Prep U Questions / Miscellaneous for Final

What best describes the role of the major histocompatibility complex as a barrier defense? It allows the body to distinguish cells as foreign or belonging to the person. It physically prevents pathogens from entering the internal tissues of the body. It protects areas that are exposed to the external environment. It destroys many potential pathogens that are ingested or swallowed.

It allows the body to distinguish cells as foreign or belonging to the person. Major histocompatibility complex allows the body to be able to distinguish between self-cells and foreign cells. The skin physically prevents pathogens from entering the body. The mucous membranes protect exposed areas that are not covered by skin. Gastric acid destroys would-be pathogens that are ingested or swallowed.

When reviewing bathing habits for a child with dermatitis, which statements by the child's mother indicates the need for further instruction? Select all that apply. "When drying the skin I should pat instead of rubbing it." "Antibacterial soap will be helpful in preventing infections at the site of the rash." "It is important to avoid soaps with dyes and perfumes." "I should apply the topical ointments after bathing." "I should use the warmest water my child can tolerate during the bath."

"Antibacterial soap will be helpful in preventing infections at the site of the rash." "I should use the warmest water my child can tolerate during the bath." Explanation: Bathing and hygiene practices used for the child with dermatitis are important in the treatment. It is important to bath using warm and not hot water temperatures. Soaps used should be free of dye and perfumes. Antibacterial soaps are not recommended as they may be harsh and irritating. Topical medications should be applied after the bath.

A manufacturing plant has exploded, and the nurse is assigned to triage burn victims as they arrive to the hospital. Which is the most important question for the nurse to ask prior to the arrival of victims? "Are the victims suffering from thermal burns?" "How many victims are anticipated for transport?" "Are the burns associated with chemicals used in the plant?" "Are any of the victims expected to have electrical burns?"

"Are the burns associated with chemicals used in the plant?" Explanation: If the victim has sustained chemical burns, the chemicals must be removed from the skin to prevent burns to others, including the triage nurse and emergency staff. Thermal and electrical burn victims do not require special handling considerations. The number of victims expected is not a significant issue for the triage nurse but rather for the external disaster team dispatch personnel.

A mother calls a clinic nurse to ask if her infant born prematurely should receive the seasonal influenza vaccine. The nurse's next question should be: "How old is your baby?" "How much premature was your baby?" "Does your baby have any allergies?" "Did your baby have any respiratory problems?"

"How old is your baby?" Flu vaccine and all other vaccines are administered according to chronological age. Flu vaccine is recommended for all infants at 6 months of age and given yearly thereafter. An underlying respiratory problem makes flu vaccine important. Awareness of allergies is also necessary, but the first question is chronological age to determine if the infant is old enough to receive the vaccine.

The nursing instructor has completed a presentation on normal immune function. Which statement by a student would suggest a need for further education? "Phagocytosis is the process in which phagocytes swallow up and break down microorganisms." "Humoral immunity is immunity mediated by antibodies secreted by B cells." "Cellular immunity is cell-mediated immunity controlled by T cells." "Humoral immunity is generally functional at birth."

"Humoral immunity is generally functional at birth." Normal immune function is a complex process involving phagocytosis (process by which phagocytes swallow up and break down microorganisms), humoral immunity (immunity mediated by antibodies secreted by B cells), cellular immunity (cell-mediated immunity controlled by T cells), and activation of the complement system. Cellular immunity is generally functional at birth, and as the infant is exposed to various substances over time, humoral immunity develops.

A client with schizophrenia states, "I hear the voice of King Tut." Which response by the nurse is therapeutic? "I don't hear the voice, but I know you hear what sounds like a voice." "You shouldn't focus on that voice; it is not real." "Does the voice sound like someone you know?" "King Tut has been dead for years, so that can't be his voice."

"I don't hear the voice, but I know you hear what sounds like a voice." This response makes a factual statement about the client's hallucination. Telling the client not to focus on the voice is judgmental. Telling the client not to worry because the voice is not real is a flippant, dismissive response. Saying "King Tut has been dead for years" is dismissive.

A nurse notices that a client with obsessive-compulsive disorder dresses and undresses several times each day. Which comment by the nurse would be most therapeutic? "I saw you change clothes several times today. Do you find this tiring?" "It might be helpful if you dress only once per day so you won't be so tired." "It must really bother you to change your clothes so often. How can I help?" "I see that you're a perfectionist about the clothes you wear."

"I saw you change clothes several times today. Do you find this tiring?" Mentioning to the client that "changing their clothes so often may be tiring" focuses on the client's feelings rather than making an assumption. This helps reduce the intensity of the client's ritualistic behavior, thereby promoting trust and rapport. Suggesting to the client to dress only once per day and implying that the client's behavior is bothersome or foolish would convey disapproval, impede trust and rapport, promote dysfunctional behavior, and worsen anxiety. Saying to the client that "you're a perfectionist about the clothes you wear" is sarcastic and does not promote trust and rapport. The client has been dressing and undressing repetitively in response to anxiety not perfectionism. The client already knows the need for repetitive dressing and undressing is frustrating and wants to be understood instead of misunderstood. Perfectionism is more reflective of OCD personality disorder instead of OCD.

A 40-year-old client is admitted for a surgical biopsy of a suspicious lump in the left breast. The client is tearfully writing a letter to the the client's two children and tells the nurse, "I want to leave this for my children in case anything goes wrong today." Which response by the nurse would be most therapeutic? "In case anything goes wrong? What are your thoughts and feelings right now?" "I can understand that you're nervous, but this really is a minor procedure. You'll be back in your room before you know it." "Try to take a few deep breaths and relax. I have some medication that will help." "I'm sure your children know how much you love them. You'll be able to talk to them on the phone in a few hours."

"In case anything goes wrong? What are your thoughts and feelings right now?" By acknowledging how the client feels, this response encourages discussion about what the client is thinking and feeling. Minimizing the client's feelings or offering empty reassurances isn't therapeutic or helpful. Deep breathing and preoperative medication would be appropriate only after the client has expressed the fears and dealt with them.

A client with osteoarthritis tells the nurse they are concerned that the disease will prevent them from doing their chores. Which suggestion should the nurse offer? "Do all your chores in the morning, when pain and stiffness are least pronounced." "Do all your chores after performing morning exercises to loosen up." "Pace yourself and rest frequently, especially after activities." "Do all your chores in the evening, when pain and stiffness are least pronounced."

"Pace yourself and rest frequently, especially after activities." A client with osteoarthritis must adapt to this chronic and disabling disease, which causes deterioration of the joint cartilage. The most common symptom of the disease is deep, aching joint pain, particularly in the morning and after exercise and weight-bearing activities. Because rest usually relieves the pain, the nurse should instruct the client to rest frequently, especially after activities, and to pace themself during daily activities. Telling the client to do the chores in the morning is incorrect because the pain and stiffness of osteoarthritis are most pronounced in the morning. Telling the client to do all chores after performing morning exercises or in the evening is incorrect because the client should pace themself and take frequent rests rather than doing all chores at once.

Which statement regarding health care reform trends is most accurate? "Systems are in place to pay for performance and penalize hospitals for excessive readmissions." "Distinctive to the United States is the dominance of the public element over the private one." "The United States is secnd in the world in total health care dollars spent annually." "Spending on medical services will rise to almost 32% of the U.S. gross domestic product by 2021."

"Systems are in place to pay for performance and penalize hospitals for excessive readmissions." Health care trends already include paying for performance (HEDIS, HCAHPS) and penalizing hospitals for excess readmissions. In the United States, private insurers dominate over public, unlike in most countries. The United States is first in health care spending worldwide, and it is estimated that 20% of the gross domestic product will be spent on medical services by 2021.

The nurse is preparing discharge teaching for a client with a history of recurrent pneumonia. What deep breathing techniques will the nurse plan to teach? "Take in a small amount of air and exhale quickly." "Take in as much air as possible, hold your breath briefly, and exhale slowly." "Take in a large volume of air and hold your breath as long as you can." "Take in a little air, hold your breath 15 seconds, and exhale slowly."

"Take in as much air as possible, hold your breath briefly, and exhale slowly." This technique maximizes ventilation taking in a large volume of air fills alveoli to a greater capacity, which improves gas exchange. Deep breathing is useful for client's who has been inactive or in pain as associated with pneumonia. The other techniques do not promote improved gas exchange.

A client is 36 weeks' gestation and has been admitted to the antenatal unit for gestational hypertension. The client states that she is alone because she has recently moved from another country, and she begins to cry. What is the best response by the nurse? "Do you belong to any community groups that may be able to support you?" "It appears that you are concerned about where your friends and family are living right now." "Tell me more about how you are feeling." "Would you like to speak to the hospital social worker?"

