Passpoint PrepU - Practice NCLEX #2

Which nursing intervention will promote successful achievement of Erikson's stage of development for the 3-year-old toddler?

Encourage the toddler to assist in removing a dressing on the leg. Explanation: Toddlers are in Erikson's stage of autonomy versus shame and doubt. They want to do things on their own and experience despair when they are not allowed to be independent in areas which they are capable. Allowing the toddler to participate in the dressing change promotes their independence. Medications must be administered on a schedule to maintain therapeutic levels. Toddlers have short attention spans and would not likely complete an art project. Toddlers commonly engage in parallel play. Having another toddler visit will not aid in the achievement of Erikson's stage of development.

A 4-year-old child is brought to the emergency department in cardiac arrest. The staff performs cardiopulmonary resuscitation (CPR). Identify the area where the child's pulse would be checked.

Explanation: The carotid artery would be used to check for a pulse when performing CPR on children and adults. The brachial pulse would be used when performing CPR on an infant.

Which intervention will the nurse expect for a client with a positive tuberculin skin test?

Prepare the client for a chest X-ray. Explanation: The tuberculin skin test is a screening tool to determine if the client has been exposed to TB. The next step would be to determine if any chest infiltrates exist. The sputum specimen is the only definitive diagnostic test and would only be necessary if the X-ray was positive. The rifampin would only be administered if the chest X-ray was positive. Thus the chest X-ray is the next intervention to be implemented for this client.

A nurse is monitoring a client who appears to be hallucinating. The client is gesturing at a figure on the television and appears agitated with speech containing paranoid content. Which nursing interventions are appropriate at this time? Select all that apply.

Reassure the client that there is no danger. Acknowledge the presence of the hallucinations. Give simple commands in a calm voice. Explanation: Hallucinations are false or distorted sensory perceptions that appear to be real. Using a calm voice and giving simple commands, the nurse would reassure the client of safety. The nurse would not challenge the client; rather, the nurse would acknowledge the hallucinatory experience. It is not appropriate to ask the client to stop the behavior. Ignoring behavior will not reduce the client's agitation. During an acute episode of hallucinations, it is not appropriate to delegate skilled assessment.

A nurse is named as a defendant in a pediatric client case. What are guidelines for the nurse to follow prior to the trial? Select all that apply.

Use polite language while answering questions. Be prepared to answer questions about the case during the trial. Explanation: The nurse involved as a defendant should be prepared to answer questions and use polite language. The nurse named as a defendant should not discuss the case with anyone except the defendant's attorney. The nurse should answer the questions and not volunteer any further information unless asked.

When assessing a toddler's growth and development, the nurse understands that a child in this age group displays behavior that fosters which developmental task?

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

A client comes to the clinic for a routine checkup. To assess the client's gag reflex, the nurse should use which method?

Place a tongue blade lightly on the posterior aspect of the pharynx. Explanation: To assess a client's gag reflex, the nurse should gently touch the posterior aspect of the pharynx with a tongue blade, which should elicit gagging. Having the client say "ah" allows the nurse to evaluate cranial nerves IX and X. However, the nurse needn't use a tongue blade to hold down the tongue; the client need only stick out their tongue. Placing a tongue blade on the middle of the tongue and asking the client to cough has no value. Placing a tongue blade on the uvula may traumatize the area and harm the client.

When teaching a client about lithium, the nurse should instruct the client to:

drink at least six to eight glasses of water per day and avoid caffeine. Explanation: Caffeine should be avoided because it increases urine output. Clients need to maintain adequate fluid intake to avoid lithium toxicity. Don't limit or increase salt intake; the kidneys will retain or excrete lithium if salt intake varies. Clients should remain on medication even though they're feeling better.

The nurse has discussed sexuality issues during the prenatal period with a primigravid client who is at 32 weeks' gestation. She has had one episode of preterm labor. The nurse determines that the client understands the instructions when she makes which statement?

"I shouldn't get sexually aroused or have any nipple stimulation." Explanation: This client has already had one episode of preterm labor at 32 weeks' gestation. Sexual intercourse, arousal, and nipple stimulation may result in the release of oxytocin, which can contribute to continued preterm labor and early birth. The client should be advised to refrain from these activities until closer to term, which is 6 to 8 weeks later.

A client being admitted to hospital is asked to sign a statement confirming that the client understands the rights to communicate information related to life support and resuscitation. The client asks the nurse why signing such a statement is necessary. What is the best response by the nurse?

"We make sure our clients know they have the right to specify advance directives and appoint someone to speak for them." Explanation: Telling the client that clients have the right to specify advance directives and appoint someone to speak for them provides factual information. Telling the client not to worry is dismissive. Stating the nurse is doing something because it is required or policy does not inform the client about what the document signifies and fails to answer the question.

A mother approaches the nurse to discuss which childbirth education classes she should take. Which one of the following responses would be the most appropriate initial response from the nurse?

"What do you want to learn about?" Explanation: To be client centered, the nurse needs to determine what this mother's learning needs are. Other barriers that exist, such as finances and access to classes, should be part of the nurse's role to work with the parent to overcome as part of working to full scope of practice. This would not be the first question asked, however.

The nurse will assist with the sedation procedure for a client who is undergoing an ankle reduction. Which medication should the nurse prepare?

Ketamine Explanation: Ketamine is a common medication used for procedures that require moderate sedation, such as an ankle reduction. Glyburide is a sulfonylurea hypoglycemic oral medication used for treating diabetes. Rocuronium and succinylcholine are neuromuscular blocking agents and would not be used in moderate sedation; they cause paralysis and the client would become apneic, requiring immediate airway management.

A client with chronic pancreatitis should be assessed for which finding?

nausea and vomiting Explanation: Common manifestations of chronic pancreatitis include nausea, vomiting, and intermittent pain. Chronic pancreatitis does not cause confusion or agitation. There is no change in vital signs, and there are no musculoskeletal manifestations such as muscle twitching.

A nurse is admitting a client diagnosed with psychogenic amnesia. The client is in apparent good health. The nurse would expect the client to exhibit which of the following behaviors?

demonstrating disinterest toward the impact of the memory loss Explanation: A client with psychogenic amnesia blocks a severe or traumatic anxiety-producing event and is likely to react with disinterest to the loss of memory and identity. The client will not have a desire to discover one true identity, because this forces the client to remember the event and confront the anxiety. The client will also not experience personality switches; this is associated with dissociative identity disorder. Fluctuating level of speech is more common with dementia.

A client who's a member of Jehovah's Witnesses refuses a blood transfusion based on religious beliefs and practices. The client's decision must be followed based on which ethical principle?

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 they are 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 their 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 their 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 client is hospitalized for open reduction of a fractured femur. During the postoperative assessment, the nurse notes that the client is restless and observes petechiae on the client's chest. Which nursing action is indicated first?

Administer oxygen. Explanation: The client is demonstrating clinical manifestations consistent with a fatty embolus. Administering oxygen is the top priority. Elevating the extremity won't alter the client's condition. Notifying the nursing supervisor may be indicated by facility policy after other immediate actions have been taken. The nurse should contact the physician after administering oxygen.

The nurse is caring for a client who has been diagnosed with pernicious anemia. Which statement by the client indicates an understanding of the treatment of pernicious anemia?

"I'll need to take vitamin B12 replacements for the rest of my life." Explanation: Clients who have been diagnosed with pernicious anemia are lacking adequate amounts of the intrinsic factor (IF) that is secreted by the gastric mucosa. IF is necessary for the absorption of cobalamin (vitamin B12) in the distal ileum. Without the presence of IF, dietary intake of vitamin B12 is useless because it cannot be absorbed. Treatment of pernicious anemia includes IM injections of cobalamin, at first daily for 2 weeks, then weekly until the anemia is corrected. A maintenance schedule of monthly injections is then implemented. The injections will need to be continued for the rest of the client's life.

The nurse is caring for a client with pneumonia who is confused about time and place and has intravenous fluids infusing. Despite the nurse's attempt to reorient the client and then provide distraction, the client has begun to pull at the IV tubing. After increasing the frequency of observation, in which order should the nurse implement interventions to ensure the client's safety? All options must be used.

Assess the client's respiratory status, including oxygen saturation. Ensure the client does not need toileting or pain medications. Review the client's medications for interactions that may cause or increase confusion. Contact the health care provider (HCP) and request a prescription for soft wrist restraints. Explanation: The nurse should first assess the client's respiratory status to determine if there is a physiological reason for the client's confusion. Other physiological factors to assess include pain and elimination. Safety needs including medication interactions should then be evaluated. Requesting restraints in order to maintain client safety should be used as a last resort.

After undergoing surgery the previous day for a total knee replacement, a client states not feeling ready to ambulate yet. What should the nurse do?

Discuss the complications that the client may experience if they don't cooperate with the care plan. Explanation: The nurse should discuss the care plan and its rationale with the client. Calling the physician to report the client's noncompliance won't alter the client's degree of participation and shouldn't be used to force the client to comply. Doing nothing isn't acceptable. Although the client does have the right to make choices, it's the nurse's responsibility to provide education to help the client make informed decisions. Although the nurse should ultimately document the client's refusal, the nurse should first discuss the care plan with the client.

