monitored every 2 hours. Vital signs should be monitored frequently, at least every hour.

A client diagnosed with arthritis doesn't want to take medications. Physical therapy and occupational therapy have been consulted for nonpharmacologic measures to control pain. What might physical and occupational therapy include in the care plan to help control this client's pain? Acupuncture An exercise routine that includes range-of-motion (ROM) exercises Heat therapy and nonsteroidal anti-inflammatory medications (NSAIDs) Cold therapy

An exercise routine that includes range-of-motion (ROM) exercises Explanation: Physical and occupational therapy will most likely develop an exercise routine that includes ROM exercises to control the client's pain. Acupuncture may help relieve the client's pain; however, it isn't within the scope of practice for physical and occupational therapists. Heat therapy may help the client, but it's coupled with NSAIDs in this option, which goes against the client's wishes. Cold therapy aggravates joint stiffness and causes pain.

When coaching a client to improve their health, which strategy is the most effective for the nurse to use to help clients take an active role in their health care? Ask clients to complete a questionnaire. Provide clients with written instructions. Ask clients for their views of their health and health care. Ask clients if they have any questions about their health.

Ask clients for their views of their health and health care. Explanation: One of the best strategies to help empower clients to manage their health is to ask them their view of situations and to respond to what they say. This technique acknowledges that clients' opinions have value and relevance to the interview. It also promotes an active role for clients in the process. Use of a questionnaire or written instructions is a means of obtaining information but promotes a passive client role. Asking whether clients have questions encourages participation, but alone it does not acknowledge their views

The nurse is caring for a very ill child with a large extended family. Members of the family repeatedly ask the same questions of the nurse and other healthcare team members. To effectively manage the accurate dissemination of information, which of the following should be the priority action by the nurse? Ask team members to share information with the nurse instead of the family. Inform team members that only the parents should receive information. Review policies to see who should be informed of the child's treatment plans. Ask the family to identify a spokesperson to be the communicator with the team.

Ask the family to identify a spokesperson to be the communicator with the team. Explanation: In situations with large extended families where frequent updates are required or the state of the child is critical, it is imperative that a spokesperson be identified for receiving information and for disseminating the information to the extended family members.

Which task may be safely delegated to a licensed practical nurse (LPN)? Teaching a client newly diagnosed with diabetes mellitus about insulin administration Admitting a client who underwent a thoracotomy to the nursing unit from the postanesthesia care unit Changing the dressing of a client who underwent surgery 2 days ago Administering an I.V. bolus dose of morphine sulfate to a client experiencing incisional pain

Changing the dressing of a client who underwent surgery 2 days ago Explanation: The registered nurse may safely delegate dressing changes for the client who underwent surgery 2 days ago to the LPN. Teaching a client newly diagnosed with diabetes mellitus about insulin administration requires careful evaluation of the effectiveness of teaching and may not be delegated to an LPN. Admitting a client to the postanesthesia care unit is beyond the scope of practice for an LPN; LPNs aren't permitted to give I.V. push drugs.

A nurse is working day shift on a surgical unit at a hospital that was recently unionized and has insufficient staffing to provide competent care to the clients. What should the nurse do? Select all that apply. Ask the supervisor to be placed on a different unit for the shift. Complete an unsafe staffing form and provide care as safely as possible. File a written protest to the administration, but accept the assignment. Tell the clients about the staffing issue while trying to provide safe care. Refuse the unsafe client assignment and leave the surgical unit.

Complete an unsafe staffing form and provide care as safely as possible. File a written protest to the administration, but accept the assignment. Explanation: The nurse must accept the assignment or be liable for negligence and abandonment. The nurse should fill out an unsafe staffing form as soon as possible as this may be evidence to provide protection in the case of a medical error during the shift. Refusing the assignment is illegal and abandonment. Verbal notification can be provided but is not the best action as there is not a record of the conversation if a problem occurs. Clients should never know that staffing is unsafe as this will create unnecessary anxiety or stress for the client.

What role will the nurse have when admitting a client to a hospital for outpatient surgery that will result in discharge the same day? Complete regular admission procedures. Schedule the client for screening tests. Prepare for long-term care needs. Provide detailed information on the procedure.

Complete regular admission procedures. Explanation: Clients entering the hospital setting for outpatient surgery have regular admission procedures conducted by the nurse. Scheduling of screening tests and initial teaching is completed in the days prior to the surgery. Same-day surgery and discharge may require community-based follow-up, but it generally does not require long-term care. Detailed information on the procedure will be provided by the physician performing the procedure.

A nurse administering medications is unfamiliar with ropinirole, the medication ordered for a client with Parkinson's disease. What actions should the nurse perform prior to administering the medication? Select all that apply. Check the client's medication administration record for clarification of the medication. Contact the pharmacist for information about this medication. Refer to a reliable nursing drug handbook to verify the action, usual dosage, adverse effects, and nursing considerations for this medication. Ask an experienced nurse on the unit who is familiar with the medication for necessary dosing considerations. Check with the client regarding the medication, verifying its accuracy.

Contact the pharmacist for information about this medication. Refer to a reliable nursing drug handbook to verify the action, usual dosage, adverse effects, and nursing considerations for this medication. Explanation: A nurse must be knowledgeable about a medication before administering it to a client. A reliable nursing drug handbook will include information about the drug's expected action, usual dosage, adverse effects, and nursing considerations. It is also acceptable to consult the pharmacist. The client's medication administration record will not include this information. It is also not necessarily reliable to refer to the client regarding the medication. While many clients are very knowledgeable, you should not assume this.

A client with a history of cocaine abuse is receiving intravenous therapy and exits the hospital "to visit a friend." The client returns to the nursing unit 1 hour later, agitated, aggressive, combative, and reporting "chest pain." Place the nurse's actions in priority order from first to last. All options must be used. 1 Contact the security department. 2 Obtain an ECG. 3 Obtain a urine sample. 4 Initiate a referral to obtain drug rehabilitation counseling.