"Tell me more about how you are feeling." Recent immigrants may be separated from their friends, family, and support systems. There are many variations in how cultural and ethnic beliefs and practices impact how individuals respond to the experience of pregnancy and birth. This nurse's response further explores the client's feelings to assist in a culturally competent and sensitive manner. It would be inappropriate to assume that the client is concerned about the family's living arrangements. It would be inappropriate to ask the client about belonging to any support groups or to refer the client to a social worker at this time. It would be most beneficial at this time to explore the client's feelings to identify what the concerns are and how the client believes the nurse may be able to help.

The nursing student asks the nurse to describe the difference between sinus rhythm and sinus bradycardia on the electrocardiogram strip. What is the nurse's best reply? "The only difference is the heart rate." "The P waves will be shaped differently." "The QRS complex will be smaller in sinus bradycardia." "The P-R interval will be prolonged in sinus bradycardia."

"The only difference is the heart rate." All characteristics of sinus bradycardia are the same as those of normal sinus rhythm except for the rate, which will be below 60 in sinus bradycardia. The P waves will be shaped differently in other dysrhythmias. The QRS is the same voltage for sinus rhythms. The P-R interval is prolonged in aterioventricular blocks.

The nurse assessing an adolescent's need for further information regarding sexual health should ask which question? "Are you involved in an intimate relationship at this time?" "How many sexual partners have you had?" "What questions or concerns do you have about your sexual health?" "Have you ever been diagnosed with a sexually transmitted infection?"

"What questions or concerns do you have about your sexual health?" An open-ended, nonthreatening question related to the client's need for further information should be included while obtaining a sexual history. "Are you involved in an intimate relationship at this time?" and "Have you ever been diagnosed with a sexually transmitted disease?"are closed ended questions requiring a yes or no response. Asking how many sexual partners, while open ended, is threatening and assumes that the adolescent has had multiple partners.

A 35-year-old client is delirious after being lost in the woods for several days and becoming severely dehydrated. At 9 p.m. the client tells the nurse to get the client's clothes because the client has to get home to the client's family. Which response by the nurse is most therapeutic? "It's time to sleep now; you can see your family in the morning." "We don't have your clothes; they are at home. You'll be going home when you recover." "Your family is fine. You need to take care of yourself now." "You're in the hospital. You did not drink for several days, but you're getting better now."

"You're in the hospital. You did not drink for several days, but you're getting better now." Staff members can try to direct the client's activity and cognitive focus by reorienting the client to the environment with displays of calendars, clocks, and decorations commemorating upcoming holidays. Therapeutic communications concerning the day's activities, repetition of facts concerning why the client is hospitalized, and reassurance that the hallucinations and delusions experienced are part of the transient condition of delirium are helpful.

A client with asthma is confused by her primary care provider continuing her medication while she is pregnant, since she read online the medications can cause birth defects. What is the nurse's best response? "Your primary care provider will order safe doses of your medication." "It's OK to not use them if you would feel more comfortable." "They won't cause any major defects." "I'll let your primary care provider know how you feel about it."

"Your primary care provider will order safe doses of your medication." Women should take no medication during pregnancy except that prescribed by their primary care provider. The PCP will work with the mother to ensure the safest amount is given to adequately handle the mother's health issues and not injure the fetus. The PCP must weigh the risks against the benefits for both the mother and her fetus. The nurse should not encourage the client to stop her asthma medication as that may result in the client having an asthma attack, which could result in injury to the fetus or even miscarriage. The nurse should not tell the client a drug will not cause any defects, especially if it is known that it can. That could make the nurse liable for damages. The nurse should inform the PCP of the client's concerns; however, it is more important for the nurse to calm the client's anxiety and offer positive reinforcement that the PCP is working hard to protect the mother and infant from harm.

The nurse tells the client that if exposure to an allergen occurs around 8:00 AM, then the client should expect a mild or moderate reaction by what time? 10:00 AM 11:00 AM 1:00 PM 3:00 PM

10:00 AM Mild and moderate reactions begin within 2 hours of exposure.

A patient is suspected of having glaucoma. What reading of IOP would demonstrate an increase resulting from optic nerve damage? 0 to 5 mm Hg 6 to 10 mm Hg 11 to 20 mm Hg 21 mm Hg or higher

21 mm Hg or higher

During a period of extreme excess fluid volume, a renal dialysis client may be administered which type of IV solution to shrink the swollen cells by pulling water out of the cell? 0.9% sodium chloride. 5% dextrose and water. 3% sodium chloride. Lactated Ringer's solution.

3% sodium chloride. When cells are placed in a hypotonic solution, which has a lower effective osmolality than the ICF, they swell as water moves into the cell. When they are placed in a hypertonic solution, which has a greater effective osmolality than the ICF, they shrink as water is pulled out of the cell.

A client experiencing a severe anxiety attack and hyperventilating presents to the emergency department. The nurse would expect the client's pH value to be 7.50 7.45 7.35 7.30

7.50 Explanation: The patient is experiencing respiratory alkalosis. Respiratory alkalosis is a clinical condition in which the arterial pH is >7.45 and the PaCO2 is <38 mm Hg. Respiratory alkalosis is always caused by hyperventilation, which causes excessive "blowing off" of CO2 and, hence, a decrease in the plasma carbonic acid concentration. Causes include extreme anxiety, hypoxemia, early phase of salicylate intoxication, gram-negative bacteremia, and inappropriate ventilator settings.

On what client would it be appropriate for the nurse to perform a rectal temperature? A newborn infant during the initial assessment A toddler who is admitted with rotavirus and frequent diarrhea A child who has suffered a head injury and is comatose A post-cardiac surgery patient

A child who has suffered a head injury and is comatose Explanation: Rectal temperatures are not the preferred method of obtaining a child's temperature but are appropriate if the child is unconscious and the nurse cannot do an oral temperature. Clients who have diarrhea, hemorrhoids or are cardiac patients are not appropriate candidates for rectal temperatures. The rectal thermometer can cause arrhythmias in cardiac patients, irritate the rectal mucosa further in patients with diarrhea and in newborns.

Which of the following best describes the health-illness continuum? A person with chronic illness is at the far end of the continuum reflecting illness. A person may be considered neither completely healthy or completely ill. A person with high-level wellness is free of any disease or infirmity. A person on the continuum remains at the point based on his or her initial state of health.

A person may be considered neither completely healthy or completely ill. The health-illness continuum views a person as being neither completely healthy nor completely ill. Use of the continuum makes it possible to view a person as simultaneously possessing degrees of both health and illness. People with chronic illness or disability may attain a high-level of wellness if they are successful in meeting their health potential withing the limits of their condition. A person's state of health is ever-changing and can fall anywhere along the continuum at any time. High-level wellness does not necessarily mean that a person is free of disease or infirmity.

Which is a true statement regarding pharmacologic aspects of aging? Elderly have a decreased percentage of body fat. Potential for drug-drug reactions decreases with the number of drugs prescribed. Absorption may be affected by changes in gastric pH. Aged population tends to be compliant with their medication regimen.

Absorption may be affected by changes in gastric pH. Explanation: During the aging process, absorption may be affected by changes in gastric pH. The elderly have an increased percentage of body fat. The potential for drug-drug interaction increases with the number of drugs prescribed. The aged population tends to be less compliant with their medication regimen.

What is the priority assessment for the nurse when developing a plan of care for a client living in poverty? Access to care Access to health insurance Access to affordable housing Access to financial assistance

Access to care Poverty has long been a barrier to adequate health care. If clients cannot access health care, it does not matter if they have affordable housing, health insurance, or financial assistance. It is not possible to create a plan of care with client involvement without adequate support and access to care.

An elderly male client was in an automobile accident 2 weeks ago and incurred a spinal cord injury with resulting paralysis. The nurse assesses this disability as Developmental Age-related Acquired Permanent

Acquired An acquired disability results from an acute and sudden injury, such as trauma to the spinal cord. The paralysis may be temporary. It may not be known to be permanent until swelling in the spinal cord has decreased. This may take weeks to months. A developmental disability is one that occurs prior to age 22 years. An age-related disability occurs in the elderly population as a result of the aging process.

A client is being treated in a substance abuse unit of a local hospital. The nurse understands that when this client has compulsive behavior to use a drug for its psychic effect, the client needs to be monitored for which effect? Placebo Dependence Tolerance Addiction

Addiction Addiction is a behavioral pattern of substance use characterized by a compulsion to take the substance primarily to experience its psychic effects. Placebo effect is analgesia that results from the expectation that a substance will work, not from the actual substance itself. Dependence occurs when a client who has been taking opioids experiences a withdrawal syndrome when the opioids are discontinued. Tolerance occurs when a client who has been taking opioids becomes less sensitive to their analgesic properties.