When teaching the client with a urinary tract infection about taking a prescribed antibiotic for 7 days, the nurse should tell the client to report which symptoms to the health care provider (HCP)? Select all that apply.

blood in the urine rash fever above 100° F (37.8° C) Explanation: The nurse should instruct the client to report signs of adverse reaction to the antibiotic or indications that the urinary tract infection is not clearing. Blood in the urine is not an expected outcome, rash is an adverse response to the antibiotic, and an elevated temperature indicates a persistent infection. These signs should be reported to the HCP. Cloudy urine can be expected during the first few days of antibiotic treatment. Mild nausea is a side effect of antibiotic therapy, but it can be managed with eating small, frequent meals. Urinating every 3 to 4 hours or more is expected, particularly if the client is increasing the fluid intake as directed.

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 nurse notifies the healthcare provider because the nurse suspects which disorder?

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 exstrophy.

A 14-year-old client in skeletal traction for treatment of a fractured femur is expected to be hospitalized for several weeks. When planning care, the nurse should take into account the client's need to achieve what developmental milestone?

identity Explanation: According to Erikson's theory of personal development, the adolescent is in the stage of identity versus role confusion. During this stage, the body is changing as secondary sex characteristics emerge. The adolescent is trying to develop a sense of identity, and peer groups take on more importance. The hospitalized adolescent is separated from the peer group and the adolescent's body image may be altered. This alteration in body image may interfere with the ongoing development of the adolescent's identity. Toddlers are in the developmental stage of autonomy versus shame and doubt. Preschool children are in the stage of initiative versus guilt. School-age children are in the stage of industry versus inferiority.

An 8-year-old child with severe cerebral palsy is underweight and undersized for his age. He is being fed a diet of pureed foods. The nurse determines the child's biggest nutritional risk is which factor?

impaired oral motor control Explanation: A child with severe cerebral palsy commonly has a lack of oral motor control that interferes with tongue control, chewing, and swallowing. This is the reason that this child is being fed pureed foods and fluids. Lack of tongue control commonly causes the child to push the food back out of the mouth while trying to chew and swallow. A child with cerebral palsy has a nonprogressive central nervous system insult.Cerebral palsy does not affect the child's metabolism. This child should be able to absorb and metabolize ingested nutrients.Cerebral palsy does not affect the child's metabolism of fats.Cerebral palsy may affect elimination but does not significantly alter absorption.

Which of the following is a normal response from an adolescent who has just returned to her room after an open appendectomy?

"I am worried about the size of my scar." Explanation: Adolescents are concerned about the immediate state and functioning of their bodies. The adolescent needs to know whether any changes (e.g., illness, trauma, surgery) will alter her lifestyle or interfere with her quest for physical perfection. Having a scar may be devastating to the adolescent. The need for plastic surgery cannot be determined at this point. The adolescent has just returned from surgery and has yet to see the scar. Healing has yet to occur. Typically scars become smaller and fade over time. The desire for no pain is unrealistic. Although adolescents are worried about pain and how they will respond, they typically are discharged within 24 hours after an appendectomy with pain well controlled by oral analgesics. The immediate concern of adolescents is the state and functioning of their bodies. After concerns about themselves, then adolescents are concerned about their peer group and their responses. Although the boyfriend's response will matter, this concern would be more common later in the course of the adolescent's recovery.

The client presents at the clinic for a cough and is ordered codeine. What should the nurse include in the client's teaching concerning the administration of codeine? Select all that apply.

"Use of codeine can cause dizziness." "Use of codeine can cause constipation." "Use of codeine can cause nausea." Explanation: The nurse should explain that adverse effects of codeine include dizziness, nausea, and constipation.

A school-age client with hemophilia A has fallen and badly bruised his knee. Which action should the nurse do first to manage the client's hemarthrosis?

Apply pressure and immobilize the joint. Explanation: Application of pressure and immobilization of the affected limb are the first priority. Pressure is required to stop the bleeding, and immobilization aids in reducing swelling and pain. Active range of motion is recommended after the bleeding is controlled. The application of cold packs can be helpful in diminishing swelling and pain. Cold packs will also promote vasoconstriction, which can help reduce the bleeding. The health care provider (HCP) should be informed of the bleeding episode after initial measures to control the bleeding are implemented.

A nurse is caring for a client who underwent surgical repair of a detached retina in the right eye. Which nursing interventions would the nurse perform postoperatively? Select all that apply.

Approach the client from the left side. Discourage the client from bending down. Orient the client to the environment. Administer a stool softener. Explanation: A detached retina is repaired by surgical procedures such as a scleral buckle, pneumatic retinopexy or a vitrectomy, which places the retina back in its proper position. Postoperatively, the nurse would approach the client from the left side—the unaffected side—to avoid startling. The nurse would also discourage the client from bending down, deep breathing, hard coughing and sneezing, and other activities that can increase intraocular pressure during the postoperative period. The client would be oriented to the environment to reduce the risk of injury. Stool softeners would be administered to discourage straining during defecation. The client would lie on the back or on the unaffected side to reduce intraocular pressure in the affected eye. The client's feet would not be higher than the head, as in the Trendelenburg position.

The nurse who cared for a client in the home environment for several months learns that the client has died. What should the nurse do to support the family at this time?

Attend the funeral. Explanation: It is appropriate for the nurse who took care of a client for a prolonged period to attend the funeral. It also is appropriate for the nurse to make a follow-up personal or phone call to the client's family after the funeral or memorial service to offer both concern and care for the family's well-being. Follow-up visits are important to give support to the family. Flowers may not be desired by the family. The nurse needs to do more than just remove the client's name from the care list.

A physical therapist has instructed the nursing staff on how to perform range-of-motion (ROM) exercises for an infant with torticollis. The nurse is uncomfortable when the infant cries and grimaces during the exercises. What is the most important action for the nurse to take?

Call the physical therapist. Explanation: The only cure for the torticollis is exercise or surgery. The physical therapist is the expert in exercise and should be called for assistance in this situation. The primary health care provider should only be called if there is concern over the orders written, or an abnormal development in the child.

When making rounds on the pediatric neurology unit, the nurse manager notes that, when giving IV medications, many of the staff nurses are disconnecting the flush syringe first and then clamping the intermittent infusion device. The nurse manager is concerned that the nurses do not understand the benefits of positive pressure technique and turbulence flow flush in preventing clots. After the nurse manager discusses the problem with the staff educator, which intervention would be the most effective way to improve the nursing practice?

Create a poster presentation on the topic with a required posttest. Explanation: A poster presentation is an eye-catching way to disseminate information that can be used to educate nurses on all shifts. The addition of the posttest will verify that the poster information has been received. Because of the large volume of emails the typical employee receives, information sent this way might be overlooked. If several nurses are observed not using the most current practice, it is quite possible many more do not understand it. Thus, a larger scale plan is needed. Posting an article will not assure that the information is read.

A nurse is preparing to give an IM injection into the left leg of a 2-year-old client. Where should the nurse administer this injection?

Explanation: The nurse should administer this IM injection in the vastus lateralis, located in the child's thigh. To give the injection, the nurse should first divide the distance between the greater trochanter and the knee joints into quadrants and then inject in the center of the upper quadrant.

Which laboratory test result does the nurse anticipate for a client diagnosed with a bite from a pit viper?

INR (international normalized ratio) of 2.3 Explanation: Pit viper envenomation can cause increased INR and positive D-dimers. A late effect of severe envenomation can be kidney damage. Potassium is not greatly affected.

A client moves in with her family after her boyfriend of 4 weeks told her to leave. She is admitted to the subacute unit after reporting feeling empty and lonely, being unable to sleep, and eating very little for the last week. Her arms are scarred from frequent self-mutilation. What should the nurse do in order of priority from first to last? All options must be used.

Monitor for suicide and self-mutilation. Monitor sleeping and eating behaviors. Discuss the issues of loneliness and emptiness. Discuss her housing options for after discharge. Explanation: Safety is the priority concern, and then eating and sleeping patterns need to be reestablished. After intervening to meet basic needs, delving into the loneliness and emptiness are important for determining underlying issues that need to be followed up in outpatient counseling. Although the client is living with her family currently, other options might be appropriate for her to consider.

An obese adolescent tells the nurse that he would like to lose weight and asks the nurse's opinion on how to accomplish his goal. Which suggestion would be most appropriate?

Participate in an adolescent weight-reduction program. Explanation: Weight loss treatment modalities that include peer involvement have been proven to be the most successful approach with obese adolescents. This is because peer support is critical to adolescents, especially with an all-encompassing problem such as obesity.Increasing the amount of exercise is helpful, but this is just one aspect of a weight-reduction program.Strict calorie restriction is not recommended because it can result in use of muscle protein as well as fat for energy.Although decreased ingestion of nonnutritive snacks is helpful in dietary control, weight loss needs to be about long term behavior changes that also include physical activity.

A nurse is examining a client in active labor, who has had spontaneous rupture of the amniotic membrane, and notes a protruding umbilical cord. What is the priority nursing action?

Place the client in knee-chest position. Explanation: A Trendelenburg or knee-chest position takes the weight of the fetus off the umbilical cord, allowing blood to flow. The cord should never be pushed back into the uterus, as this could damage the cord, obstruct the flow of blood through the cord to the fetus, or introduce infection into the uterus. The client should not be instructed to push, as she is only in active labor, and emergency surgery may be necessary. The cord should be wrapped in a sterile saline-soaked gauze.

A laboring client is restless and moving frequently in the bed. She is uncomfortable but refuses pain medication when offered. Which of the following responses from the nurse is most helpful?

Stand next to her at the side of the bed. Explanation: The client is alone and is progressing well in labor, as evidenced by her restless behaviors. She is refusing analgesia but will benefit from the 1:1 nursing care model if she is aware that the nurse is attending her at the bedside. Standing behind her will not provide a sense of nursing presence. Turning up the music or turning on the television is not appropriate unless the client requests them as a distracter.