Contact the security department. Obtain an ECG. Obtain a urine sample. Initiate a referral to obtain drug rehabilitation counseling. Explanation: The nurse should first provide for safety of the client and the staff by requesting assistance from the security department. Next, the nurse should obtain an ECG because the client reports having chest pain. The nurse should then obtain a urine sample to identify if the client has been using illegal drugs. When the client is stabilized, the nurse can develop a care plan that includes treatment goals to support the respiratory and cardiovascular functions and enhance clearance of the agent and initiate a referral for treatment where access to the drug is eliminated and drug rehabilitation is provided as part of therapeutic management of clients with substance abuse and/or a drug overdose.

A nurse is caring for a primigravid client at 40 weeks gestation in active labor. Assessments include: cervix 5 cm dilated; 90% effaced; station 0; cephalic presentation, FHR baseline is 135 bpm and decreases to 125 bpm shortly after onset of 5 uterine contractions and returns to baseline before the uterine contraction ends. Based on this assessment what action should the nurse take first? Position woman on her left side, and administer oxygen via face mask. Document findings on the woman's medical record, and continue to monitor labor progress. Perform vaginal exam to rule out umbilical cord prolapse. Notify the health care provider (HCP) immediately, and prepare for emergency caesarean section.

Document findings on the woman's medical record, and continue to monitor labor progress. Explanation: The nurse would document these findings as "early" decelerations. Early decelerations are thought to be the result of vagal nerve stimulation caused by compression of the fetal head during labor. They are considered normal physiologic response to labor and do not require any intervention. Early decelerations do not require position change or oxygen, as they are not a sign of fetal distress. Variable decelerations are thought to be due to umbilical cord compression. Early decelerations are not emergent and do not require immediate reporting to the health care provider (HCP) or preparing for caesarean section.

In preparing for a client's admission to the unit, what is the nurse's responsibility? Ensuring the completion of room preparation responsibilities that may have been delegated to ancillary staff. Ensuring that all staff caring for the client are in the client's room when he or she arrives at the unit. Greeting the client in the emergency department or admitting office. Delegating the admission assessment to a nursing assistant.

Ensuring the completion of room preparation responsibilities that may have been delegated to ancillary staff. Explanation: Although the nurse might delegate most activities in preparing the room for admission, it is the nurse's responsibility to ensure that the other personnel complete the preparation. It is not necessary for all care staff to be present when the client arrives and, in fact, it might be quite overwhelming to the client to have them all present. The nurse will greet the client and family members upon their arrival to the unit. An admission assessment is the responsibility of the nurse, not a nursing assistant, who is not educated to perform this skill.

A surgeon is discussing surgery with a client diagnosed with colon cancer. The client is visibly shaken over the possibility of a colostomy. Based on the client's response, the surgeon should collaborate with which health team member? Social worker Staff nurse Clinical educator Enterostomal nurse

Enterostomal nurse Explanation: The surgeon should collaborate with the enterostomal nurse, who can address the client's concerns. The enterostomal nurse may schedule a visit with a client who has a colostomy to offer support to the client. The clinical educator can provide information about the colostomy when the client is ready to learn. The staff nurse and social worker aren't specialized in colostomy care, so they aren't the best choices for this situation.

A nurse is reluctant to provide care at an accident scene. Which of the following legal definitions is true regarding the provision of nursing care? Good Samaritan laws are designed to protect the caregiver in emergency situations. Negligence is intentional failure to act responsibly or deliberate omission of a professional act. Malpractice is failure to perform professional duties that result in client injury. Scope of practice involves general guidelines that define nursing.

Good Samaritan laws are designed to protect the caregiver in emergency situations. Explanation: Good Samaritan laws are designed to protect the caregiver in emergency situations. If the nurse stopped to provide care, legally there is protection. Failure to stop would constitute an issue. Malpractice involves the failure to perform professional duties; it may involve omissions of important care measures or performing care measures that are not appropriate in the situation. Negligence is failure to act professionally. Scope of practice includes specific guidelines of professional conduct.

The nurses in the neonatal intensive care unit are not identifying important clinical changes in the clients that need to be documented. What should the unit director do? Select all that apply. Identify the problem at a staff meeting without placing blame on any individual or group. Ask the unit staff to develop a plan that they think will work for the unit members. Ask an experienced nurse to spend time reorienting newer staff members. Collaborate with the staff development educator to develop a plan. Ask the neonatologist to give a presentation about assessing newborns.

Identify the problem at a staff meeting without placing blame on any individual or group. Ask the unit staff to develop a plan that they think will work for the unit members. Collaborate with the staff development educator to develop a plan. Explanation: All areas concerned with the safety and quality of care need to participate in the decision-making process and arrive at a plan that will meet the needs of the clients on the neonatal care unit. Identifying the problem at a staff meeting is an ideal forum to bring up the need for improvement and education. The staff is an integral part of the development team. The staff educator is an important member of the team and is responsible for orienting new nurses to the unit. Asking an experienced staff member to spend time in reorienting staff members is difficult to do as the nurses have their own clients to care for. Although the unit director can obtain additional information from the health care providers (HCPs) about the problem, the nursing staff has responsibility for assuring that they are providing safe and high quality care.

A client with a history of osteoarthritis is admitted to the rehabilitation unit after hospitalization for a hip fracture. Which plan by the multidisciplinary team best optimizes client outcomes? Coordinating activities in the morning so that the client can rest in the afternoon and evening Coordinating all activities in the afternoon so that the client is tired at bedtime. Alternating periods of activity with periods of rest to optimize client participation Including the client in developing a care plan that works toward meeting discharge goals

Including the client in developing a care plan that works toward meeting discharge goals Explanation: Involving the client in the care plan development optimizes client outcomes; alternating periods of activity and rest helps optimize participation. Coordinating all activities in the morning or afternoon doesn't necessarily optimize client participation.

Which of the following involves charting information about the client and client care in chronological order? Focus charting. SOAP charting. Narrative charting. PIE charting.