A patient with frostbite to both lower extremities from exposure to the elements is preparing to have rewarming of the extremities. What intervention should the nurse provide prior to the procedure? Administer an analgesic as ordered. Massage the extremities. Elevate the legs. Apply a heat lamp.

Administer an analgesic as ordered. Explanation: During rewarming, an analgesic for pain is administered as prescribed, because the rewarming process may be very painful. To avoid further mechanical injury, the body part is not handled. Massage is contraindicated.

The nurse is caring for a client who has recurrent sinusitis. Which consideration could the nurse suggest to best decrease the frequency of infections? Administer an over-the-counter decongestant. Use an anti-allergy medication to decrease rhinitis. Place a warm cloth over the sinus area of the forehead. Gently blow the nose to eliminate nasal secretions.

Administer an over-the-counter decongestant. The principle causes of sinusitis are the spread of infection from the nasal passages to the sinus and the blockage of normal sinus drainage. Interference with sinus drainage predisposes a client to sinusitis. Administering a decongestant opens the nasal passages for drainage. The other options can be helpful for a sinus infection, but opening the passages is best.

Which support surface is best for a comatose client who has multiple stage III pressure ulcers over two bony prominences? Static support surface Alternating pressure surface Low-air-loss surface Air-fluidized surface

Air-fluidized surface Explanation: The air-fluidized surface is the best choice for this client because this surface protects the skin from moisture — an important feature for the client who can't change position on her own. However, the client maintained on this surface should be monitored closely because this bed places the client at risk for dehydration. The static support surface is designed to prevent stage II pressure ulcers; it isn't designed to care for the client with multiple stage III wounds. Although the alternating air surface is effective for a client with multiple wounds, it doesn't offer enough pressure reduction for complex wounds occurring on multiple surfaces. The low-air-loss surface protects the skin from moisture, but it doesn't offer enough pressure reduction for this client.

Which is the antibiotic of choice used to treat acute bacterial rhinosinusitis (ABRS)? Amoxicillin Levofloxacin Keflex Ceftin

Amoxicillin Antibiotics should be administered as soon as the diagnosis of ABRS is established. Amoxicillin-clavulanic acid is the antibiotic of choice. For clients who are allergic to penicillin, doxycycline or respiratory quinolones, such as levofloxacin or moxifloxacin, can be used. Other antibiotics previously prescribed to treat ABRS, including cephalosporins such as cephalexin and cefuroxime, are no longer recommended because they are not effective in treating antibiotic-resistant organisms that are now more commonly implicated in ABRS.

The nursing instructor is explaining the utilization of regionalized or centralized care to a group of maternal infant students. Which example should the instructor point out best demonstrates regionalized or centralized care? All deliveries occur at one central facility. An at-risk mother is sent to a specialized facility to deliver. Mothers deliver in the communities in which they live. Sick infants are sent to a facility close to the clients home to receive care.

An at-risk mother is sent to a specialized facility to deliver. Regionalized or centralized care was designed to prevent duplication of services in communities. To accomplish this goal, a regional or central facility may be created that contains the most highly specialized care in one central location even though it may not be the closest facility to the client's home. Regionalized or centralized care may require that a sick infant go to a facility that is actually farther away from the community in order to receive specialized care.

Which nursing intervention is an example of tertiary preventive care? Assisting with speech therapy a client with a traumatic brain injury Administration of immunizations to a 6-month-old child Blood pressure screenings at a senior center Teaching stress reduction classes at a wellness center

Assisting with speech therapy a client with a traumatic brain injury Tertiary prevention begins after the illness and is used to help rehabilitate clients. Speech therapy is an example of tertiary preventive care. The administration of immunizations and teaching stress reduction classes are examples of primary preventive care. Blood pressure screening is an example of secondary preventive care.

A homeless client presents to the ED. Upon assessment, the client is experiencing hypothermia. The nurse will plan to complete which priority intervention during the rewarming process? Attach a cardiac monitor Insert a Foley urinary catheter Assist with endotracheal intubation Administer inotropic drugs

Attach a cardiac monitor Explanation: Continuous electrocardiograph (ECG) monitoring is performed during the rewarming process because cold-induced myocardial irritability leads to conduction disturbances, especially ventricular fibrillation. A urinary catheter should be inserted to monitor urinary output; however, ECG monitoring is the priority. There is no indication for endotracheal intubation. Inotropic medications are contraindicated because they can stimulate the heart and increase the risk for fatal dysrhythmias, such as ventricular fibrillation.

The nurse is conducting discharge teaching for a client who was admitted with a kidney stone. The nurse includes which instruction as a measure to prevent additional kidney stones? Increase protein intake. Adhere to a low-calcium diet. Avoid drinking water before bedtime. Avoid drinking tea.

Avoid drinking tea. Explanation: The nurse should teach the client to avoid tea and other oxalate-containing foods, such as spinach, strawberries, rhubarb, peanuts, and wheat bran. The client should restrict protein intake to 60 g/day and should drink two glasses of water at bedtime. Low-calcium diets are generally not recommended.

An individual's exposure to an airborne pathogen has prompted an immune response that includes both cellular and humoral components. Which of the following activities is most closely associated with the humoral immune response? T cells directly attack the foreign pathogen. A circulating lymphocyte containing an antigenic message returns to the nearest lymph node. B lymphocytes produce antibodies that are specific to the pathogen. Granulocytes and macrophages engulf and destroy the invading agents.

B lymphocytes produce antibodies that are specific to the pathogen. The humoral response is characterized by the production of antibodies by B lymphocytes in response to a specific antigen. T cells are more closely associated with cellular immunity, and the action of circulating lymphocytes containing antigenic messages is associated with the proliferation stage that precedes the humoral and cellular response. Phagocytic immunity is associated with the actions of granulocytes and macrophages.

A client comes to the emergency department reporting severe substernal chest pain radiating down the left arm. The client is admitted to the coronary care unit with a diagnosis of myocardial infarction (MI). Which should the nurse do first when the client is admitted to the coronary care unit? Begin telemetry monitoring. Obtain a health history. Auscultate heart sounds. Evaluate the client's pain.

Begin telemetry monitoring. Telemetry monitoring should be started as soon as possible. Life-threatening arrhythmias are the leading cause of death in the first hours after MI. The other options are secondary in importance to assessing abnormal, life-threatening rhythms.

A new nursing student is studying ethics in nursing and informs a client who wants to stop medication about its benefits and how the client will continue to feel better only if use of the drug continues. Which concept is the nursing student using? Beneficence Autonomy Veracity Justice

Beneficence Beneficence is the principle of using the knowledge of science and incorporating the art of caring to develop an environment in which individuals achieve their maximal health care potential. It is "doing good."

Which clinical manifestation of type 2 diabetes occurs if glucose levels are very high? Hyperactivity Blurred vision Oliguria Increased energy

Blurred vision Blurred vision occurs when blood glucose levels are very high. The other clinical manifestations are not consistent with type 2 diabetes.

Which theory of ethics prioritizes the nurse's relationship with clients and the nurse's character in the practice of ethical nursing? Care-based ethics Principle-based ethics Utilitarianism Deontology

Care Based Ethics Central to the care-based approach to ethics is the nurse's relationships with clients and the nurse's "being," or character and identity. Deontology is the study of the nature of duty and obligation. Utilitarianism is the doctrine that actions are right if they are useful or for the benefit of a majority. Principle-based ethics prioritizes goals and principles that exist beyond the particularities of the nurse-client relationship.

A client with calculi in the gallbladder is said to have Cholecystitis Cholelithiasis Choledocholithiasis Choledochotomy

Cholelithiasis Explanation: Calculi, or gallstones, usually form in the gallbladder from the solid constituents of bile; they vary greatly in size, shape, and composition. Cholecystitis is acute inflammation of the gallbladder. Choledocholithiasis is a gallstone in the common bile duct. Choledochotomy is an incision into the common bile duct.

A nurse is providing care to a client experiencing symptoms associated with terminal illness. Which of the following would be most appropriate to use as a means for managing the client's symptoms? Physician's orders Client's goals Length of required treatment Invasiveness of the treatment

Client's goals When managing the symptoms of a client with a terminal illness, the client's goals take precedence over the clinician's goals to relieve all symptoms at all costs. Although the length and invasiveness of the treatment may influence decision making, ultimately it is the client's goals that determine what will be done.

The fire alarm sounds on the maternal-neonatal unit at 0200. How can a nurse best care for the unit's clients during a fire alarm? Permit the mothers and their neonates to continue sleeping. Immediately evacuate the unit. Close all of the doors on the unit. Do nothing because it's most likely a fire drill.