The nurse is caring for a frail, older adult client who is experiencing pain. At the client care meeting, the family asks if it is safe for the client to receive narcotics. The nurse is aware that the client is receiving hydromorphone hydrochloride for pain. What is the nurse's most appropriate response to this family?

The narcotic is safe because it does not accumulate in the body. Explanation: Hydromorphone is a fast-acting narcotic analgesic drug and is a useful alternative to morphine or meperidine due to its short half-life. Morphine and meperidine can increase the risk of confusion in older adults. Hydromorphone is a synthetic drug similar to morphine with an 8 to 10 times more potent analgesic effect. Respiratory depression may occur, but is less frequent than with some other narcotics.

A student nurse is questioning a nursing instructor about the responsibility to have malpractice insurance. The nursing instructor confirms the safeguard of malpractice insurance by emphasizing which points regarding student liability? Select all that apply.

The student nurse is responsible for the student nurse's actions. The student nurse is held to the same standard of care as a nurse. The nursing instructor can be liable if the assignment is above the student's competency. Explanation: Student nurses are responsible for their actions and are held to the same standard of care as a nurse. The nursing instructor can be liable if the student assignment is above the student's competency. Students cannot practice as employees during an educational clinical experience. Students are responsible for being familiar with hospital policy and procedures.

A primigravida at 8 weeks' gestation tells the nurse that she wants an amniocentesis because there is a history of hemophilia A in her family. The nurse informs the client that she will need to wait until she is at 15 weeks' gestation for the amniocentesis. Which is the most appropriate rationale for the nurse's statement regarding amniocentesis at 15 weeks' gestation?

The volume of amniotic fluid needed for testing will be available by 15 weeks. Explanation: The volume of fluid needed for amniocentesis is 15 mL, and this is usually available at 15 weeks' gestation. Fetal development continues throughout the prenatal period. Cells necessary for testing for hemophilia A are available during the entire pregnancy but are not accessible by amniocentesis until 12 weeks' gestation. Amniocentesis carries a slight risk of infection regardless of when the procedure is performed.

The nurse establishes the goal of preventing the development of a stress ulcer in a burn client. Which would most likely contribute to the achievement of this goal?

administering famotidine as ordered Explanation: Clients with burns are susceptible to the development of Curling's ulcer, a gastroduodenal ulcer that is caused by a generalized stress response. The stress response results in increased gastric acid secretion and a decreased production of mucus. Prevention is the best treatment, and clients are frequently treated prophylactically with antacids and H2 histamine blockers such as famotidine.

A client in an inpatient psychiatric unit tells the nurse, "I'm going to divorce my no-good husband. I hope he rots in hell. But I miss him so bad. I love him. When is he going to come get me out of here?" The nurse interprets the client's statements as indicative of which condition?

ambivalence Explanation: Ambivalence refers to strong conflicting attitudes or feelings toward an object, person, goal, or situation, evidenced in this instance by the client stating she is going to divorce her husband and then stating that she misses and loves him. Autistic thinking is preoccupation with self with little concern for external reality. For example, a client's attention cannot be diverted from examining his hands. Associative looseness is characterized by simultaneous expression of unrelated, or only slightly related, ideas or thoughts. For example, a client states, "We went to a basketball game. Where is my father?"

A client in surgery has an endotracheal tube (ET) in place. The nurse should call a time-out if which requirements are not in place? Select all that apply.

an identification band an IV line oxygen administration an anesthetist/anesthesiologist Explanation: The nurse is responsible for the client's safety in the operating room. The nurse should call a time-out if the client is not properly identified with an identification band. In addition, an IV line and oxygen should always be established when an ET tube is placed. This practice applies whenever a client's airway is compromised enough for intubation to occur, not only in the operating room environment. An anesthetist or anesthesiologist should be present during surgery to manage the airway. Postoperative pain medication is administered in the recovery room.

An infant is brought to the emergency department. The infant is limp and has central cyanosis, a heart rate of 60 beats/minute, and a respiratory rate of 12 breaths/minute. The parents state that they have an advance directive for their infant, who has a terminal illness. A nurse's initial action should be to:

ask to see a copy of the advance directive. Explanation: To have information about how to proceed, the nurse must evaluate the advance directive. Until the nurse evaluates the legitimacy and content of the advance directive, it's inappropriate to administer oxygen or provide palliative care. The nurse should ask to see the advanced directive before proceeding with care; contacting the nursing supervisor isn't the most appropriate initial response.

A nurse must monitor a client receiving chloramphenicol for adverse drug reactions. What is a toxic reaction to chloramphenicol?

bone marrow suppression Explanation: The most toxic reaction to chloramphenicol is bone marrow suppression.

What type of isolation precautions would the nurse request for a child diagnosed with group-A beta-hemolytic streptococcus?

droplet precautions Group-A beta-hemolytic streptococcal infections are spread through droplets. Group-A beta-hemolytic streptococcal infections do not require specialized masks.

A client tells the nurse, "Everybody smiles at me because they know that I was chosen by God for this mission." The nurse interprets this statement as which finding?

idea of reference Explanation: An idea of reference is a person's view that other people recognize that she has an important characteristic or power. Thought insertion refers to a person's belief that others, or a specific other, can put thoughts into her mind. Visual hallucinations involve seeing objects or persons not based on reality. A neologism is a word or phrase that has meaning only to the person using it.

After giving birth to an 8-lb (3.6-kg) girl, a client asks the nurse what her daughter should receive for the first feeding. For a bottle-fed neonate, the first feeding usually consists of

iron-fortified infant formula. Explanation: For a bottle-fed neonate, the first feeding usually consists of iron-fortified formula. It isn't necessary to start with sterile water or glucose water.

A client in the manic phase of bipolar disorder is admitted to the facility. Which agents are appropriate for this client?

lithium and valproic acid Explanation: Lithium and valproic acid are the drugs of choice for treatment of bipolar disorder. Bupropion is an antidepressant, not an antimanic. Haloperidol, fluphenazine, clozapine, and risperidone are antipsychotic agents. Antipsychotics may be used if the client's agitation increases; however, they aren't mood stabilizing agents.

In addition to teaching regarding medications, what would the nurse include to reinforce health promotion and illness prevention for a client with acquired immunodeficiency syndrome (AIDS)?

measures to prevent transmission, maintaining optimal nutrition, and exercise Explanation: When a client has been identified as human immunodeficiency virus (HIV) positive, prevention of transmission is an important legal consideration. It is also critical to support of the immune system through proper exercise and nutrition. There is no need for isolation precautions at home. The other choices are not appropriate for health promotion and illness prevention.

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

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

A client is admitted to the hospital with an exacerbation of multiple sclerosis after an MRI revealed progressive demyelination. The nurse should assess for which symptom? Select all that apply.

progressive weakness of the extremities inability to ambulate independently urinary incontinence Explanation: Multiple sclerosis is a chronic, progressive disease that results in the destruction of the myelin sheath. This eventually affects the proper transmission of nerve impulses and results in weakness of the extremities with exacerbations and remissions where the client may be wheelchair dependent. In later stages, urinary incontinence is present due to the lack of tone to the bladder. Increased appetite and loss of cognition are not symptoms of multiple sclerosis. The appetite may decrease due to weakness of muscles that involve chewing. Cognition is not affected. The client continues to be alert and oriented despite the other widespread neurological impairments.

When planning care for a client with hepatitis A, the nurse should review lab reports for which lab value?

prolonged prothrombin time Explanation: The prothrombin time may be prolonged because of decreased absorption of vitamin K and decreased production of prothrombin by the liver. The client should be assessed carefully for bleeding tendencies. Blood glucose, serum potassium, and serum calcium levels are not affected by hepatitis.

A 4-year-old child is admitted for a cardiac catheterization. Which is most important to include as the nurse teaches this child about the cardiac catheterization?

the parents Explanation: The most important aspect of teaching a preschooler is to have the family members there for support. Preschoolers are able to understand information that is individualized to their level. Including a plastic model of the heart and a catheter as part of the preoperative preparation may be helpful. The other family members will understand the heart model and catheter better than the preschooler will.

A child, age 4, is hospitalized because of alleged sexual abuse. Which nursing intervention promotes healing for this child?

providing play situations that allow disclosure Explanation: The nursing intervention that promotes healing is to provide play situations. Through certain play situations, sexually abused child can disclose information without actually talking about themselves. Avoiding touch would be inappropriate because an abused child needs to be touched and cared for like any other hospitalized child. The nurse cannot restrict visitation unless the threat of repeated abuse exists while the child is hospitalized. A sexually abused child may not want to talk about what happened, so the nurse should provide a play situation and allow for the child to initiate conversation about the incident.

What is the most important information for the nurse to include when teaching a 17-year-old female client about the adverse effects of isotretinoin?

teratogenicity Explanation: The use of even small amounts of isotretinoin has been associated with severe birth defects. Most female clients taking this medication are prescribed hormonal contraceptives. Cleocin T, another medicine used in the treatment of acne, is associated with both diarrhea and gram-negative folliculitis. Tetracycline is associated with yeast infections

A client with rheumatoid arthritis arrives at the clinic for a checkup. Which statement by the client refers to the most overt clinical manifestation of rheumatoid arthritis?

"My finger joints are oddly shaped." Explanation: Joint abnormalities are the most obvious manifestations of rheumatoid arthritis. A systemic disease, rheumatoid arthritis attacks all connective tissue. Although muscle weakness may occur from limited use of the joint where the muscle attaches, such weakness isn't the most obvious sign of rheumatoid arthritis; also, it occurs only after joint abnormalities arise. Subcutaneous nodules in the hands, although common in rheumatoid arthritis, are painless. The disease may cause gait disturbances, but these follow joint abnormalities.