Narrative charting. Explanation: Narrative charting involves writing information about the client and client care in chronological order. In SOAP charting, everyone involved in the client's care makes entries in the same location in the chart. Focus charting follows a data, action, and response (DAR) model to reflect the steps in the nursing process. PIE charting is a method of recording the client's progress under the headings of problem, intervention, and evaluation.

A nurse is caring for a client with multiple sclerosis. The client informs the nurse that a lawyer is coming to prepare a living will and requests the nurse to sign as witness. Which of the following actions should the nurse take? State that the physician will be a witness. Arrange for other colleagues to sign as a witness. Note that the nurse caring for the client cannot be a witness. Inform the physician about the living will.

Note that the nurse caring for the client cannot be a witness. Explanation: A living will is an instructive form of an advance directive. It is a written document that identifies a person's preferences regarding medical interventions to use in a terminal condition, irreversible coma, or persistent vegetative state with no hope of recovery. Employees of the health care facility should not sign as witnesses; therefore, the nurse cannot sign as witness. Refusing a client may not be a good communication method; instead, the nurse could politely indicate the reason for declining. Calling for a physician or asking another colleague to sign is an inappropriate action.

A nursing supervisor asks a pediatric nurse to work temporarily (float) in the intensive care unit (ICU) because there are few clients in the pediatric unit. The pediatric nurse has never worked in ICU and has no intensive care experience. Which action should this nurse take? Refuse to float to the ICU. Notify the nursing supervisor that she feels unqualified and untrained for the assignment. Report to the ICU and accept a total client assignment; ask the nurses for assistance when necessary. Report to the ICU, tell the ICU nurses she has never worked in the ICU, and let the nurses decide what tasks she can perform.

Notify the nursing supervisor that she feels unqualified and untrained for the assignment. Explanation: The pediatric nurse should notify the nursing supervisor about feeling unqualified and untrained to float in the ICU. The nursing supervisor can advise the pediatric nurse about tasks she is qualified to perform in the ICU without jeopardizing her nursing license. When the census on a unit is low, many facilities use staff to float to another unit as a cost-effective and reasonable way for managing resources. Having the ICU nurses determine what tasks the pediatric nurse can perform makes the ICU nurses responsible for the pediatirc nurse's performance. However, the nursing supervisor should make those decisions because the supervisor knows the overall needs of the facility and can, therefore, best allocate nursing resources. A nurse should never accept responsibility for a total client care assignment if she doesn't have the skills to plan and deliver care.

A nurse takes informed consent from a client scheduled for abdominal surgery. Which of the following is the most appropriate principle behind informed consent? Protects the client's right to self-determination in health care decision making. Helps the client refuse treatment that he or she does not wish to undergo. Helps the client to make a living will regarding future health care required. Provides the client with in-depth knowledge about the treatment options available.

Protects the client's right to self-determination in health care decision making. Explanation: Informed consent protects the client's right to self-determination in health care decision making. Informed consent helps the client to refuse a treatment that the client does not wish to undergo and helps the client to gain in-depth knowledge about the treatment options available, but the most important function is to encourage shared decision making. Informed consent does not help the client to make a living will.

A couple admitted to the labor and birth unit show the nurse their birth plan. The nurse inquires about their specific choices and wishes for the birth of their first baby. Which of the following best describes why the nurse is asking questions about the family's birth plan? Establishing rapport with the family Acting as an advocate for the family Attempting to correct any misinformation the family may have received Recognizing the family as active participants in their care

Recognizing the family as active participants in their care Explanation: The nurse recognizes the family as active participants in their care by discussing and inquiring about their birth plans, fostering a collaborative relationship with the family. After acknowledging the family as active participants, the nurse is then able to advocate for the family throughout the labor and birth experience. Considering principles of family-centered maternity and newborn care, nurses must advocate for clients to have autonomy in decision making and provide respect and informed choice to ensure that clients and their families are empowered to take responsibility to make decisions. It is the nurse's role to guide and support choices rather than direct or correct.

A 17-year-old unmarried primigravida at 10 weeks' gestation tells the nurse that her family does not have much money and her dad just got laid off from his job. What should the nurse do? Instruct the client in methods for low-cost, highly nutritious meal preparation. Determine whether the client qualifies for local assistance programs. Refer the client to a social worker for enrollment in a food assistance program. Ask the client if she has a job and the amount of income earned.

Refer the client to a social worker for enrollment in a food assistance program. Explanation: The nurse should refer the client to a social worker for assistance in enrolling in a food assistance program. Instructing the client in low-cost, highly nutritious meal preparation will not meet the client's needs for additional funds for food. Determining whether the client qualifies for government assistance is part of the role of the social worker, not the nurse. Asking the client if she has a job and the amount of income earned is not within the role of the nurse. The social worker can determine whether the family income guidelines are met for assistance.

A client has undergone a laparoscopic cholecystectomy. Which instruction should the nurse include in the discharge teaching? Empty the bile bag daily. Breathe deeply into a paper bag when nauseated. Keep adhesive dressings in place for 6 weeks. Report bile-colored drainage from any incision.

Report bile-colored drainage from any incision. Explanation: There should be no bile-colored drainage coming from any of the incisions postoperatively. A laparoscopic cholecystectomy does not involve a bile bag. Breathing deeply into a paper bag will prevent a person from passing out due to hyperventilation; it does not alleviate nausea. If the adhesive dressings have not already fallen off, they are removed by the surgeon in 7 to 10 days, not 6 weeks.

An older adult client who has been diagnosed with delusional disorder for many years is exhibiting early symptoms of dementia. His daughter lives with him to help him manage daily activities, and he attends a day care program for seniors during the week while she works. A nurse at the day care center hears him say, "If my neighbor puts up a fence, I'll blow him away with my shotgun. He has never respected my property line, and I've had it!" Which action should the nurse take? Observe the client more closely, but do not report his threat since he will likely not be able to follow through with it because of his dementia. Report the comment to the client's daughter so she can observe him more closely, but refrain from telling the neighbor due to privacy regulations. Report the comment to the neighbor, the intended victim, but refrain from telling the daughter since she will just worry about actions of her father she cannot control. Report the comment to the neighbor, the daughter, and the police since there is the potential for a criminal act.