Close all of the doors on the unit. The nurse should respond quickly by closing all of the doors on the unit. This action prevents the spread of smoke in case of a fire. The nurse shouldn't begin evacuating the unit until given notification to do so. The nurse shouldn't ignore the alarm because fire drills are necessary to prepare the staff for a fire. The mothers should be awakened in case evacuation is necessary.

The nurse is reviewing the medication administration record of the client. Which medication would lead the nurse to suspect that the client is suffering from an acute attack of gout? penicillamine methotrexate prednisone colchicine

Colchicine is prescribed for the treatment of an acute attack of gout.

Which of the following nursing interventions contributes to achieving a client's pain relief? Minimize the client's description of pain or need for pain relief. Collaborate with the client about his or her goal for a level of pain relief. Use all forms of available pain management techniques. Prevent the client from self-administering analgesics.

Collaborate with the client about his or her goal for a level of pain relief. The nurse should collaborate with each client about his or her goal for a level of pain relief; this helps implement interventions for achieving the goal. The client's description of pain or need for pain relief should never doubted or minimized. The client need not refrain from self-administering analgesics; providing a client with equipment to self-administer analgesics promotes a more consistent level of pain relief. The nurse should also inform the client of available pain management techniques and incorporate any preferences or objections to interventions for pain management that the client may have when establishing a plan of care; using all forms of available pain management techniques is not necessary.

The nurse is completing a routine urinalysis using a dipstick. The test reveals an increased specific gravity. The nurse should suspect which condition? Decreased fluid intake Increased fluid intake Glomerulonephritis Diabetes insipidus

Decreased fluid intake When fluid intake decreases, specific gravity normally increases. With high fluid intake, specific gravity decreases. Disorders or conditions that cause decreased urine-specific gravity include diabetes insipidus, glomerulonephritis, and severe renal damage. Disorders that can cause increased specific gravity include diabetes, nephritis, and fluid deficit. Reference:

The nurse is instructing a client with advanced kidney disease (AKD) about a dietary regimen. Which restriction should the nurse be sure to include in the treatment plan to decrease the progress of renal impairment in people with AKD? Fats Dietary protein Carbohydrates Foods high in calcium

Dietary protein Restriction of dietary proteins may decrease the progress of renal impairment in people with advanced renal disease. Proteins are broken down to form nitrogenous wastes, and reducing the amount of protein in the diet lowers the blood urea nitrogen and reduces symptoms.

A client has been treated with abacavir for the past 6 weeks. The client contacts the physician's office with reports of diarrhea, abdominal pain, sore throat, cough, and shortness of breath. Which is the appropriate action to take for this situation? Discontinue the therapy and then reintroduce it. Discontinue the therapy. Reduce the dose. Administer the drug at bedtime.

Discontinue the therapy. Hypersensitivity is a common adverse effect of abacavir that usually appears within 6 weeks of beginning therapy. Abacavir treatment should be discontinued if any signs of hypersensitivity occur. Reintroducing the drug after a hypersensitivity reaction may result in fatal hypotension and is therefore not advised. Reducing the dose and administration of the drug at bedtime will not minimize this adverse effect.

The nurse is developing a discharge teaching plan for clients taking opioid pain medication. Which of the following should the nurse include? Select all that apply Do not drive while taking pain medication. Do not smoke without someone else present. Avoid alcohol. Avoid diary products. Take medication on an empty stomach.

Do not drive while taking pain medication. Do not smoke without someone else present. Avoid alcohol. The teaching plan developed by the nurse should include instructions to take the medication with food to prevent stomach irritation. It should also include not smoking without someone else present to decrease the risk of the client falling asleep and starting a fire. The client should also be instructed to avoid alcohol and to avoid driving. The client does not need to avoid diary products.

A patient is experiencing an allergic reaction to a dose of penicillin. What should the nurse look for in the patient's initial assessment? Dyspnea, bronchospasm, and/or laryngeal edema. Hypotension and tachycardia The presence and location of pruritus The severity of cutaneous warmth and flushing

Dyspnea, bronchospasm, and/or laryngeal edema. Severe systemic, anaphylactic reactions have an abrupt onset with the same signs and symptoms described previously. These symptoms progress rapidly to bronchospasm, laryngeal edema, severe dyspnea, cyanosis, and hypotension. Dysphagia (difficulty swallowing), abdominal cramping, vomiting, diarrhea, and seizures can also occur. Cardiac arrest and coma may follow.

You are caring for a client who has been diagnosed with viral pneumonia. You are making a plan of care for this client. What nursing interventions would you put into the plan of care for a client with pneumonia? Give antibiotics as ordered. Place client on bed rest. Encourage increased fluid intake. Offer nutritious snacks 2 times a day.

Encourage increased fluid intake. Explanation: The nurse places the client in semi-Fowler's position to aid breathing and increase the amount of air taken with each breath. Increased fluid intake is important to encourage because it helps to loosen secretions and replace fluids lost through fever and increased respiratory rate. The nurse monitors fluid intake and output, skin turgor, vital signs, and serum electrolytes. He or she administers antipyretics as indicated and ordered. Antibiotics are not given for viral pneumonia. The client's activity level is ordered by the physician, not decided by the nurse.

The nurse is caring for a 4-year-old child who is admitted for minor elective surgery. The child is frightened and anxious. Which of the following interventions would be most appropriate for the nurse to take to help the child? Provide teaching about the surgery. Encourage parental reinforcement. Introduce the child to the surgeon. Ask the child to explain what's frightening.

Encourage parental reinforcement. Explanation: Positive parental reinforcement has the greatest impact on a child and provides reassurance and comfort to face potentially frightening experiences. The other options will not have this impact.

Several times, family members have asked a nurse to share personal prescriptions when they were in need of pain medication or antibiotics. Which type of rules or standards should govern the nurse's moral decision? ethics administrative law common law civil law

Ethics Although all of the options may affect the decision, moral decisions are guided by ethics (moral principles and values that guide the behavior of honorable people). Ethical standards dictate the rightness or wrongness of human behavior. Laws are written rules for conduct and actions. They are binding for all citizens and ensure the protection of rights.

Priority setting is based on the information obtained during reassessment and is used to rank nursing diagnoses. Each factor contributes to priority setting except which? Finances of the client The client's condition Time and resources Feedback from the family

Finances of the Client The client's condition, time and resources, and feedback or input from the family are all of great value when the nurse is prioritizing the client's nursing diagnoses. The client's finances, however, should not influence the nurse's priority setting. The nursing code of ethics states that clients should receive the same treatment regardless of their ability to pay.

A nurse is caring for a client with suspected diabetes insipidus. Which test does the nurse anticipate the physician will order to confirm the diagnosis? Capillary blood glucose test Fluid deprivation test Serum ketone test Urine glucose test

Fluid deprivation test Explanation: The fluid deprivation test involves withholding water for 4 to 18 hours and periodically checking urine and plasma osmolarity. A client with diabetes insipidus will have an increased serum osmolarity of less than 300 mOsm/kg. Urine osmolarity won't increase. The capillary blood glucose test rapidly measures glucose level in whole blood. The serum ketone test is used to diagnose diabetic ketoacidosis. The urine glucose test monitors glucose levels in urine; however, diabetes insipidus doesn't affect urine glucose levels, so this test isn't appropriate.

A lactation nurse visits a new mother after delivery of her first child and encourages the mother to breast-feed her infant, even for a short time. Which statement made by the nurse correctly explains the importance of breast-feeding? For several months, colostrum will provide the infant with passive immunity to diseases to which the mother has immunity. Colostrum will provide the infant with active immunity to many childhood illnesses for several years. Colostrum will provide the infant with passive immunity to all childhood illnesses for several months. Colostrum will provide the infant with innate immunity to diseases to which the mother is immune.

For several months, colostrum will provide the infant with passive immunity to diseases to which the mother has immunity. After birth, the neonate receives IgG antibodies from the mother in breast milk or colostrum. Therefore, infants are provided with some degree of protection from infection for approximately 3 to 6 months, giving their own immune systems time to mature. IgA is primarily a secretory Ig that is found in saliva, tears, colostrum (i.e., first milk of a nursing mother), and bronchial, gastrointestinal, prostatic, and vaginal secretions. Its primary function is in local immunity on mucosal surfaces. IgA prevents the attachment of viruses and bacteria to epithelial cells.

A client with lupus has had antineoplastic drugs prescribed. Why would the physician prescribe antineoplastic drugs for an autoimmune disorder? To decrease the body's risk of infection Because an autoimmune disease is a neoplastic disease So the client has strong drug therapy For their immunosuppressant effects

For their immunosuppressant effects Drug therapy using antiinflammatory and immunosuppressive agents is the mainstay for alleviating symptoms. Some antineoplastic (cancer) drugs also are used for their immunosuppressant effects. Antineoplastic drugs do not decrease the body's risk of infection; an autoimmune disease is not a neoplastic disease. Drugs are not ordered just so the client has strong drug therapy.