At which time should the nurse anticipate assisting a client to breastfeed her neonate?

during the neonate's first period of reactivity Explanation: A neonate is active and alert soon after birth, if no complications exist. The American Academy of Pediatrics and Canadian Pediatric Society recommend beginning breastfeeding as soon as possible after childbirth which coincides with the first period of reactivity. Because colostrum is not irritating if aspirated and is readily absorbed by the neonate's respiratory system, breastfeeding can be initiated immediately after birth.After the first period of reactivity, the neonate goes to sleep, thus making breastfeeding difficult.Maternal/infant bonding will be delayed if breastfeeding is not initiated during the first period of reactivity.

A client involved in a motor vehicle accident is admitted to the intensive care unit. The emergency department admission record indicates that the client hit their head on the steering wheel. The client complains of a headache, and a nursing assessment reveals that the client has difficulty comprehending language and diminished hearing. Based on these findings, the nurse suspects injury to which lobe of the brain?

temporal Explanation: The temporal lobe controls hearing, language comprehension, and storage and recall memory. The frontal lobe influences personality, judgment, abstract reasoning, social behavior, language expression, and movement. The occipital lobe functions primarily in interpreting visual stimuli. The parietal lobe interprets and integrates sensations, including pain, temperature, and touch.

A school-age child is admitted to the medical facility with a diagnosis of acute lymphocytic leukemia (ALL). Which nursing interventions are most appropriate?

washing hands before/upon entering room Explanation: Both ALL and its treatment cause immunosuppression. Therefore, thorough hand washing is the single most effective way to prevent infection in an immunosuppressed client. Reverse isolation does not significantly reduce the incidence of infection in immunosuppressed clients; furthermore, isolation may cause psychological stress. The client does not need to wear a mask when in their room. Instead of limiting the number of visitors to the client, the nurse should keep persons with known infections out of the client's room.

The nurse is caring for a client on the psychiatric unit. The client states, "The voices are bothering me. They are yelling and telling me stuff. They are really bad." Which responses by the nurse would be most appropriate?

"I do not hear any voices. What are you hearing?" Explanation: A hallucination is a false sensory perception. It involves all five senses and bodily sensations. Initially, the nurse needs to assess what kind of voices are being heard. That is, are they friendly, commanding, or controlling voices? Acknowledging that the client is experiencing the voices but telling the client that the nurse does not may help the client realize that the voices are not real. Then the nurse can focus on the client's feelings or redirect the client to reality by initiating a simple task with the client such as coloring. When the voices are less severe, the nurse can do a more thorough assessment of the client's hallucinations and begin to assist the client in learning to deal with the voices.

A nurse is providing instruction to a client undergoing treatment for anxiety and insomnia. The practitioner has prescribed lorazepam 1 mg PO t.i.d.. The nurse determines that teaching has been effective when the client states

"I'll avoid coffee." Explanation: Lorazepam is a benzodiazepine used to treat various forms of anxiety and insomnia. Caffeine is contraindicated because it is a stimulant and increases anxiety. A client taking lorazepam should avoid alcoholic beverages. Clients taking certain antipsychotic medications should avoid sunlight. Salt intake has no effect on lorazepam.

A client diagnosed with schizophrenia is being switched to risperidone long-acting injection. The client is told that he will remain on his oral dose of risperidone daily for approximately 1 month. The client says, "I didn't have to take pills when I was on fluphenazine shots in the past." What should the nurse tell the client?

"Risperidone long-acting injection initially takes a little longer to reach the ideal blood level." Explanation: Achieving a therapeutic blood level is a slower process with risperidone long-acting injection. Oral fluphenazine does not decrease the effectiveness of the intramuscular version and might increase the incidence of adverse effects. There is no evidence that the potency of the two medications is significantly different. Blaming the client for noncompliance with these two medications is inappropriate.

A client with end-stage dementia is admitted to the orthopedic unit after undergoing internal fixation of the right hip. How should the nurse manage the client's postoperative pain?

Administer analgesics around the clock. Explanation: Because assessing pain medication needs in a client with end-stage dementia is difficult, analgesics should be administered around the clock. Clients at this stage of dementia typically can't request oral pain medications when needed. They're also unable to use patient-controlled analgesia devices. Transdermal patches are used to manage chronic pain; not postoperative pain.

A client recovering from a stroke is prescribed a leg brace and needs to be transferred out of bed to a chair. Which action should the nurse take first before beginning this transfer?

Apply the leg splint before beginning the transfer. Explanation: It is recommended that any braces or devices the client wears to be applied before assisting the client out of bed. The head of the bed should be raised so that the client is in a sitting position before beginning the transfer. There is no reason to roll the client away from the side of the transfer. This would not facilitate the movement and could cause injury to both the client and nurse during the transfer.

A client has not had a bowel movement for 2 days and is feeling uncomfortable. The physician writes an order that states, "laxative of choice." How should the nurse proceed with this order?

Ask the physician to prescribe a specific laxative. Explanation: The physician's order leaves the nurse in the position of prescribing a medication. To be a complete order, the physician must write the drug, dose, frequency, route, and purpose or reason for the drug. The other options are incorrect because they put the nurse in the position of prescribing a medication and not following established professional standards for the administration of medication.

A nurse is teaching a client about taking antihistamines. Which information should the nurse include in the teaching plan? Select all that apply.

Increase fluid intake to 2,000 mL/day. Operating machinery and driving may be dangerous while taking antihistamines. Do not use alcohol with antihistamines.

A client is told that she needs to have a nonstress test to determine fetal well-being. After 20 minutes of monitoring, the nurse reviews the strip and finds two 15-beat accelerations that lasted for 15 seconds. What should the nurse do next?

Inform the physician and prepare for discharge; this client has a normal strip. Explanation: Fetal well-being is determined during a nonstress test by two accelerations occurring within 20 minutes that demonstrate a rise in heart rate of at least 15 beats. This fetus has successfully demonstrated that the intrauterine environment is still favorable. The test results don't suggest fetal distress, so preparation for immediate birth is unnecessary. In research studies, eating foods or drinking fluids hasn't been shown to influence the outcome of a nonstress test.

When teaching the family of an older infant who has had a spica cast applied for developmental dysplasia of the hip, which information should the nurse include when describing the abduction stabilizer bar?

It adds strength to the cast. Explanation: The abduction bar is incorporated into the cast to increase the cast's strength and maintain the legs in alignment. The bar cannot be removed or adjusted, unless the cast is removed and a new cast is applied. The bar should never be used to lift or turn the client because doing so may weaken the cast.

Which instruction should the nurse include in the teaching plan for a client with seizures who is going home with a prescription for gabapentin?

Notify the health care provider (HCP) if vision changes occur. Explanation: Gabapentin may impair vision. Changes in vision, concentration, or coordination should be reported to the HCP. Gabapentin should not be stopped abruptly because of the potential for status epilepticus; this is a medication that must be tapered off. Gabapentin is to be stored at room temperature and out of direct light. It should not be taken with antacids.

A postmenopausal client is scheduled for a bone density scan. What should the nurse instruct the client to do?

Remove all metal objects on the day of the scan. Explanation: Metal will interfere with the test. Metallic objects within the examination field, such as jewelry, earrings, and dental amalgams, may inhibit organ visualization and can produce unclear images. Ingesting foods and beverages days before the test will not affect bone mineral status. Short-term calcium gluconate intake will also not influence bone mineral status. The client may already have had chronic pain as a result of a bone fracture or from osteoporosis.

A nurse is reviewing a teaching plan with parents of an infant undergoing repair for a cleft lip. Which instructions are the most appropriate for the nurse to give? Select all that apply.

Sit the infant up for each feeding. Give the infant extra care and support. Clean the suture line after each feeding by dabbing it with saline solution. Explanation: The nurse should instruct the parents to feed the infant in the upright position with a syringe and attached tubing to prevent stress to the suture line from sucking. In addition, to prevent crusts and scarring, the suture line should be cleaned after each feeding by dabbing it with half-strength hydrogen peroxide or saline solution. The parents should give the infant extra care and support because the infant cannot meet emotional needs by sucking. Extra attention may also prevent crying, which stresses the suture line. Offering a pacifier is not appropriate. Pacifiers should not be used during the healing process because they stress the suture line. Arm restraints keep the infant's hands away from the infant's mouth; the restraints should be loosened every 2 hours, not every 4 hours.

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.

Which statement best describes the therapeutic action of loop diuretics?

They block sodium reabsorption in the ascending loop and dilate renal vessels. Explanation: Loop diuretics block sodium reabsorption in the ascending loop of Henle, which promotes water diuresis. They also dilate renal vessels. Although loop diuretics block potassium reabsorption, this isn't a therapeutic action. Thiazide diuretics, not loop diuretics, promote sodium secretion into the distal tubule.

A health care provider has placed a stat order for a urine specimen for culture and sensitivity. What is the best way for the nurse to delegate this task to an unlicensed assistive personnel?

We need to collect urine from the client in room 101 for a stat culture. Please tell me when you send it to the lab. Explanation: This option not only delegates the task but also provides a checkpoint. To effectively delegate, you need to follow up on what someone else is doing. The other options don't provide for feedback, which is essential for communication and delegation.