Report the comment to the neighbor, the daughter, and the police since there is the potential for a criminal act. Explanation: The neighbor could be harmed as well as the daughter if she should try to stop her father from using the gun, so both should be notified. Any use of firearms against another person requires the involvement of the police. The nurse has a legal/ethical responsibility to warn potential victims and other involved parties as well as law enforcement authorities when one person makes a threat against another person. This duty supersedes confidentiality statutes. Failure to do so and to document it can result in civil penalties. The client's early dementia would likely not prevent him from carrying through his threat.

The nurse is providing care for a client with a tracheotomy whose pulse oximeter has recently alarmed, showing the oxygen saturation to be 77%. The nurse has repositioned the client and applied supplemental oxygen, interventions that have raised the oxygen levels to 80% and somewhat decreased work of breathing. The client is not in immediate distress, and level of consciousness remains high. The nurse should page which of the following practitioners? Respiratory therapist. Physical therapist. Physician. Occupational therapist.

Respiratory therapist. Explanation: A respiratory therapist is an expert in lung function and oxygenation whose expertise is needed in the care of this client. Because the client is not experiencing severe distress or respiratory arrest, the nurse is justified in forgoing contact with the physician in the short term. A physical therapist or occupational therapist is not likely to provide needed interventions at this time.

The charge nurse is preparing for the day shift on the labor and birth unit. Which would be included in the responsibilities for this position? Select all that apply. Review the current status of each labor patient with the primary nurse. Admit the new labor patient sent from the triage area. Complete the work of the nurse who had to leave 30 minutes early. Follow up with the primary nurse after a birth. Complete report of unit with the oncoming charge nurse.

Review the current status of each labor patient with the primary nurse. Follow up with the primary nurse after a birth. Complete report of unit with the oncoming charge nurse. Explanation: In most settings, the charge nurse coordinates and directs the activities of the unit. Prior to the change of shift, the nurse will review and update the status of each of the laboring clients on the unit to include any difficulties or unusual situations that may be occurring with each of them, including following up with a primary nurse after a birth. A change-of-shift report with the oncoming charge nurse is among the last activities completed before ending the shift. Activities such as admitting a client in labor and completing the nursing responsibilities of the nurse who had to leave 30 minutes early can be delegated to staff members. In an emergency, the charge nurse could assume responsibility for client care.

The health care provider (HCP) has prescribed a chemotherapy drug to be administered to a client every day for the next week. The client is on an adult medical-surgical floor, but the nurse assigned to the client has not been trained to handle chemotherapy agents. What is the nurse's most appropriate response? Send the client to the oncology floor for administration of the medication. Ask a nurse from the oncology floor to come to the client and administer the medication. Ask another nurse to help mix the chemotherapy agent. Ask the pharmacy to mix the chemotherapy agent and administer it.

Send the client to the oncology floor for administration of the medication. Explanation: The nurse should call the oncology unit to institute a transfer. The nurse handling chemotherapy agents should be specially trained. It is an unwise use of nursing resources to send a nurse from one unit to administer medications to a client on another unit. It is better to centralize and send the client who needs chemotherapy to one unit. Even if the pharmacy mixes the agent, the drug must be administered by a specially trained nurse.

A nurse meets his/her neighbor and new baby at the local market. The neighbor states that she received outstanding nursing care from one of the nurse's colleagues during her labor and childbirth. What is the best way for the nurse to recognize her nursing colleague's professional efforts? Post accolades to the nurse at the nurses' station. Send the colleague an anonymous card. Share the feedback with the nursing colleague directly. It is a breach of confidentiality to share this information with the colleague.

Share the feedback with the nursing colleague directly. Explanation: It is not a breach of confidentiality for the nurse to share the feedback with the colleague, and by doing so the nurse will recognize the value of the colleague's professional efforts and accomplishments. It is not appropriate to place an announcement at the nurses' station or to send an anonymous card. It is crucial that nurses uphold the standards for professional practice and consider the American Nurses Association (Canadian Nurses' Association) Code of Ethics, in particular surrounding the principles of preserving dignity and maintaining privacy and confidentiality.

What are important nursing responsibilities when a referral to other health team members has been made for a client? Ensuring that the physician reports the level of functioning of the client Recommending that each health team member independently completes his or her own assessment and then consults with each other Recommending that each member read the history and nurse's notes to understand the client's progress Sharing assessment information and information on the client's capability and level of participation in meeting activities of daily living

Sharing assessment information and information on the client's capability and level of participation in meeting activities of daily living Explanation: Sharing assessment findings and relevant information helps prepare other health team members and helps coordinate the team efforts, which is one of the nurse's primary roles in relation to the health team.

A client is admitted to the emergency department with a ruptured abdominal aortic aneurysm. No family members are present, and the surgeon instructs the nurse to take the client to the operating room immediately. Which of the following actions should the nurse take regarding informed consent? Ask the nursing supervisor to contact the hospital lawyer. Keep the client in the emergency department until the family is contacted. Take the client to the operating room for surgery without informed consent. Contact the hospital chaplain to sign the consent on the client's behalf.

Take the client to the operating room for surgery without informed consent. Explanation: All attempts should be made to contact the family, but delaying life-saving surgery is not an option. The other options are not correct because the surgeon can perform surgery without consent if there is a risk of loss of life or limb if the surgery is not performed. The nurse should take the client to the operating room.

The nurse notes that which statement concerning informed consent is true? Minors may give informed consent to all medical and nursing procedures without consent of the parent(s). The professional nurse and physician must each obtain informed consent because the practice of medicine and of nursing are two distinct entities. The client must be fully informed regarding treatment, tests, alternative treatments, and the risks and benefits of each. Mentally incompetent clients may legally give informed consent only if they are hospitalized under a mental health regulatory law.

The client must be fully informed regarding treatment, tests, alternative treatments, and the risks and benefits of each. Explanation: Before giving informed consent, the physician performing the procedure must tell the client about the treatment, tests, alternative treatments, and the risks and benefits of each. A professional nurse involved in the informed consent process witnesses the consent and doesn't actually obtain the consent. The physician is responsible for obtaining consent. Only a minor who is married or emancipated may give informed consent. A client must be mentally competent to legally give informed consent for procedures.