The health care provider is reviewing laboratory results of a client. Select the diagnostic test that is considered the best measurement of overall kidney function. Glomerular filtration rate (GFR) Serum creatinine levels Urine albumin levels Blood urea nitrogen (BUN)

Glomerular filtration rate (GFR) Explanation: GFR is the best overall measure of kidney function. GFR is usually estimated using the serum creatinine concentration. Creatinine, a by-product of muscle metabolism, is produced at a fairly constant rate, is freely filtered in the glomerulus, and is not reabsorbed in the renal tubules. Essentially all of the creatinine filtered by the kidneys is lost in the urine; therefore, serum creatinine is an indirect measure of GFR. Proteinuria serves as a key adjunctive tool for measuring nephron injury and repair. Urine normally contains small amounts of protein. Blood tests for BUN and creatinine provide information regarding the ability to remove nitrogenous wastes from the blood.

A nurse is reviewing the different types of health care delivery services available in the community. Which method would the nurse identify as having the primary care goal of reducing costs by preventing illness? Health maintenance organization (HMO) Preferred provider organization (PPO) Accountable care organization (ACO) Community health center

Health maintenance organization (HMO) Health maintenance organizations (HMOs) are prepaid, group-managed care plans that allow subscribers to receive all the medical services they require through a group of affiliated providers. Their primary care goal is to reduce costs by preventing illness. Preferred provider organizations provide services at a lower fee in return for prompt payment and a guaranteed volume of clients and services. Accountable care organizations offer incentives to provide integrated, well-coordinated care. Community health centers ensure that everyone who needs care has access regardless of the ability to pay.

The nurse identifies which of the following as a potential cause of premature ventricular complexes (PVCs)? Hypokalemia Alkalosis Hypovolemia Bradycardia

Hypokalemia Explanation: PVCs can be caused by cardiac ischemia or infarction, increased workload on the heart (eg, exercise, fever, hypervolemia, heart failure, tachycardia), digitalis toxicity, acidosis, or electrolyte imbalances, especially hypokalemia.

The nurse asks the parents of a child about the family health history. The father asks the nurse why she needs his information. The nurse would explain that the family health history is gathered for what reason? The number of family members that have a certain health problem will help the nurse know if the child will have the same problem. Identifying risk factors in families decreases the child's risk of developing the same conditions or health problems. The nurse needs to know everything about a family to take care of the child. By establishing family behavior, the nurse forces the parents to alter their care of their child and make them healthier.

Identifying risk factors in families decreases the child's risk of developing the same conditions or health problems. Collection a complete family health history helps the nurse learn if there certain behaviors or risk factors for the family and, hopefully, educate the family in how to improve both their health and the child's health, as well as reduce the incidence of diseases and chronic conditions.

The nurse is aware that the only class of immunoglobulins to cross the placenta is: IgG IgM IgA IgD

IgG IgG is the only class of immunoglobulins to cross the placenta. Levels of maternal IgG decrease significantly during the first 3 to 6 months of life, while infant synthesis of immunoglobulins increases.

The nurse is caring for a client with ketoacidosis who is complaining of increasing lethargy and occasional confusion following several weeks of rigid adherence to a carbohydrate-free diet. The nurse understands which phenomenon is most likely occurring? High fat, low carbohydrate dietary intake is associated with respiratory acidosis. In the absence of carbohydrate energy sources, her body is metabolizing fat and releasing ketoacids. Metabolism of dietary fats without the buffer action of carbohydrates results in the catabolism of ketoacids. Decreased carbohydrate intake induces insulin deficiency and consequent ketoacidosis.

In the absence of carbohydrate energy sources, her body is metabolizing fat and releasing ketoacids. Explanation: Low carbohydrate diets can induce the fat metabolism and consequent metabolic acidosis that is more commonly associated with diabetic ketoacidosis. The acidotic state is not classified as respiratory in nature, and does not involve a buffer role for carbohydrates or insulin deficiency.

Which assessment findings would the health care provider consider as most indicative of acute renal failure? Alterations in blood pH; peripheral edema Increased nitrogenous waste levels; decreased glomerular filtration rate (GFR) Decreased serum creatinine and blood urea nitrogen (BUN); decreased potassium and calcium levels Decreased urine output; hematuria; increased glomerular filtration rate (GFR)

Increased nitrogenous waste levels; decreased glomerular filtration rate (GFR) The hallmark of acute renal injury is azotemia, an accumulation of nitrogenous wastes such as creatinine, urea nitrogen, and uric acid plus a decrease in the GFR of the kidneys. While pH alterations, edema, electrolyte imbalances and decreased urine output may accompany acute renal failure, they are all potentially attributable to other pathologies. Creatinine, GFR, and BUN would be unlikely to rise during renal failure.

During the admission assessment of a 27-year-old client who has been diagnosed with an anxiety disorder, the nurse observes that the client is becoming increasingly restless and agitated. How should the nurse respond to this development? Inform the client that the assessment can be postponed if the client is finding it overwhelming. Increase the speed of the assessment in order to ensure that it is completed sooner and inform the client that the nurse is doing so. Provide education regarding the level of anxiety that the client may be experiencing. Explain to the client that the client's current feelings of anxiety have the potential to foster better coping skills in the future.

Inform the client that the assessment can be postponed if the client is finding it overwhelming. If a client becomes agitated during an assessment, it is appropriate for the nurse to tell the client that the nurse can continue the assessment later. Performing the assessment faster or persisting is likely to exacerbate the client's anxiety. It would be inappropriate for the nurse to provide education regarding anxiety during a time that the client is restless and agitated. This indicates the client is experiencing moderate anxiety, narrowing the perceptual field to the immediate task. The client would not be receptive to any education provided. It would be inappropriate to tell the client that the client's current anxiety will serve a later purpose.

A nurse is assessing a female client and notes that her left arm is swollen from the shoulder down to the fingers, with non-pitting edema. The right arm is normal. The client had a left-sided mastectomy 1 year ago. What does the nurse suspect is the problem? Venous stasis Lymphedema Arteriosclerosis Deep vein thrombosis

Lymphedema The lymphatic system filters fluid at the lymph nodes and removes foreign particles such as bacteria. When lymph flow is obstructed, a condition called lymphedema occurs. Involvement of lymphatic structures by malignant tumors and removal of lymph nodes at the time of cancer surgery are common causes of lymphedema.

A patient has enlarged lymph nodes in his neck and a sore throat. This inflammatory response is an example of a cellular immune response whereby: Antibodies reside in the plasma Antibodies are released into the bloodstream B-lymphocytes respond to a specific antigen Lymphocytes migrate to areas of the lymph node

Lymphocytes migrate to areas of the lymph node Lymphocytes migrate to areas other than those programmed to become plasma cells.

Which nursing intervention should a nurse perform to reduce cardiac workload in a client diagnosed with myocarditis? Maintain the client on bed rest Administer a prescribed antipyretic Elevate the client's head Administer supplemental oxygen

Maintain Bed Rest The nurse should maintain the client on bed rest to reduce cardiac workload and promote healing. The nurse should administer supplemental oxygen to relieve tachycardia that may develop from hypoxemia. If the client has a fever, the nurse should administer a prescribed antipyretic along with independent nursing measures like minimizing layers of bed linen, promoting air circulation and evaporation of perspiration, and offering oral fluids. The nurse should elevate the client's head to promote maximal breathing potential.

The nurse is caring for a client with severe diarrhea. The nurse recognizes that the client is at risk for developing which acid-base imbalance? Metabolic acidosis Respiratory acidosis Metabolic alkalosis Respiratory alkalosis

Metabolic acidosis Explanation: The client is at risk for developing metabolic acidosis. Metabolic acidosis is caused by diarrhea, lower intestinal fistulas, ureterostomies, and use of diuretics; early renal insufficiency; excessive administration of chloride; and the administration of parenteral nutrition without bicarbonate or bicarbonate-producing solutes (e.g., lactate).

A client's arterial blood gases indicate normal oxygen levels but increased carbon dioxide levels. The client's vital signs are within normal range except for respiratory rate of 12 breaths/min. While not evident from assessment and diagnostics, the client's kidneys are minimizing both H+ excretion and HCO3- reabsorption. What is this client's most likely diagnosis? Respiratory alkalosis Metabolic acidosis Respiratory acidosis Metabolic alkalosis

Metabolic alkalosis Explanation: In response to increased bicarbonate, the client is hypoventilating to increase carbon dioxide partial pressure. As well, renal compensation is aimed at lowering pH by both reducing H+ excretion and HCO3- reabsorption. The given data are incongruent with the other major acid-base imbalances.