The nurse has just received report on four clients. Which client should be seen first?

a client feeling sweaty and requesting antacid for stomach upset Explanation: Signs of indigestion and sweating can be signs of impending myocardial infarction that should be carefully assessed by the nurse. The client who had the cardiac catheterization has stable vital signs and should be reassessed after assessing the client with a potential impending myocardial infarction. The client who had respiratory therapy does not require immediate attention. The client with diabetes has a normal finger stick glucose level and does not require immediate attention.

A client with an intravenous (I.V.) site is experiencing pain. The nurse understands that pain with infusion is a sign of:

catheter position at the insertion site due to movement. Explanation: The catheter pressing against the vein causes the pain. This would be a common result due to normal movement of the client throughout the day. The other choices should not cause pain at insertion.

A nurse is teaching child care classes for adolescent parents. To enhance the adolescents' understanding of infant safety, the nurse would suggest that the parent:

crawl around on the floor looking for potential hazards from the viewpoint of an infant. Explanation: Crawling on the floor is a participative activity that can help promote understanding of infant safety in relation to the infant's perspective. The nurse doesn't need to instruct adolescents to discuss infant safety with the pediatrician because the nurse can provide such information in the class environment. Presenting a lecture or video doesn't directly focus on the infant's perspective regarding items that may be a safety threat.

A 10-year-old child is taking high doses of aspirin. Which finding indicates the child is experiencing early salicylate toxicity?

dizziness Explanation: Signs and symptoms of early salicylate toxicity include tinnitus, disturbances in hearing and vision, and dizziness. Salicylate toxicity may cause nausea, vomiting, diarrhea, and bleeding from mucous membranes from long-term use.Pink-colored urine, a slowed pulse rate, and chest pain, rarely occurring in children, are not associated with salicylate toxicity.

The nurse is documenting client information in the client's medical record. Which action by the nurse is appropriate when documenting information in a client's medical record?

ending each entry with a signature and title Explanation: The end of each entry should include the nurse's signature and title; the signature holds the nurse accountable for the recorded information. The nurse can refer to the client and care providers by name in the medical record because it is kept secure and contains numerous identifiers already. Practitioners being referred to in a note should be identified by name instead of by titles (e.g., physician or charge nurse). The nurse is accountable for the information recorded and therefore shouldn't leave any blank lines in which another healthcare worker could make additions.

A young child who has been sexually abused has difficulty putting feelings into words. Which approach should the nurse employ with the child?

engaging in play therapy Explanation: The dolls and toys in a play therapy room are useful props to help the child remember situations and reexperience the feelings, acting out the experience with the toys rather than putting the feelings into words. Role-playing without props commonly is more difficult for a child. Although drawing itself can be therapeutic, having the abuser see the pictures is usually threatening for the child. Reporting abuse to authorities is mandatory, but does not help the child express feelings.

The nurse is making a postpartum visit at the home of a client who delivered 14 days earlier. After assessing the vital signs (temperature, 99° F [37.2° C]; pulse, 88 bpm; respiration rate, 20 breaths/min; and blood pressure, 112/60 mm Hg), the nurse records the other assessments. (See exhibit.) Which finding indicates delayed involution?

fundus Explanation: The fundus descends at the rate of one to two centimeters per day and by 2 weeks is no longer a pelvic organ. The vital signs, breasts, heart, lungs, abdomen (with exception of fundus), lochia, perineum, and extremities are within normal limits.

Which factor is most important to assess when determining the impact of the cancer diagnosis and treatment modalities on a long-term survivor's quality of life?

individual values and beliefs Explanation: Individuals with cancer have various cultural values and beliefs that help them cope with the cancer experience. Quality of life cannot be evaluated solely by quantifiable factors such as employability, functional status, or evidence of disease. It must be evaluated by the survivors within the context of their subjective and individual values and beliefs.

A client is diagnosed with syndrome of inappropriate antidiuretic hormone (SIADH). Laboratory results reveal serum sodium level 130 mEq/L and urine specific gravity 1.030. Which nursing intervention helps prevent complications associated with SIADH?

restricting fluids to 800 ml/day Explanation: Excessive release of antidiuretic hormone (ADH) disturbs fluid and electrolyte balance in SIADH. The excessive ADH causes an inability to excrete dilute urine, retention of free water, expansion of extracellular fluid volume, and hyponatremia. Symptomatic treatment begins with restricting fluids to 800 ml/day. Vasopressin is administered to clients with diabetes insipidus a condition in which circulating ADH is deficient. Elevating the head of the bed decreases vascular return and decreases atrial-filling pressure, which increases ADH secretion, thus worsening the client's condition. The client's sodium is low and, therefore, shouldn't be restricted.

A nurse manager is implementing a plan to improve the use of standard precautions by the staff on the unit. After collecting observational data on the staff's use of personal protective equipment, which behavior would the nurse manager identify as an indication of the need for education? Select all that apply.

use of gowns when caring for every client use of sterile gloves for urine specimen collection recapping of needles after use Explanation: Standard precautions include using gowns if there will be splashing or spattering of blood or body fluids (not for every client), using clean (not sterile) gloves to collect urine specimens, and never recapping needles once used. Standard precautions include performing hand hygiene after removing gloves and disposing of contaminated dressings in the proper biohazard container. These behaviors do not indicate a need for education.

The nurse is caring for a client in the recovery room after electroconvulsive therapy (ECT). Which would be the priority nursing assessment?

vital signs Explanation: Although ECT is an operative procedure, and a failure or reduction of peristalsis (also known as paralytic ileus) can accompany some surgical procedures, it is least expected after ECT procedure. Headache, disorientation, and memory loss are common short-term side effects, but the priority assessment would be client vital signs in the postictal state. The nurse would not be able to assess the client's response to ECT immediately postprocedure.

The nurse is caring for a client with an I.V. line. During care of the I.V. line, the nurse would be required to wear protective gloves in which situations? Select all that apply.

when inserting the I.V. When discontinuing the I.V. When changing the I.V. site Explanation: The nurse should wear protective gloves when inserting the I.V., when discontinuing the I.V., and when changing the I.V. site due to the risk of exposure to blood and bodily fluids. The nurse would not be required to wear protective gloves while spiking or hanging a new bag of solution.

The nurse should advise the mother of a toddler suspected of having pinworms to do the cellophane tape test at which time?

while the child is asleep Explanation: Pinworms come out of the rectum during the nighttime and early morning hours. Therefore, the best time to apply the tape to get results is while the child is asleep.

A young client develops a fever and rash and is diagnosed with rubella. The client's mother has just given birth to another child. Which statement by the mother best indicates that she understands the implications of rubella?

"I'll call my neighbor who's 2 months pregnant and tell her not to have contact with my children." Explanation: By saying she'll call her pregnant neighbor, the mother demonstrates that she understands the implications of rubella. Fetal defects can occur during the first trimester of pregnancy if the pregnant woman contracts rubella. Aspirin shouldn't be given to young children because aspirin has been implicated in the development of Reye's syndrome. Acetaminophen should be used instead of aspirin. Rubella immunization isn't recommended for children until ages 12 to 15 months. Having the measles (rubeola) won't provide immunity for rubella.

On her third postpartum day, a client complains of chills and aches. Her chart shows that she has had a temperature of 100.6° F (38.1° C) for the past 2 days. The nurse assesses foul-smelling, yellow lochia. What should the nurse do next?

Anticipate that the physician will order laboratory tests and cultures. Explanation: Signs and symptoms of localized infection include a morbid temperature, chills, malaise, generalized pain or discomfort, and foul-smelling, yellow lochia. The physician may order laboratory tests, including a complete blood count and cultures, to confirm an infection and the causative organisms. Rechecking the client's temperature in 4 hours isn't appropriate because the client requires intervention now. The client's signs and symptoms don't suggest breast engorgement. Laboratory work should be done before starting antibiotics.

A client who is in rehabilitation following a cerebrovascular accident (or brain attack) is experiencing total hemiplegia of the dominant right side. The nurse finds that the client needs assistance with eating to ensure optimum nutrition. Which action is most important for the nurse to take to facilitate rehabilitation with eating?

Assist the client in learning to eat with the left hand. Explanation: It is important to involve the client in care. The client will need to learn to eat with the non-dominant hand. Promoting independence and supporting attainment of this skill will help the client positively meet the goal of rehabilitation. Feeding the client or having the family feed the client does not promote independence. The client is not having difficulty chewing or swallowing, so a thickened liquid diet is not needed.

A client who is 1 day postoperative is using a morphine patient-controlled analgesia (PCA) pump. The client is confused and disoriented. What is the priority intervention by the nurse?

Check respiratory rate and depth as well as oxygen saturation levels. Explanation: Morphine depresses respiration, so the nurse should assess the client's respiratory rate and depth. If the rate is below 12 breaths/min, morphine can be withheld. Checking oxygen saturation levels will also indicate whether there is effective oxygenation of the blood. Morphine's effect is not usually significant on the cardiovascular system. The calculation of effective morphine dose includes that administered via the bolus. Pulmonary embolism is not a problem in the initial postoperative period.

A client admitted to the alcohol detoxification program asks the nurse if there is a medication to "stop me from wanting a drink so badly." The nurse should teach the client about:

naltrexone. Explanation: Naltrexone is a drug that can decrease alcoholic cravings. Chlordiazepoxide and other sedatives help reduce the symptoms of alcohol withdrawal but don't decrease cravings. Haloperidol may be given to treat clients with psychosis, severe agitation, or delirium. Magnesium sulfate and other anticonvulsant medications are only administered to treat seizures if they occur during withdrawal.