A nurse administers medications to the wrong client in a hospital. The client has an anaphylactic reaction to one of the medications and expires. What legal actions against the nurse can the family pursue? Select all that apply. There are no legal consequences with the common error. The family can open a legal claim for malpractice against the nurse. The family can open a legal claim for malpractice against the hospital. The family can seek a fair settlement outside the courtroom. The nurse can resign from the hospital and no further legal action will occur.

The family can open a legal claim for malpractice against the nurse. The family can open a legal claim for malpractice against the hospital. The family can seek a fair settlement outside the courtroom. Explanation: The family can open a legal claim for malpractice with the nurse and with the hospital. The family can seek a settlement outside the courtroom. There are legal consequences with a sentinel event. Medication safety errors are not common. The nurse can resign from the hospital but further legal action can be pursued against the nurse.

A graduate nurse and her preceptor are establishing priorities for their morning assessments. Which client should they assess first? The newly admitted client with acute abdominal pain The client who underwent surgery 3 days ago and who now requires a dressing change The client receiving continuous tube feedings who needs the tube-feeding residual checked The sleeping client who received pain medication 1 hour ago

The newly admitted client with acute abdominal pain Explanation: The graduate nurse and her preceptor should assess the new admission with acute abdominal pain first because he just arrived on the floor and might be unstable. Next, they should change the abdominal dressing for the postoperative client or measure feeding tube residual in the client with continuous tube feedings. These tasks are of equal importance. They should assess the sleeping client who received pain medication 1 hour ago last because he just received relief from his pain and is able to sleep.

Nurse researchers have proposed a study to examine the efficacy of a new wound care product. Which of the following aspects of the methodology demonstrates that the nurses are attempting to maintain the ethical principle of nonmaleficence? The nurses are taking every responsible measure to ensure that no participants experience impaired wound healing as a result of the study intervention. The nurses have organized the study in such a way that the foreseeable risks and benefits are distributed as fairly as possible. The nurses have given multiple opportunities for potential participants to ask questions and have been following the informed consent process systematically. The nurses have completed a literature review that suggests the new treatment may result in decreased wound healing time.

The nurses are taking every responsible measure to ensure that no participants experience impaired wound healing as a result of the study intervention. Explanation: The principle of nonmaleficence dictates that nurses avoid causing harm. In this study, this may appear in the form of taking measures to ensure that the intervention will not cause more harm than good. The principle of justice addresses the distribution of risks and benefits and the informed consent process demonstrates that autonomy is being protected. Preliminary indications of the therapeutic value of the intervention show a respect for the principle of beneficence.

A charge nurse completing a deceased client's chart audit notes that the chart contains a copy of the client's advance directive and the do-not-resuscitate (DNR) order. While reviewing the nurses' notes, the charge nurse finds documentation of a code blue and cardiopulmonary resuscitation with a physician entry to "Discontinue code blue due to existing advanced directives and DNR from client." What does the charge nurse conclude? Select all that apply. The nurse was correct to call a code blue. The physician was correct to stop resuscitation efforts. By calling a code blue, the nurse disregarded the client's advance directives and DNR order. She must have read the chart incorrectly. The code should have continued.

The physician was correct to stop resuscitation efforts. By calling a code blue, the nurse disregarded the client's advance directives and DNR order. Explanation: By initiating a code blue, the nurse didn't follow the client's advance directive and DNR order. The physician was correct to follow the client's wishes and stop resuscitation efforts. The physician had the authority to stop the code.

A client underwent insertion of a nasogastric (NG) tube for partial bowel obstruction the previous evening. The nurse notes that the tube is not secured to the client's face. How will the nurse precede? Call the healthcare provider immediately Securely tape the tube in place Note the findings on the client's flow sheet Verify placement of the tube

Verify placement of the tube Explanation: The NG tube placement should be verified prior to re-taping the NG tube; the other options require verification of the NG tube placement first and the healthcare provider will need to know.

The nurse is assisting with a bone marrow aspiration and biopsy. Place the tasks in the order in which the nurse should perform them, from highest priority to least priority. All options must be used. 1 Verify the client has signed an informed consent. 2 Position the client in a side-lying position. 3 Clean the skin with an antiseptic solution. 4 Apply ice to the biopsy site.

Verify the client has signed an informed consent. Position the client in a side-lying position. Clean the skin with an antiseptic solution. Apply ice to the biopsy site. Explanation: First, the nurse must verify that the client has voluntarily signed a consent form before the procedure begins and check that the client understands the procedure. The nurse then positions the client in a side-lying, or lateral decubitus, position with the affected side up. Then, the nurse should clean the skin site and surrounding area with an antiseptic solution before the health care provider (HCP) numbs the site and collects the specimen. When the procedure is finished, the nurse must apply ice to the biopsy site to reduce pain.

A mother who is Mexican brings her 2-month-old son to the emergency department with a high fever and possible sepsis. A lumbar puncture is prescribed, but the mother will not sign the consent until the father arrives to give permission. What should the nurse do? Report this to the social worker. Call the regional protective services for children. Wait until the father arrives. Inform the health care provider (HCP) that the mother has refused to have the procedure.

Wait until the father arrives. Explanation: In the traditional Mexican household, the man is the head of the family and makes the major decisions. Efforts should be made to reach the father as soon as possible to acquire his permission. It is not necessary to contact the social worker at this point. The client has not refused the procedure, so it is premature to contact the HCP. This is not a situation of suspected child abuse.

Under which circumstance may a nurse communicate medical information without the client's consent? when certifying the client's absence from work when requested by the client's family When treating the client with a sexually transmitted disease when prescribed by another health care provider (HCP)

When treating the client with a sexually transmitted disease Explanation: Sexually transmitted infections are communicable diseases that must be reported. The nurse is responsible for reporting these diseases to the appropriate public health agency and to otherwise maintain the client's confidentiality. The client's family cannot request release of medical information without the client's consent. A HCP's prescription is not a substitute for a client's consent to release medical information in the absence of a communicable disease.