A patient experiences a life-threatening hypercalcemic crisis. The provider orders a cytotoxic agent. Which of the following is most likely the drug that is prescribed? Calcitonin Didronel Mithramycin Aredia

Mithramycin Explanation: Mitramycin is a cytotoxic agent commonly used in a hypercalcemic crisis. Didronel and Aredia are bisphosphonates that decrease serum calcium levels. Calcitonin can be ordered but it is not a cytotoxic agent.

Included in the nursing care plan for the child receiving total parenteral nutrition (TPN) will be which intervention?

Monitoring the blood glucose is important with TPN since the glucose content of the solution is high and can cause hyperglycemia. The need for a stool softener would be determined on an individual basis. Children receiving TPN may or may not be taking food and fluids orally. The catheter delivering the TPN solutions will be centrally placed to accommodate the concentrated TPN solution (larger vessel with more rapid blood flow).

A client is receiving long-term treatment with high-dose corticosteroids. Which of the following would the nurse expect the client to exhibit? Weight loss Pale thick skin Moon face Hypotension

Moon face Explanation: Clients who are receiving long-term high-dose corticosteroid therapy often develop a cushingoid appearance, manifested by facial fullness and the characteristic moon face. They also may exhibit weight gain, peripheral edema, and hypertension due to sodium and water retention. The skin is usually thin, and ruddy.

An adult client has had mumps when the client was a child. The client had a titer prior to entering nursing school and shows immunity. What type of immunity does this reflect? Artificially acquired active immunity Naturally acquired active immunity Passive immunity Natural passive immunity

Naturally acquired active immunity Naturally acquired active immunity occurs as a direct result of infection by a specific microorganism. An example is the immunity to measles that develops after the initial infection. Not all invading microorganisms produce a response that gives lifelong immunity. Artificially acquired immunity is obtained by receiving a killed or weakened microorganism or toxoid. Passive immunity is acquired when ready-made antibodies are given to a susceptible person.

A school nurse is teaching a class on immunity. Which statement contains an accurate explanation about cellular defenses? Neutrophils engulf invading organisms where lysosomes break them down. Active transport draws invading organisms through cell channels to be destroyed. Ion channels allow rapid polarity changes, which inactivate invading organisms. Cells release enzymes into the extracellular fluid and this degrades invading organisms.

Neutrophils engulf invading organisms where lysosomes break them down. Phagocytosis is when a cell, such as macrophages or neutrophils, engulfs an invading organism or damaged cells. Once inside the cell, the encapsulated particle is broken down by lysosomal enzymes.

Parents tell the nurse that they have been told to keep their newborn away from windows and be sure to cover the baby with a light blanket. They do not understand why this is necessary. What rationale would the nurse provide for this care? Newborns weighing below 8 pounds lack enough brown fat to produce heat. Windows can be drafty and placing the newborn by one can result in evaporative heat loss. Since newborns cannot shiver to produce heat, parents need to be sure to keep them covered up and away from sources of heat loss like a window. Newborns have very thin skin, which allows radiant heat loss.

Newborns have very thin skin, which allows radiant heat loss. Correct response: Since newborns cannot shiver to produce heat, parents need to be sure to keep them covered up and away from sources of heat loss like a window.

A pregnant woman diagnosed with diabetes should be instructed to perform which action? Discontinue insulin injections until 15 weeks gestation. Ingest a smaller amount of food prior to sleep to prevent nocturnal hyperglycemia. Notify the primary care provider if unable to eat because of nausea and vomiting. Prepare foods with increased carbohydrates to provide needed calories.

Notify the primary care provider if unable to eat because of nausea and vomiting. During pregnancy, the insulin levels change in response to the production of HPL. The client needs to alert her provider if she is not able to eat or hold down appropriate amounts of nutrition. The client is at risk for episodes of hypoglycemia during the first trimester. She should never discontinue insulin therapy without her provider's directions. The increase of carbohydrates needs to be balanced with protein, and smaller meals would result in hypoglycemia rather than hyperglycemia.

A client is receiving auranofin as treatment for rheumatoid arthritis. The nurse should expect this drug to be given by which route? Oral Subcutaneous Intramuscular Intravenous

Oral Auranofin is administered orally. Aurothioglucose and gold sodium thiomalate are given IM. Auranofin is administered orally. Aurothioglucose and gold sodium thiomalate are given IM. Auranofin is not given via the subcutaneous, intramuscular, or intravenous routes.

A client has been receiving 100% oxygen therapy by way of a nonrebreather mask for several days. Now the client complains of tingling in the fingers and shortness of breath, is extremely restless, and describes a pain beneath the breastbone. What should the nurse suspect? Oxygen-induced hypoventilation Oxygen toxicity Oxygen-induced atelectasis Hypoxia

Oxygen toxicity Explanation: Oxygen toxicity may occur when too high a concentration of oxygen (greater than 50%) is administered for an extended period (longer than 48 hours) (Urden, Stacy, & Lough, 2014). Signs and symptoms of oxygen toxicity include substernal discomfort, paresthesias, dyspnea, restlessness, fatigue, malaise, progressive respiratory difficulty, refractory hypoxemia, alveolar atelectasis, and alveolar infiltrates evident on chest x-rays.

A nurse is reviewing the history and physical examination of a client with a suspected malignant tumor of the bladder. Which finding would the nurse identify as the most common initial symptom? Urinary retention Fever Frequency Painless hematuria

Painless hematuria The most common first symptom of a malignant tumor of the bladder is painless hematuria. Additional early symptoms include UTI with symptoms such as fever, dysuria, urgency, and frequency. Later symptoms are related to metastases and include pelvic pain, urinary retention (if the tumor blocks the bladder outlet), and urinary frequency from the tumor occupying bladder space.

When assessing the impact of medications on the etiology of acute renal failure, the nurse recognizes which of the following as the drug that is not nephrotoxic? Penicillin Gentamicin Tobramycin Neomycin

Penicillin The three nephrotoxic drugs are aminoglycerides.

What is one method that the nurse can teach community members to prevent many parasitic infections? Avoidance of campgrounds Personal and public hygiene practices Avoidance of specific vacation spots Avoidance of nonbottled water

Personal and public hygiene practices Personal and public health hygienic practices can prevent many parasitic infections and should be followed diligently. Reference:

A client presents to the ED with a suspected allergic reaction. The client is experiencing laryngeal edema, which is causing obstruction, and is demonstrating retractions in the neck during inspiration. Which is the nurse's priority intervention? Prepare for endotracheal intubation with mechanical ventilation. Prepare to administer subcutaneous epinephrine and corticosteroids. Apply 100% oxygen via a face mask. Prepare for immediate tracheostomy.

Prepare to administer subcutaneous epinephrine and corticosteroids. The use of accessory muscles to maximize airflow is often manifested by retractions in the neck during inspiration and is an ominous sign of impending respiratory distress. The client's obstruction is caused by edema resulting from an allergic reaction, and treatment should include immediate administration of subcutaneous epinephrine and a corticosteroid. The other interventions may be indicated for a client with a laryngeal obstruction; however, in this instance the most appropriate intervention to treat the client's laryngeal edema is the administration of the medications.

A client complaining of bloody urine has scheduled an appointment with a family practitioner. What type of care is the client receiving? Tertiary Secondary Convalescent Primary

Primary The first provider that clients contact about a health need provides primary care; this person is typically a family practitioner or nurse practitioner. Secondary care includes referrals to facilities for additional testing. Tertiary care is provided in hospitals where specialists and advanced technologies are available. Convalescent care helps clients recover health gradually after an illness.

The nurse is caring for a client following a coronary artery bypass graft (CABG). The nurse notes persistent oozing of bloody drainage from various puncture sites. The nurse anticipates that the physician will order which medication to neutralize the unfractionated heparin the client received? Protamine sulfate Alteplase Clopidogrel Aspirin

Protamine sulfate Explanation: Protamine sulfate is known as the antagonist for unfractionated heparin (it neutralizes heparin). Alteplase is a thrombolytic agent. Clopidogrel is an antiplatelet medication that is given to reduce the risk of thrombus formation after coronary stent placement. The antiplatelet effect of aspirin does not reverse the effects of heparin.