The mother of an 8-year-old child with a fluid restriction of 1,000 mL/day is staying in the child's room. Which intervention would be most appropriate for the nurse to include in the child's plan of care?

Discuss the fluid restriction with the mother and child, and allow them to decide how to allocate the fluids over the 24 hours. Explanation: Planning the child's fluid restriction with the mother and child is most appropriate because the mother and child would best know the child's usual pattern of fluid intake. Doing so also provides the mother with a feeling of some control over her child's situation and helps to promote compliance. Anyone, not just hospital personnel, can provide the child with fluids. However, a strict record of the child's intake must be kept to ensure adherence to the restriction. gelatin counts as a fluid, thus it must also be limited. Telling the mother exactly how much fluid the child can have each hour restricts the extent of the mother's and child's participation in care. Additionally, doing so ignores the child's usual needs, such as the usual pattern of fluid intake, possibly interfering with adherence to the fluid restriction.

A mother states that a health care provider (HCP) described her daughter as having 20/60 vision, and she asks the nurse what this means. The nurse responds based on the interpretation that the child is experiencing which condition?

ability to see at 20 feet what she should see at 60 feet Explanation: A child with 20/60 vision sees at 20 feet what those with 20/20 vision see at 60 feet. A visual acuity of 20/200 is considered to be the boundary of legal blindness.

When the nurse is preparing the room for admission of a multigravid client at 36 weeks' gestation diagnosed with severe preeclampsia, which item is most important for the nurse to obtain?

padding for the side rails Explanation: The client with severe preeclampsia may develop eclampsia, which is characterized by seizures. The client needs a darkened, quiet room and side rails with thick padding. This helps decrease the potential for injury should a seizure occur. Airways, a suction machine, and oxygen also should be available. If the client is to undergo induction of labor, oxytocin infusion solution can be obtained at a later time. Tongue blades are not necessary. However, the emergency cart should be placed nearby in case the client experiences a seizure. The ultrasound machine may be used at a later point to provide information about the fetus. In many hospitals, the client with severe preeclampsia is admitted to the labor area, where she and the fetus can be closely monitored. The safety of the client and her fetus is the priority.

The nurse advises a client recovering from a myocardial infarction to decrease fat and sodium intake. Which foods should the nurse instruct the client to avoid? Select all that apply.

pepperoni pizza bacon cheese soft drinks Explanation: Foods high in sodium include cheese, processed meats such as pepperoni and bacon, and soft drinks. Bacon and cheese also have a high fat content.

The nurse carefully documents the premature neonate's response to oxygen therapy, delivering only as much oxygen as is necessary to prevent the development of which complication?

retinopathy of prematurity Explanation: High levels of oxygen delivered to a preterm neonate can result in retinopathy of prematurity. The immature blood vessels in the eye constrict, then overgrow, resulting in edema and hemorrhage that produce scarring, retinal detachment, and eventual blindness.Cataracts and glaucoma are congenital abnormalities in the neonate unrelated to oxygen therapy.Ophthalmia neonatorum is a gonorrheal infection of the eyes that is likely to occur if a mother has the gonorrheal organism in her birth canal.

A client is entering the alcohol treatment program for the fourth time in 5 years. Which statement by the nurse will be most helpful to the client?

"I'm a nurse in the program. The staff and I will help you through the program." Explanation: Stating "I'm a nurse in the program; the staff and I will help you" is a nonjudgmental, caring approach that promotes trust and a therapeutic relationship. The statement "I hope you're serious about maintaining your sobriety this time" blames the client, subsequently decreasing the client's self-worth. Saying "You'll get it right this time" is threatening to the client, possibly leading to decreased self-worth by reinforcing the client's past failures at maintaining sobriety. The statement "I know someone who was successful after the fifth program" is impersonal and irrelevant to the client's situation.

On a medical-surgical floor, a nurse is caring for a cluster of clients with diabetes mellitus. Which client should the nurse assess first?

A 55-year-old complaining of chest pressure Explanation: The nurse should assess the client with chest pressure first because that client might be experiencing a myocardial infarction. The blood glucose levels in 20-year-old client and 80-year-old client are abnormal, but not life threatening; therefore, these clients don't require immediate attention. After assessing the client with chest pressure, the nurse should assess the client experiencing nausea and vomiting.

A client diagnosed with anxiety disorder is prescribed buspirone. What priority teaching will the nurse provide?

Buspirone has a delayed therapeutic effect of between 14 to 30 days. Explanation: The client should be informed that the drug's therapeutic effect might not be achieved for 14 to 30 days. The client must be instructed to continue taking the drug as directed. Tachycardia, not bradycardia, is a reported effect of buspirone. Blood level checks are not necessary. Neuroleptic malignant syndrome has not been reported with this drug.

Which instruction should the nurse expect to include in the discharge teaching plan for the parent of an infant who has had an inguinal herniorrhaphy?

Change diapers as soon as they become soiled. Explanation: Changing a diaper as soon as it becomes soiled helps prevent wound infection, the most common complication after inguinal hernia repair in an infant secondary to possible wound contamination with urine and stool. Because the surgical wound is unlikely to separate, an abdominal binder is unnecessary. The incision may or may not be covered with a dressing. If a dressing is not used, the health care provider (HCP may apply a topical spray to protect the wound. Restraining the infant's hands is unnecessary if the diaper is applied snugly. The infant would be unable to get the hands into the diaper close to the surgical site.

A nurse is working with a client being evaluated for social anxiety disorder. Which assessment question by the nurse would be most appropriate?

Do you feel others are judging you? Explanation: With social anxiety disorder, the client experiences feeling dread of social situations and overwhelming fear of being scrutinized or judged by others and embarrassed in public. Asking about sudden intense fear reaction is characteristic of a panic attack. With social anxiety disorder, the client knows the fears about social/public situations. Asking the client about ways to escape situations is defeating the purpose of treatment for the avoidance. Repeating actions is characteristic of obsessive-compulsive disorder.

A 15-year-old with acute lymphocytic leukemia has been caught hiding her oral chemotherapy each morning. Which nursing intervention will improve compliance?

Have the child meet teenage survivors of cancer who were compliant with treatment. Explanation: Have the teenager talk to other teenagers who are going through similar experiences. Talking to age-appropriate peers will make a bigger impact than trying to force the teenager to conform.

The nurse is admitting a client directly from a healthcare clinic. The healthcare provider's orders are illegible. What should the nurse do next? Select all that apply.

Hold all orders. Call the healthcare provider to clarify orders. Explanation: If the nurse cannot correctly interpret the components of a medication order, the nurse should hold the orders and call the healthcare provider for clarification. The only person that can interpret the components of the orders are the person who wrote the orders.

When completing the preoperative checklist on the nursing unit, the nurse discovers an allergy that the client has not reported. What should the nurse do first?

Inform the anesthesiologist. Explanation: The anesthesiologist who administers the anesthetic agent and monitors the client's physical status throughout the surgery must have knowledge of all known allergies for client safety. The completed record (with the preoperative checklist) must be available to all members of the surgical team, and any unusual last-minute observations that may have a bearing on anesthesia or surgery are noted prominently at the front of the medical record. The preanesthetic medication can cause light-headedness or drowsiness. The nurse in the scrub role provides sterile instruments and supplies to the surgeon during the procedure.

A client is admitted to the psychiatric unit exhibiting extreme agitation, disorientation, and incoherence of speech with frantic and aimless physical activity and grandiose delusions. Which would the highest priority goal in planning nursing interventions?

The client will show no self-harm or harm to staff. Explanation: The client is at increased risk for injury because of their hyperactivity, agitation, and disorientation. The goal for no self-harm or harm to staff best fits the priority for this situation. Although the client's anxiety and orientation is a concern and is important for the client's care, the client's safety always takes highest priority. The nurse should plan first and foremost to prevent injury and harm for which the client is at risk given their current condition.

The registered nurse (RN) is teamed with a licensed practical/vocational nurse (LPN/VN) in caring for a group of cardiac clients on a pediatric unit. Which action by the LPN/VN indicates the nurse should intervene immediately?

The LPN/VN assists a child to the bathroom 2 hours after a cardiac catheterization. Explanation: Because the femoral artery is usually used as the access site during a cardiac catheterization, children are required to remain on bed rest (with the head only slightly elevated) for several hours after the procedure to avoid arterial bleeding at the site. A knee chest position is the correct position for an infant during a cyanotic episode as it will create peripheral resistance to the extremities, shunting blood to the heart. The apical heart rate is assessed prior to administering this medication; administration can be performed by an experienced LPN/VN, although medication is checked with the RN prior to administration. Because echocardiography is noninvasive, there is no need to withhold meals before this procedure.

A physician orders lactulose, 30 ml three times daily, for a client with cirrhosis to treat elevated serum ammonia level. The nurse will know that this medication is effective by which finding?

The client's level of consciousness (LOC) would improve. Explanation: In cirrhosis, the liver fails to convert ammonia to urea. Ammonia then builds up in the blood and is carried to the brain, causing cerebral dysfunction. When this occurs, the client will often have a decreased level of consciousness and appear confused. Lactulose is administered to promote ammonia excretion in the stool and thus improve cerebral function. Because LOC is an accurate indicator of cerebral function, the nurse can evaluate the effectiveness of lactulose by monitoring the client's LOC. Monitoring urine output, abdominal girth, and stool frequency helps evaluate the progress of cirrhosis, not the effectiveness of lactulose.

While reviewing the admission assessment of a client scheduled for colorectal surgery, the nurse discovers that the client stopped taking medications to treat emphysema 3 months ago. What would be a priority in planning collaborative care with the respiratory therapist?