A nurse is obtaining consent for a bone marrow aspiration. Which actions should the nurse take? Select all that apply. Witness the client signing the consent form. Evaluate that the client understands the procedure. Explain the risks of the procedure to the client. Verify that the client is signing the consent form of his or her own free will. Determine that the client understands postprocedure care.

Witness the client signing the consent form. Evaluate that the client understands the procedure. Verify that the client is signing the consent form of his or her own free will. Determine that the client understands postprocedure care. Explanation: The nurse can serve as a witness for consent for procedures. The nurse also ascertains whether the client has an understanding that is consistent with the procedure listed on the form, determines that the client is signing the consent of his or her own free will, and determines that the client understands post-procedure care. The nurse's role does not include explaining the risks of the procedure; that responsibility belongs to the person who is to perform the procedure, such as the health care provider (HCP).

Which client should the nurse assess first? a client being treated for chronic stable angina who reports a recent increase in chest pain frequency a client with type 2 diabetes requesting medication refills whose A1C level is 5 mg/dL a client being treated for right side heart failure who has 1+ pitting edema to lower extremities bilaterally and reports a 2 lb (0.9 kg) weight gain in the last week a client with chronic hypertension whose blood pressure today is 182/98 mm Hg

a client being treated for chronic stable angina who reports a recent increase in chest pain frequency Explanation: A report of increasing frequency of chest pain suggests that the client may have developed unstable angina that can lead to an acute coronary syndrome. It requires additional testing and immediate assessment. The diabetic client's A1C level is within normal limits. Pitting edema and weight gain are expected findings with right side heart failure exacerbations—this client is not unstable. The hypertensive client is not in any acute distress.

A client is admitted to the hospital. The graduate nurse is completing a nursing assessment and asks the client if he/she has an advanced directive. The client asks for an explanation of advanced directives. The registered nurse preceptor would intervene if she heard the graduate nurse inform the client that an advance directive is: a legal document initiated by the physician to give the client "do not resuscitate" (DNR) status. a legal document, made by the client when he/she is healthy, that directs others to follow the client's wishes if he/she is incapacitated legal document that is commonly referred to as a living will and recognized in all North America. also known as a health care proxy, where the client indicates a person or persons to make health care decisions for them if they become incapacitated.

a legal document initiated by the physician to give the client "do not resuscitate" (DNR) status. Explanation: A facility refers to an advance directive, a document the client writes or completes, to provide care at a time when the client cannot make his/her own choices. The living will and health care proxy are both examples of advance directives. A living will is a document which a competent adult prepares and which provides direction regarding medical care if the client becomes incapacitated. Health care proxy is an authorization enabling any competent individual to designate someone else to exercise decision-making authority on the individual's behalf under specific circumstances.

The charge nurse on the adolescent unit must decide which nurse should admit a new client. Based on the present client care assignments, who is the best candidate to admit the client? a nurse who was reassigned from another ward at the beginning of the shift a nurse whose patient with asthma has decreasing oxygen saturation levels a nurse caring for a client who is paralyzed and has no visiting family a nurse who is about to start a complicated wet-to-damp dressing change

a nurse who was reassigned from another ward at the beginning of the shift Explanation: The nurse's work load would be low because she was reassigned to the ward at the beginning of the shift. The client with asthma requires constant monitoring by the nurse until the situation is resolved. Simple tasks and procedures are commonly more time-consuming when clients with paralysis are involved because these clients can't directly aid in their own care. Additional time must also be allotted for the nurse about to undertake a complicated procedure, such as a wet-to-damp dressing change.

Which family should the nurse determine as most in need of follow-up? a single mother with a 7-month-old child whose immunizations are delayed a two-parent family whose 3-year-old has a fractured leg from an automobile accident a single parent with a toddler who has third-degree burns over 20% of the body a two-parent family with a foster child who has a history of caustic liquid ingestion

a single parent with a toddler who has third-degree burns over 20% of the body Explanation: Toddlers receive burns usually as the result of not being closely supervised. Toddlers are very inquisitive and need constant supervision; therefore, close follow-up is necessary. In addition, the child probably will need some type of wound care requiring involvement of the parent and possibly others. The amount of support available to the single parent of the 7-month-old child is not known. Although immunization schedules need to be adhered to, it is very possible for a 7-month-old to be delayed in receiving immunizations because of illness or other conflicts. An automobile accident can happen to anyone and does not indicate a lack of safety or supervision. A history of caustic liquid ingestion in a foster child may have been from a time before the child began living with the foster parents; it does not indicate a lack of safety or supervision.

The nurse is planning care for a group of pregnant clients. Which client should be referred to a health care provider (HCP) immediately? a woman who is at 10 weeks' gestation, is having nausea and vomiting, and has +1 ketones in her urine a woman who is at 37 weeks' gestation and has insulin-dependent diabetes experiencing two to three hyperglycemic episodes weekly a woman at 32 weeks' gestation who is preeclamptic with +3 proteinuria a primigravida at 15 weeks' gestation who reports she has not felt fetal movement

a woman at 32 weeks' gestation who is preeclamptic with +3 proteinuria Explanation: The nurse should refer the preeclamptic client with 3+ proteinuria to an HCP. The 3+ urine is significant, indicating there is much protein circulating. The woman who is 37 weeks' gestation with insulin-dependent diabetes and who has experienced hypoglycemic episodes in the past week can be managed with food and glucose tablets until she can obtain an appointment with the care provider. The client at 10 weeks' gestation with nausea and vomiting and +1 ketones should also be seen by an HCP, but at this point, although this client is uncomfortable, her life is not in danger. The 15-week client would not be expected to feel her baby move this soon in the pregnancy, and this would not be considered a problem that requires immediate referral to an HCP.