Inspection of the skin is an important part of nursing assessment. Interpretation of abnormalities is based on an understanding of structure and function. The nurse is aware that the epidermis, especially the stratum cornea, has many vital functions. What are some of these functions? Select all that apply. Provides an effective barrier to water loss Contains the nerve receptors for pain perception Contains lipids that resist penetration by microbes Provides the elasticity of the skin's foundation Produces keratin, the hardening ingredient of the nails Secretes fibroblast cells that help repair the skin

Provides an effective barrier to water loss Contains lipids that resist penetration by microbes Produces keratin, the hardening ingredient of the nails Explanation: The incorrect choices refer to functions of the dermis. The stratum corneum, the outer layer of the epidermis provides the most effective barrier to epidermal water loss, maintains a homeostatic environment, and prevents the penetration of environmental factors such as chemicals, microbes, and insect bites. Various lipids are synthesized in the stratum corneum and are the basis for the barrier function of this layer, especially keratin, the principal hardening ingredient of the hair and nails.

A nurse is reviewing the history of a client who is suspected of having glomerulonephritis. Which of the following would the nurse consider significant? Previous episode of acute pyelonephritis History of hyperparathyroidism Recent history of streptococcal infection History of osteoporosis

Recent history of streptococcal infection Explanation: Glomerulonephritis can occur as a result of infections from group A beta-hemolytic streptococcal infections, bacterial endocarditis, or viral infections such as hepatitis B or C or human immunodeficiency virus (HIV). A history of hyperparathyroidism or osteoporosis would place the client at risk for developing renal calculi. A history of pyelonephritis would increase the client's risk for chronic pyelonephritis.

To ensure ethical nursing care when dealing with genetic and genomic information, which principle would the nurse integrate as the foundation for all nursing care? Fidelity Veracity Justice Respect for people

Respect for people Although fidelity, veracity, and justice are ethical principles that may be involved with ethical issues surrounding genetic and genomic informaiton, respect for people is the ethical principle underlying all nursing care.

A nurse who has been caring for a client for the past few days is preparing the client for discharge and termination of the nurse-client relationship. Which activity would the nurse be carrying out during this phase of the relationship? Reviewing health changes Attending to physical health care needs Establishing trust and rapport Developing solutions that will be enacted

Reviewing health changes During the termination phase of the nurse-client relationship, the nurse and the client review health changes and how the client has dealt with physical and emotional responses. During the orientation phase of the nurse-client relationship, the nurse and client work toward establishing trust and rapport. During the working phase of the nurse-client relationship, the nurse attends to the physical health care needs of the client and develops solutions that the client will act on.

A patient has just received the first dose of imatinib and the nurse on the oncology unit is amending the patient's care plan accordingly. What nursing diagnosis is most appropriate in light of this addition to the patient's drug regimen? Risk for Infection related to bone marrow suppression Risk for Acute Confusion related to adverse neurological effects of imatinib Risk for Impaired Skin Integrity related to exaggerated inflammatory response Risk for Deficient Fluid Volume related to changes in osmotic pressure

Risk for Infection related to bone marrow suppression Like many cancer treatments, imatinib causes bone marrow suppression that creates a consequent risk of infection. The drug does not typically result in cognitive changes, fluid overload, or skin breakdown.

The nurse working in the emergency department is asked to explain allergy testing to a client who experienced an allergic reaction to an unknown allergen. Which test indicates the quantity of allergen necessary to evoke an allergic reaction? Serum-specific IgE test Provocative testing Scratch test Intradermal test

Serum-specific IgE test The serum-specific IgE test, formerly known as RAST, is a radioimmunoassay that measures allergen-specific IgE. It indicates the quantity of allergen necessary to evoke an allergic reaction. Provocative testing involves the direct administration of the suspected allergen to the sensitive tissue such as the conjunctiva. The scratch test does not indicate the quantity of allergen.

The nurse is working with a 50-year-old client admitted for a major depressive episode. The client has remained isolated and withdrawn since admission and is reluctant to speak. Which therapeutic communication skill is most likely to encourage the client to verbalize the client's feelings? Direct confrontation Reality orientation Projective identification Silence and active listening

Silence and active listening Silence and active listening are powerful tools for use with a client who is depressed and withdrawn. Direct confrontation can lead to feelings of shame or embarrassment. The client who is not psychotic does not need reality orientation, and projective identification is a primitive subconscious ego defense mechanism.

A nurse is monitoring a client closely for malignant hyperthermia because the client received which NMJ blocker? Pancuronium Vecuronium Atracurium Succinylcholine

Succinylcholine Explanation: Succinylcholine is associated with the development of malignant hyperthermia in susceptible clients. Pancuronium, vecuronium, and atracurium are not associated with the development of this condition.

Which therapeutic communication technique may occur during the planning stage, when the client is presented with alternative ideas for consideration relative to problem solving? Suggesting Clarification Focusing Reflection

Suggesting Suggesting is the presentation of alternative ideas for the client's consideration relative to problem solving. Clarification is asking the client to explain what he or she means or attempting to help verbalize the client's vague ideas or unclear thoughts to enhance the nurse's understanding. Focusing includes questions or statements to help the client develop or expand an idea.

x Which of the following endocrine disorder causes the patient to have dilutional hyponatremia? Syndrome of inappropriate antidiuretic hormone secretion (SIADH) Diabetes insipidus (DI) Hypothyroidism Hyperthyroidism

Syndrome of inappropriate antidiuretic hormone secretion (SIADH) Explanation: Reference: Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia: Wolters Kluwer, 2018, Chapter 52: Assessment and Management of Patients With Endocrine Disorders, Syndrome of Inappropriate Antidiuretic Hormone Secretion, p. 1510.

A client with pneumonia is admitted with these vital signs: temperature 99.7ºF (37.6°F), pulse 80 beats/min, respirations 18/minute, and BP 120/80 mm Hg. Which set of vital signs does the nurse anticipate when the client begins to shiver and requests another blanket several hours later? T 100.9ºF (38.3°C), P 90/min, R 20/min, BP 126/80 mm Hg T 99.7ºF (37.6°C), P 86/min, R 18/min, BP 130/82 mm Hg T 98.4ºF (36.9°C), P 82/min, R 16/min, BP 106/70 mm Hg T 97.2ºF (36.2°C), P 70/min, R 12/min, BP 114/60 mmHg

T 100.9ºF (38.3°C), P 90/min, R 20/min, BP 126/80 mm Hg Explanation: During the chill phase of fever, the client feels cold and may experience pale skin with goosebumps, but the temperature is rising. When the body reaches the new set point, shivering will stop, and flushing will begin.

The nurse is caring for a client preoperatively for a lung tumor removal. Which interventions should the nurse implement? Select all that apply. Keep the client in a side lying position to protect the airway. Teach the client to use the incentive spirometer. Encourage the client to splint chest with deep breathing and coughing. Protect the I.V. line to prevent dislodgement during isometric leg exercises. Administer subcutaneous heparin to prevent deep vein thrombosis.

Teach the client to use the incentive spirometer. Encourage the client to splint chest with deep breathing and coughing. During the preoperative period the nurse will focus on teaching the client to use the incentive spirometer and encouraging the client to splint chest with deep breathing and coughing. Keeping the client side lying, protecting the I.V. line to prevent dislodgement during isometric leg exercises, and administering subcutaneous heparin to prevent deep vein thrombosis are part of postoperative care.

A school health nurse is teaching a group of 7-year-old girls about preventing urinary tract infections. What is the most appropriate education for the nurse to include in the teaching? Teach the girls to wipe from back to front after going to the bathroom. Encourage the girls to drink cranberry juice throughout the day. Recommend that the girls wear lightweight nylon undergarments. Tell the girls to avoid bubble baths and other perfumed bath additives.

Tell the girls to avoid bubble baths and other perfumed bath additives. Avoiding bath additives that can irritate the urethra is recommended to avoid urinary tract infections in girls. Though there is some evidence cranberry juice can reduce bladder infections, it is not advised that children consume sugar-containing beverages throughout the day. Children should also drink water, not just juice. Young girls should be encouraged to wear cotton undergarments because they are breathable. Young girls need to wipe front to back to take germs away from the opening that leads to the urinary system and decrease the risk of developing urinary tract infections.

A client has come to the clinic requesting a hepatitis A and B vaccination before leaving on a tropical vacation. After assessing the client, the nurse should prioritize what finding to communicate to the provider? The client takes corticosteroids to treat rheumatoid arthritis The client uses marijuana two to three times per month The client received the annual influenza vaccine seven days ago The client has type two diabetes that is controlled by diet

The client takes corticosteroids to treat rheumatoid arthritis Corticosteroids decrease the normal immune response and could interfere with the intended stimulation of B cells. Recent influenza vaccination does not contraindicate the hepatitis vaccine, nor does type 2 diabetes. Occasional marijuana use would not contraindicate a hepatitis vaccination.