Timely administration of breathing treatments. Explanation: The nurse should collaborate with the respiratory therapist to make sure breathing treatments are administered and the client's respiratory status is watched closely before and after surgery, because of the increased risk of infection and post operative pneumonia. An induced sputum specimen is not necessary at this time. The nurse alone can teach the client coughing and deep breathing exercises and monitor the color and consistency of sputum specimens.

Following an epidural and placement of internal monitors, a client's labor is augmented with oxytocin. Contractions are lasting greater than 90 seconds and occurring every 1½ minutes. The uterine resting tone is >20 mm Hg with an abnormal fetal heart rate and pattern. Which action should the nurse take first?

Turn off the oxytocin infusion. Explanation: The client is experiencing uterine hyperstimulation from the oxytocin. The first intervention should be to stop the oxytocin infusion, which may be the cause of the long, frequent contractions, elevated resting tone, and abnormal fetal heart patterns. Only after turning off the oxytocin should the nurse turn the client to her left side to better perfuse the mother and fetus. Then she should increase the maintenance IV fluids to allow available oxygen to be carried to the mother and fetus. When all other interventions are initiated, she should notify the HCP.

The nurse understands that with the right help at the right time, a client can successfully resolve a crisis and function better than before the crisis, based primarily on which factor?

acquisition of new coping skills Explanation: Learning new coping skills is the major factor necessary for higher functioning. Better coping is likely to lead to regaining support systems, giving up dysfunctional coping, and awareness of how to prevent future crises.

A pregnant client is diagnosed with partial placenta previa. The nurse should prepare the client for which intervention?

activity limited to bed rest Explanation: Treatment of partial placenta previa includes bed rest, hydration, and careful monitoring of the client's bleeding. Placenta previa involves an abnormal implantation of the placenta. Platelets are not affected. Therefore, a platelet infusion is not necessary.Vaginal birth is the preferred method of birth. An immediate cesarean section is not warranted unless fetal distress occurs or the client begins to hemorrhage.Induction of labor should be initiated with caution and only if birth is indicated because of the risk for possible hemorrhage or fetal distress.

Which client would be most appropriate for the nurse to assign to an unlicensed assistive personnel (UAP) for morning care?

an elderly client with chronic obstructive pulmonary disease (COPD) who is receiving oxygen therapy for mild dyspnea Explanation: The most appropriate client to assign to a UAP is the elderly client with COPD and mild dyspnea because of the relative stability of the client's chronic condition. The client with a new laryngectomy requires close observation to maintain a patent airway, promote comfort, and decrease anxiety. The client who is receiving chemotherapy will need to be monitored for adverse effects related to the chemotherapy. The client with a suspected pulmonary embolus is acutely ill and requires close observation.

Which observation is expected when the nurse is assessing the gestational age of a neonate born at term?

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 client with a diagnosis of schizophrenia is experiencing paranoia and tells the nurse about hearing a voice saying, "Don't take those poisoned pills from that nurse!" Which objective assessment regarding this statement will the nurse report to the healthcare team?

disturbed perceptions Explanation: Hallucinations are sensory experiences of perception without corresponding stimuli in the environment. This client objectively reports to the nurse the fearfulness and experience of this hallucination—a perceptual disturbance. This differs from the thought disorder (delusions).

A mother tells a nurse that her child has been exposed to roseola. After the nurse teaches the mother about the illness, which finding, if stated by the mother as the most characteristic sign of roseola, indicates successful teaching?

high fever followed by a drop and then a rash Explanation: Children with roseola have a high fever for 3 days, which drops suddenly. Then a nonpruritic rash appears, typically lasting for 1 to 2 days. High fever followed by a rash is a characteristic sign. Associated symptoms include cold symptoms, cough, and lymphadenopathy.

The nurse is conducting a health history with a client with active tuberculosis. The nurse should ask the client about:

weight loss. Explanation: Tuberculosis typically produces anorexia and weight loss. Other signs and symptoms may include fatigue, low-grade fever, and night sweats.

The chart documentation of a client with paranoid personality disorder is listed below:10/151830The client stays by oneself as much as possible during the afternoon. The client paced the hallway at times and was irritated if approached by staff or other clients. The client questioned another male client and accused that client of lying. At the beginning of the shift the nurse spoke to the client accused of lying.Which statement, from the client accused of lying, would require further intervention?

"If I have an opportunity, I will not let him get away with this." Explanation: Clients with paranoid personality disorder can be frustrating to staff and other clients. It is appropriate for the nurse to ask the person accused of lying if he is feeling rebuffed and retaliatory. Saying "I will not let him get away with this" indicates that the client is considering retaliation. The other options indicate that the accused client has a cautionary approach, and is able to set boundaries concerning the person with paranoid personality disorder.

A male client enters the oncology clinic for an evaluation. The nurse explains that the healthcare provider has ordered a prostate-specific antigen (PSA) test. The client asks the nurse, "How will this test tell if I have prostate cancer?" What is the nurse's best response?

"Individuals who have a PSA higher than 10 have a 60-70% chance of having prostate cancer." Explanation: Most men have PSA levels under 4 ng/mL, which has traditionally been used as the cutoff for concern about the risk of prostate cancer. Men with prostate cancer often have PSA levels higher than 4. Those with a PSA between 4 and 10 have a 25% chance of having prostate cancer and if the PSA is higher than 10, the risk increases to 67%.

A female client who is hospitalized for an eating disorder weighs 15 lb (6.8 kg) less than the ideal body weight. Which goal is a priority for this client?

The client gains 1 lb (0.5 kg) per week. Explanation: The actual desired weight gain of 1 lb (0.5 kg) per week is the most measurable goal for the client. Attending all eating disorder support groups is a goal, but it is not as important as actual weight gain. The client can eat a larger meal at breakfast and then not eat sufficient food and over exercise for the remainder of the day. The client's improved self-image is important, but actual weight gain is again a priority.

A client is admitted to the emergency department with a history of abdominal aortic aneurysm. The nurse assesses the client for which sign or symptom that suggests the client's abdominal aortic aneurysm is extending?

increased abdominal and back pain Explanation: Pain in the abdomen and back signify that the aneurysm is pressing downward on the lumbar nerve root and is causing more pain. The pulse rate would increase with aneurysm extension. Chest pain radiating down the arm would indicate myocardial infarction. Blood pressure would decrease with aneurysm extension, and the respiratory rate may not be affected.

A client who suffered blunt chest trauma in a motor vehicle accident complains of chest pain, which is exacerbated by deep inspiration. On auscultation, the nurse detects a pericardial friction rub — a classic sign of acute pericarditis. The physician confirms acute pericarditis and begins appropriate medical intervention. To relieve chest pain associated with pericarditis, which position should the nurse encourage the client to assume?

leaning forward while sitting Explanation: The nurse should encourage the client to lean forward, because this position causes the heart to pull away from the diaphragmatic pleurae of the lungs, helping relieve chest pain caused by pericarditis. The semi-Fowler's, supine, and prone positions don't cause this pulling-away action and therefore don't relieve chest pain associated with pericarditis.

A water-soluble biohazardous bag is placed in the room of a client in contact precautions. Which item should the nurse place into this bag?

linens Explanation: A water-soluble bag should be used for items that are dry but when the bag is placed in hot water it dissolves. Linens should be placed in the water-soluble bag for cleaning. Food wrappers and containers can be placed in the regular trash. A water pitcher and intravenous fluid would cause the water-soluble bag to disintegrate.

The client who has a history of angry outbursts when frustrated begins to curse at the nurse during an appointment after being informed that she will have to wait to have her medication refilled. Which response by the nurse is most appropriate?

"I won't continue to talk with you if you curse." Explanation: Stating "I won't continue to talk with you if you curse" sets limits on the client's behavior and points out the negative effects of her behavior. Therefore, this response is most appropriate and therapeutic. The statement "You're being very childish" reprimands the client, possibly causing the anger to escalate. The statement "I'm sorry if you can't wait" fails to provide feedback to the client about her behavior. The statement "Come back tomorrow, and your medication will be ready" ignores the client's behavior, failing to provide feedback to the client about the behavior. It also shows poor nursing judgment because the client may need her medication before tomorrow or may not return to the clinic the following day.

An older client was brought into the emergency department in a confused state, incoherent, and agitated after reportedly spray-painting their lawn furniture with metal paint earlier that day. The client has no history of illness and is not on any medication. Which intervention would be most important for the nurse to make?

Complete a baseline mental status exam. Explanation: Delirium is a state of mental confusion and excitation. Symptoms include mind wandering, incoherent speech, and continued aimless physical activity. The onset is usually rapid (within hours). Metal paint is a toxin that is known to cause delirium. The nurse must complete a baseline mental status exam to understand the client's subsequent behavior better. The assessment would be included in any communication with the practitioner. With delirium, it would be important to decrease the client's exposure to sensory stimulation, but would not be the most important action. Depression could be a cause of delirium, but in this case, the cause was the client's exposure the toxin.

An older client must be admitted for a serious respiratory condition, but resists all recommendations to do so. A nurse is able to learn that the client has an unauthorized pet cat at home that must be cared for. What is the best action for the nurse to take?

Discuss with the client ways to find a temporary caretaker. Explanation: The client cannot focus on admission, treatment, and healing until safe arrangements are made to care for the pet. Contacting the landlord would mean loss of the pet as well as possible conflicts with staying in the apartment. Contacting the fire department may mean the loss of the pet as well as incurring additional expenses, which would be an added burden. Disregarding client concerns would be nontherapeutic.