The registered nurse (RN) is working in a 30-bed long-term care facility on the night shift and is working with two licensed practical/vocational nurses (LPN/VN) and four certified nursing assistants (CNA). Which primary care provider and nursing orders are most appropriately delegated to the LPN/VN? Select all that apply. obtaining a stool culture performing catheter care checking a client for liquid stools every 1 hour reorienting the client to person, place, and time administering oral medications obtaining a urine culture

administering oral medications Explanation: The licensed nurse (LPN/VN) can perform any of these orders because the nurse has the education and license needed to perform the orders. The licensed nurse (LPN/VN) must administer the oral medications because of the education and license needed, and all the other orders can be delegated to the CNA.

Which statement indicates that the client with chronic obstructive pulmonary disease (COPD) who has been discharged to home understands the care plan? The client: will avoid direct contact with family and friends. can state actions to reduce pain. will use oxygen via a nasal cannula at 5 L/min. agrees to call the health care provider (HCP) if dyspnea on exertion increases.

agrees to call the health care provider (HCP) if dyspnea on exertion increases. Explanation: Increasing dyspnea on exertion indicates that the client may be experiencing complications of COPD. Therefore, the client should notify the HCP. It is not necessary to avoid being around others. Pain is not a common symptom of COPD. Clients with COPD use low-flow oxygen supplementation (1 to 2 L/min) to avoid suppressing the respiratory drive, which, for these clients, is stimulated by hypoxia.

A client who is taking olanzapine states he is being poisoned and refuses to take his scheduled medication. The nurse states, "If you do not take your medication, you will be put into seclusion." The nurse's statement is an example of which legal concept? assault battery malpractice invasion of privacy

assault Explanation: The nurse's statement exemplifies assault, which is the threat of being touched in an offensive way without consent. Battery is touching another person without consent. Malpractice is care below the standard of care that results in injury. Invasion of privacy is a violation of a person's right to be left alone.

The nurse is teaching the client to self-administer insulin. Learning goals most likely will be attained when they are established by the: nurse and client because both need to be responsible for teaching. health care provider and client because the health care provider is the manager of care and the client is the main participant. client because the client is best able to identify his or her own needs and how to meet those needs. client, nurse, pharmacist, and health care provider so the client can participate in planning care with the entire team.

client, nurse, pharmacist, and health care provider so the client can participate in planning care with the entire team. Explanation: Learning goals are most likely to be attained when they are established mutually by the client and members of the health care team, including the nurse, pharmacist, and health care provider. Learning is motivated by perceived problems or goals arising from unmet needs. The perception of the unmet needs must be the client's; however, the nurse, pharmacist, and health care provider help the client arrive at his or her own perception of the need or reason to learn.

A child with spastic cerebral palsy is to begin botulinum toxin type A injections. Which treatment goals should the health care team set for the child related to botulinum toxin? Select all that apply. improved nutritional status decreased pain from spasticity improved motor function enhanced self-esteem reduced caregiver strain decreased speech impediments

decreased pain from spasticity improved motor function enhanced self-esteem reduced caregiver strain Explanation: Botulinum toxin injections can be used to improve many aspects of quality of life for the child with cerebral palsy. The injections can help decrease pain from spasticity. Injections improve motor status by reducing rigidity and allowing for more effective physical therapy to improve range of motion. Decreased spasms enhance self-esteem. Improved motor status facilitates the ability to provide some aspects of care, especially transfers. Botulinum does not significantly affect nutritional status or speech.

A client was brought to the hospital in an agitated state and admitted to a psychiatric unit for observation and treatment. On admission, the client was found to be talking rapidly and folding and unfolding garments several times while putting personal belongings away. The client is unable to settle down. Which assessment of the client would have highest priority at this time? ability to care for self feelings of anxiety barriers to effective communication experiences of powerlessness

feelings of anxiety Explanation: Anxiety is the top priority at this time. The client is exhibiting behavior that is indicative of anxiety, including restlessness, irritability, rapid speech, and inability to complete tasks. The other aspects of the nursing assessment are significant, but are not the top priority.

The nurse is serving on the Quality Improvement Committee for the maternity unit. Quality improvement projects for this unit impacting safety and quality of care include which projects? Select all that apply. use of recycling bins on the unit infant identification system sibling and family visitation policies postpartum discharge instructions rooming in guidelines

infant identification system sibling and family visitation policies postpartum discharge instructions rooming in guidelines Explanation: The use of recycling bins on the unit does not impact safety or contribute to the quality of care. The infant identification system is a safety practice. Nursing influences the type of system used and how monitoring and identification occur, which improves the quality of care. The sibling and family visitation policy can be an excellent project. Sibling policies regarding visitation can influence safety (safety of mother and infant by keeping children with colds/flus, infections away from the obstetrics unit). Nursing influences development of the policy utilized and implemented on a daily basis. Postpartum instructions represent an area where the skill level, quality, and quantity of instruction represent nursing contributions to care. The ability for a family to remain together during a hospital stay is important to families. The quality of the obstetrical experience can be enhanced or determined to be negative by this particular policy, one that is often looked at by these committees.

After the nurse informs the surgeon that a chest tube is malfunctioning, the health care provider asks the nurse to reposition the tube and obtain a chest radiograph. The nurse should: inform the surgeon this is not within the safe scope of practice. report the surgeon to the Ethics Committee. report the surgeon to the nursing supervisor. follow the prescription as requested by the surgeon.

inform the surgeon this is not within the safe scope of practice. Explanation: Initially, the nurse needs to inform the surgeon that the task is outside the scope of nursing practice. If the surgeon still requests the activity, the nurse should refuse to perform the task and should follow the chain of communication for reporting unsafe practice according to the facility's policy. The nurse must not comply with any prescription that goes beyond the scope of nursing practice.