Which nursing action is most appropriate when trying to defuse a client's impending violent behavior?

helping the client identify and express feelings of anxiety and anger Explanation: In many instances, a nurse can defuse impending violence by helping a client identify and express feelings of anger and anxiety. Such statements as "What happened to make you this angry?" may help the client verbalize feelings rather than act on them. Close interaction with the client in a quiet activity may place the nurse at risk for injury should the client suddenly become violent. The danger of an agitated and potentially violent client acting out is too great for the client to be left alone or unsupervised. The client should be placed in seclusion only if other interventions fail or the client requests it. Unlocked seclusion can be helpful for some clients because it reduces environmental stimulation and gives them a feeling of security.

How does the nurse on the obstetrics unit assure client safety? Select all that apply.

reconciliation of medication prescriptions communication among staff use of two unique identifiers staff training Explanation: Client care safety is enhanced by the process of reconciling all medication prescriptions at least one time each 24 hours of hospitalization. This can rule out duplication of prescriptions, missing medication prescriptions, or alerting the staff to medications that should have been terminated. Communication among all staff members enhances client safety and prevents errors in written or in verbal format. Culturally similar clients are appreciative of being with someone who can speak their language or share thoughts and ideas, but this does not increase the safety of the clients. The use of two identifiers should be consistently used to prevent wrong client and procedure errors. Staff training is an extremely valuable tool to educate and increase communication among staff members concerning existing or potential safety situations.

The nurse working in an internal medicine clinic receives four phone calls from clients with chronic pancreatitis. Which client should the nurse contact first?

The client reporting increased thirst and hunger. Explanation: Clients with chronic pancreatitis are likely to develop diabetes as a result of the pancreatic fibrosis that occurs. The pancreas becomes unable to secrete insulin. Increased thirst and hunger are symptoms of diabetes. Chronic abdominal pain can be recurrent for months to years. The client with the need for pancreatic enzymes prescription refill is not in acute distress and can be called back later. A symptom of chronic pancreatitis is steatorrhea (fatty stools) and can become severe. The nurse should follow-up with the client to assess for volume and frequency of the stools, however, this client is not the priority.

Which aspects of client care would be most appropriate for the nurse to delegate to an unlicensed assistive personnel (UAP)?

obtaining a urine specimen for a culture and sensitivity analysis from a client who has an indwelling urinary catheter inserted Explanation: The most appropriate action to delegate to a UAP is collection of a urine specimen for a culture and sensitivity analysis. Collecting the specimen does not require sterile technique.The nurse can anticipate that the elderly client with an enlarged prostate may be difficult to catheterize. Depending on the scope of practice for a UAP, this action may not be within the UAP's responsibilities.It is not within the UAP's scope of responsibility to change IV fluids.It is the registered nurse's responsibility to assess a client's report of pain or heartburn; assessment responsibilities cannot be delegated.

A nurse is reviewing a client's medical record and notes that the health care provider has prescribed furosemide 400 mg orally twice a day. What will be the best action by the nurse?

Notify the health care provider about the concern for the prescribed dose. Explanation: The nurse is responsible for clarifying any prescription for a medication prescribed outside the normal dose. The usual dose for furosemide is 20 to 80 mg. Therefore, the nurse needs to contact the health care provider to ensure what has been prescribed is indeed correct. There may be a valid reason for the specific dosage prescribed even though it is outside the usual range. Asking the client about the medication is an option, but the nurse needs to confirm the prescribed dose with the health care provider. Although rechecking the formulary for the usual dosage would help to support the nurse's concerns, any prescription that is in question needs to be clarified. Notifying the nurse manager and filing an incident report would not be necessary. It is the nurse's responsibility to clarify the prescription.

After the nurse teaches the parent of a child with a spica cast about skin care, which parental action would indicate the need for additional teaching?

application of powder to the skin under the cast Explanation: Powder should not be applied to the skin beneath the cast because powder can cause irritation and skin breakdown. The mother would need further teaching about avoiding this measure. Checking the smoothness of the cast edges, covering the cast around the perineum, and inspecting inside the cast are all appropriate actions for the child with a spica cast to help prevent skin breakdown.

After undergoing a total cystectomy and urinary diversion, a client has a Kock pouch (continent internal reservoir) in place. Which statement by the client indicates a need for further teaching?

"I'll have to wear an external collection pouch for the rest of my life." Explanation: Additional teaching is required if the client states that an external collection pouch must be worn for the rest of the client's life. An internal collection pouch, such as the Kock pouch, allows the client to perform self-catheterization for ileal drainage. This pouch is an internal reservoir, eliminating the need for an external collection pouch. A well-balanced diet is essential for healing; the client need not include or exclude particular foods. The client should drink at least eight glasses of fluid daily to prevent calculi formation and urinary tract infection. Intervals between pouch drainings should be increased gradually until the pouch is emptied two to four times daily.

A child is brought into the emergency department with a severe asthmatic episode by the grandparents who are caring for the child over the weekend while the parents are away. What is the legal consideration(s) for the health care team? Select all that apply.

Severe asthmatic episodes can be life-threatening and must be treated immediately. A medical power of attorney signed by the parents is acceptable for the grandparents to seek treatment for the child. Treatment can be initiated with parental consent by telephone. Explanation: The nurse should acknowledge that the need to address life-threatening conditions should take priority over legal or administrative tasks. A medical power of attorney for the grandparents signed by the parents is an acceptable substitution for parental permission within the parameters of the signed document. However, even in the absence of a valid power of attorney, delaying emergency treatment until the parents can be reached is unacceptable practice. Parental consent can be done by telephone. Necessary permissions could be obtained as soon as the responsible party can do so. Children do not have advance directives unless parents have created an advanced directive on behalf of the child. Advanced directives are not needed in this case.

Which outcome criterion is appropriate for a child diagnosed with oppositional defiant disorder?

The child will recognize responsibility for behaviors. Explanation: Children with oppositional defiant disorder frequently violate the rights of others. They are defiant, are disobedient, and blame others for their actions. Recognizing accountability for actions would demonstrate progress for the oppositional child.

The nurse is educating a client with type 2 diabetes from France who speaks English as a second language. What behavior alerts the nurse to a possible lack of communication of the educational material? Select all that apply.

asking questions about shopping laughing at some of the brochures looking away from the speaker Explanation: Behaviors that indicate the client is not understanding the nurse's teaching include asking inappropriate questions to change the subject, laughing to disguise embarrassment, and looking away from the speaker. Taking notes and writing down medical terms are positive behaviors indicating that the client is engaged in learning.

The adult daughters of an older adult client inform the nurse that they fully expect their father to be combative after surgery. Preoperatively, they request that the nurse put all four side rails up and use restraints to keep him safe. What should the nurse tell the daughters?

"We will first try to keep him safe without restraint." Explanation: A least-restraint environment should always be provided as much as possible. Nursing staff are required to attempt lesser restrictive alternatives (e.g., use of family or sitter, reorientation, distraction, or a toileting schedule) prior to notifying the provider of the need for restraints. Nursing staff are also required to document clinical conditions requiring restraint, lesser restrictive alternatives attempted, and client/family education provided regarding restraint use. Provider prescriptions for restraints must be time limited and specific regarding the type of restraint. Additionally, if restraints are implemented, nursing staff must monitor clients for safety (including skin checks and range of motion) and provide frequent food/fluids/toileting.

The nurse is planning care for a client who has an allergy to latex. What intervention would be the priority for the nurse to include in the plan of care?

Place latex-free, powder-free gloves at client's bedside. Explanation: Latex-free, powder-free gloves reduce the risk of respiratory exposure to latex. Having them conveniently located will enhance staff adherence, so this is the most important intervention. Using oil-based hand lotion should be avoided when wearing latex gloves because this increases risk of latex breakdown and can increase latex exposure for the person wearing the gloves. However, the client can have oil-based lotions applied to the skin as this is not contraindicated. Obviously, the nurse would wear latex-free gloves for application, or no gloves at all if no contact with body fluids is expected. Having a roommate with a latex catheter does not pose a risk of direct exposure for the client. Clients with latex allergies should have clear signage but do not require a private room.

A physician orders a palliative care consult for a client with end-stage chronic obstructive pulmonary disease who wishes no further medical intervention. Which step should the nurse anticipate based on the nurse's knowledge of palliative care?

increasing the need for antianxiety agents Explanation: The nurse should anticipate that the physician will increase antianxiety agents during treatment to maintain comfort throughout the dying process. Bronchodilators, pain medications, and home oxygen therapy help promote client comfort. Therefore, they should be continued as part of palliative care.

While gently abducting the hips during a newborn assessment, the nurse hears a "click" as the femoral head slips into the acetabulum. The nurse interprets this as positive for which physical finding?

Ortolani's sign Explanation: Ortolani's sign refers to the "click" made when the femoral head slips forward into the acetabulum when forward pressure is exerted from behind the greater trochanter and the knee is held laterally. This sign indicates hip dislocation. A positive Barlow's test, evidenced by the femoral head slipping out over the acetabulum when pressure is applied then slipping back into place when the pressure is released, indicates that the hip is unstable with increased risk of dislocation. Galeazzi's sign refers to shortening of the affected limb in congenital hip dysplasia. It is elicited by flexing the infant's hips and knees while the infant lies supine. The soles of the feet are placed flat near the buttocks, and the knee heights are assessed for equality. Trendelenburg's sign refers to a downward tilting of the pelvis toward the normal side when a child with a dislocated hip stands on the affected side with the uninvolved leg elevated.