A term primigravida was involved in a car accident 3 hours ago. She is having labor contractions every 4 minutes, and her cervical exam is dilated 3cm, 100% effaced and station -1. She is crying uncontrollably and states her pain is constant and severe, rating it at 10/10. The priority action by the nurse is to: reassure the patient and assist with nonpharmacologic pain interventions. assess the intensity of contractions and determine if she would like an epidural. notify the provider of the pain and request an assessment for potential abruption. perform a vaginal examination and coach the woman with breathing exercises for pain control.

notify the provider of the pain and request an assessment for potential abruption. Explanation: The woman is at risk for placental abruption due to her recent car accident. Symptoms of a placental abruption include unrelenting pain and a rigid boardlike abdomen. She may or may not have vaginal bleeding. In contrast, labor contractions are intermittent. The priority action by the nurse should be to ensure that this client is further evaluated by her HCP. Subsequent actions could include assisting with pain control measures, assessing contractions, and checking cervical dilation.

A primigravid client at about 36 weeks' gestation in active labor has had no prenatal care and admits to cocaine use during the pregnancy. Which person must the nurse notify? nursing unit manager so appropriate agencies can be notified head of the hospital's security department chaplain in case the fetus dies in utero primary care provider who will attend the birth of the infant

primary care provider who will attend the birth of the infant Explanation: The fetus of a cocaine-addicted mother is at risk for hypoxia, meconium aspiration, and intrauterine growth restriction. Therefore, the nurse must notify the primary care provider of the client's cocaine use because this knowledge will influence the care of the client and neonate. The information is used only in relation to the client's care. The nurse manager may become involved depending on unit policies when information about the cocaine use is shared with other social service, legal, or health agencies that become involved with the client's long-term care, but this is not necessary until the baby is born. The head of the hospital's security department does not need to be notified unless there is a suspicion of drug dealing taking place. The chaplain need not be notified at this time. If the fetus dies in utero and the client requests a chaplain, then the nurse can contact one.

The nurse works with the health care team to establish a policy regarding sleep positions for infants with gastroesophageal reflux. What information should the nurse search for first? policies from other hospitals data from retrospective studies published national standards expert opinions

published national standards Explanation: Published national standards are based on the best evidence and when available should serve as the foundation for nursing unit policies. Policies from other hospitals may or may not be evidence based. Retrospective studies and expert opinions should only be used to form policy when data from experimental studies or national standards are not available.

Several day-shift nurses complain that the night-shift nurses aren't performing the daily calibration of the capillary glucose monitoring apparatus, which is their responsibility. It would be most prudent for a nurse-manager to: immediately remind the night-shift nurses of the daily calibrations. arrange a meeting of the day-shift and night-shift nurses. review the capillary glucose monitoring calibration log book. counsel the night charge nurse about the discrepancy.

review the capillary glucose monitoring calibration log book. Explanation: When dealing with complaints, a nurse-manager should always gather data before taking action. Therefore, the nurse-manager should review the calibration documentation, then address the findings. It would be inappropriate for the nurse-manager to remind the staff of a responsibility that they may be fulfilling, arrange a meeting that could become confrontational, or counsel the charge nurse before investigating and gathering data relative to the complaint.

A registered nurse (RN) has been "care-paired" with a licensed practical nurse (LPN) during the evening shift. Whose care should the RN assign to the LPN? the 2-year-old child who has started eating soft, solid foods following a tonsillectomy a 12-month-old infant who has a white blood cell (WBC) count of 34/μl and a fever a 17-month-old infant with a contusion as a result of a motor vehicle accident 4 hours earlier a 22-month-old infant with type 1 diabetes who has a blood glucose level of 277 mg/dl (15.37 mmol/L).

the 2-year-old child who has started eating soft, solid foods following a tonsillectomy Explanation: The nurse can delegate care of the child who had the tonsillectomy to the LPN because that child is stable and likely preparing for discharge. The infant with a WBC count of 34/μl and fever requires close monitoring for additional signs of infection. Infection could lead to sepsis or septic shock. Although the infant with contusions from the motor vehicle accident may be stable, children sometimes experience delayed reactions to injury. This infant requires close monitoring for signs or injury or shock. The RN should care for the infant with type 1 diabetes, who could become ill very quickly.

The charge nurse on a hematology/oncology unit is reviewing the policy for using abbreviations with the staff. The charge nurse should emphasize which information about why dangerous abbreviations need to be eliminated? Select all that apply. to ensure efficient and accurate communication to prevent medication errors to ensure client safety to make it easier for clients to understand the medication prescription to make data entry into a computerized health record easier

to ensure efficient and accurate communication to prevent medication errors to ensure client safety Explanation: Abbreviations can be misinterpreted and all health care professionals should avoid the use of easily misunderstood abbreviations. The purpose of avoiding abbreviations is not to make it easier for clients to understand the medication prescriptions or to make data entry easier.

A nurse is working on a unit that is short staffed for the shift and is delegating client care to a licensed practical nurse. Which activity would be appropriate for the nurse to delegate? Select all that apply. assessment of a client who has just returned from the postanesthesia care unit vital sign monitoring of a client who is 3 days postsurgical repair of a fractured hip assistance with range of motion exercises for a client diagnosed with Alzheimer's disease education about how to administer a heparin injection to a client diagnosed with deep vein thrombosis administering a sitz-bath to a client who has had perineal surgery 2 days ago

vital sign monitoring of a client who is 3 days postsurgical repair of a fractured hip assistance with range of motion exercises for a client diagnosed with Alzheimer's disease administering a sitz-bath to a client who has had perineal surgery 2 days ago Explanation: The nurse, when delegating tasks, needs to keep in mind the scope of practice for the licensed practical nurse (LPN). Vital sign monitoring, assistance with range of motion exercises, and administering a sitz-bath are within the scope of practice for an LPN. The LPN can collect or gather data and reinforce teaching, but the assessment and education are outside the LPN's scope of practice.

In which situation can a client's confidentiality be breached legally? to answer a request from a client's spouse about the client's medication in a student nurse's clinical paper about a client when a client near discharge is threatening to harm an ex-partner when a client's employer requests the client's diagnosis to initiate medical claims

when a client near discharge is threatening to harm an ex-partner Explanation: Legally, there is a duty to warn a potential victim of a client's intent to harm. Staff can be held accountable if the client injures the ex-partner and the staff failed to warn that person. The client's permission is needed to share information with a spouse. Student papers should not contain identifying information. Release of information is made directly to the client's insurance company, not to the employer.