Right Sided Heart Failure Vs. Left Sided Heart Failure

The left side of the heart brings oxygen-rich blood from the lungs through the left atrium to the left ventricle, then out into your body. When the left side of your heart is damaged or can't pump as well, it has to work harder to send blood through your body. This causes fluid to build up in your body, especially the lungs The right side of the heart usually becomes weaker in response to failure on the left side. The right side of the heart brings in the circulated blood from the body and sends it to the lungs for oxygen. When the left side of the heart weakens, the right side of the heart has to work harder to compensate. Again, as the heart muscle loses strength, blood and fluid become backed up in the body. You may experience swelling and trouble catching your breath.

A hospital patient began treatment with interferon alfa-2a several days ago and the care team is pleased with the patient's response at this point in treatment. However, the patient has stated to the nurse that he feels increasingly despondent and claims to have lost all hope of recovering from his disease, despite being an optimistic person. How should the nurse best interpret the patient's statements? The patient may have misunderstood the potential benefits of interferon alfa-2a. The patient may be having psychological adverse effects of interferon alfa-2a. The patient is likely to experience a compensatory period of mania in the coming days. The patient is likely becoming aware of psychosocial issues that surround interferon alfa-2a treatment.

The patient may be having psychological adverse effects of interferon alfa-2a. Depression, anxiety, and suicidal ideation have been reported in a substantial number of patients taking interferon alfa-2a. The possibility of this adverse effect is more likely than other psychosocial factors, given his previous baselines.

A patient has been exposed to a pathogen during an outbreak of a nosocomial (hospital-acquired) infection. The patient's immune system has responded appropriately to the virus, and the response has included the production of memory B cells. These particular B cells will have what effect? The patient will have a more pronounced immune response to the virus during future exposure. B cells will be able to produce antibodies without the assistance of T cells. The patient will have life-long immunity to the specific virus. The patient's B cells will have the ability to directly ingest the virus during a subsequent exposure.

The patient will have a more pronounced immune response to the virus during future exposure. When an antigenic message is carried back to a lymph node, specific clones of the B lymphocyte are stimulated to enlarge, divide, proliferate, and differentiate into plasma cells capable of producing specific antibodies to the antigen. Other B lymphocytes differentiate into B-lymphocyte clones with a memory for the antigen. These memory B cells are responsible for the more exaggerated and rapid immune response in a person who is repeatedly exposed to the same antigen. They do not confer the ability to produce antibodies without T-cell assistance if this ability did not previously exist. B cells do not participate in phagocytosis, and the presence of memory B cells does not necessarily confer life-long immunity.

The type of hypersensitivity reaction that is dependent on IgE-mediated activation of mast cells and basophils and the subsequent release of chemical mediators of the inflammatory response is known as which of the following types of hypersensitivity reaction? Type I Type II Type III Type IV

Type I A type I-hypersensitivity reaction is dependent on IgE-mediated activation of mast cells and basophils and the subsequent release of chemical mediators of the inflammatory response. Type II hypersensitivity reactions are mediated by IgG or IgM antibodies directed against target antigens on specific host cell surfaces or tissues and result in complement=mediated phagocytosis and cellular injury. Type III hypersensitivity is caused by the formation of antigen-antibody immune complexes in the bloodstream, which are subsequently deposited in vascular epithelium or extravascular tissues and which activate the complement system and induce a massive inflammatory response. Type IV hypersensitivity involves tissue damage in which cell-mediated immune responses with sensitized T lymphocytes cause cell and tissue injury.

When discussing diseases of the middle ear, the nursing instructor distinguishes the different types of otitis media. What generally causes purulent otitis media? Irritation associated with respiratory allergies and enlarged adenoids Bronchial tree Outer ear Upper respiratory infections

Upper respiratory infections Explanation: Purulent otitis media usually results from the spread of microorganisms from the eustachian tube to the middle ear during upper respiratory infections. It is not caused from the bronchial tree, the outer ear or irritation associated with respiratory allergies, and enlarged adenoids.

A client is being treated with colchicine for pain in the big right toe. The client begins to complain of severe right flank pain and is diagnosed with kidney stones. Which type of kidney stone does the nurse recognize this client is most likely affected by? Magnesium ammonium phosphate Cystine Calcium Uric acid

Uric acid Uric acid stones develop in conditions of gout and high concentrations of uric acid in the urine; it accounts for about 7% of all stones.

A client comes to the emergency department complaining of a sudden onset of sharp, severe flank pain. During the physical examination, the client indicates that the pain, which comes in waves, travels to the suprapubic region. He states, "I can even feel the pain at the tip of my penis." Which of the following would the nurse suspect? Acute glomerulonephritis Ureteral stricture Urinary calculi Renal cell carcinoma

Urinary calculi Symptoms of a kidney or ureteral stone vary with size, location, and cause. Small stones may pass unnoticed; however, sudden, sharp, severe flank pain that travels to the suprapubic region and external genitalia is the classic symptom of urinary calculi. The pain is accompanied by renal or ureteral colic, painful spasms that attempt to move the stone. The pain comes in waves that radiate to the inguinal ring, the inner aspect of the thigh, and to the testicle or tip of the penis in men, or the urinary meatus or labia in women. Clients with acute glomerulonephritis may be asymptomatic or may exhibit fever, nausea, malaise, headache, edema (generalized or periorbital), pain, and mild to moderate hypertension. Clients with ureteral stricture may complain of flank pain and tenderness at the costovertebral angle and back or abdominal discomfort. A client with renal cell carcinoma rarely exhibits symptoms early on but may present with painless hematuria and persistent back pain in later stages.

A client seeks treatment in the clinic for exposure to poison ivy with a rash over the right arm and hand. The nurse is aware that what toxin is found in the oils on poison ivy that is responsible for eliciting an allergic reaction? Urushiol Lymphocytes Kupffer cells Streptococcus pneumonia

Urushiol Urushiol is a toxin found in the oils on poison ivy that is responsible for initiating an allergic reaction.

Which medication is used to decrease portal pressure, halting bleeding of esophageal varices? Spironolactone Vasopressin Nitroglycerin Cimetidine

Vasopressin Vasopressin may be the initial therapy for esophageal varices because it constricts the splanchnic arterial bed and decreases portal hypertension. Nitroglycerin has been used to prevent the side effects of vasopressin. Spironolactone and cimetidine do not decrease portal hypertension.

When caring for a postoperative client, in order to promote wound healing, which of these nutrients does the nurse encourage the client to consume? Vitamin D Vitamin C Magnesium Vitamin E

Vitamin C Explanation: Vitamins are essential cofactors for the daily functions of the body; vitamins A and C play an essential role in the healing process. Vitamin C is needed for collagen synthesis. Vitamin K plays an indirect role in wound healing by preventing bleeding disorders that contribute to hematoma formation and subsequent infection. Proteins, fats, carbohydrates and microminerals such as zinc are required for wound healing as well.

A client presents at the clinic complaining of unplanned 10% weight loss, diarrhea, fever and weakness that "just won't go away." After a complete history and physical, an enzyme-linked immunosorbent assay test is ordered. This order is based on what suspected diagnosis? Wasting syndrome AIDS syndrome Beal syndrome WAGAR syndrome

Wasting syndrome In 1997, wasting became an AIDS-defining illness. The syndrome is common in persons with HIV infection or AIDS. Wasting is characterized by involuntary weight loss of at least 10% of baseline body weight in the presence of diarrhea, more than two stools per day, or chronic weakness and fever. This diagnosis is made when no other opportunistic infections or neoplasms can be identified as causing these symptoms. Beal syndrome and WAGAR syndrome are not identified with HIV/AIDS. AIDS is not a recognized syndrome.

A client with suspected exposure to HIV has been tested with the enzyme-linked immunosorbent assay (ELISA) with positive results twice. The next step for the nurse to explain to the client for confirmation of the diagnosis is to perform a: p24 antigen test for confirmation of diagnosis. Western blot test for confirmation of diagnosis. polymerase chain reaction test for confirmation of diagnosis. T4-cell count for confirmation of diagnosis.

Western blot test for confirmation of diagnosis. The enzyme-linked immunosorbent assay (ELISA) test, an initial HIV screening test, is positive when there are sufficient HIV antibodies; it also is positive when there are antibodies from other infectious diseases. The test is repeated if results are positive. If results of a second ELISA test are positive, the Western blot is performed. The p24 antigen test and the polymerase chain reaction test determine the viral load, and the T4-cell count is not used for diagnostic confirmation of the presence of HIV in the blood.

The charge nurse is completing assignments for staffing on a medical-surgical floor. Which client(s) will the nurse place in airborne precautions? Select all that apply. a client diagnosed with tuberculosis a client diagnosed with chicken pox a client with a new onset of diarrhea a client diagnosed with respiratory syncytial virus a client with a positive wound culture for Methicillin resistant Staphylococcus aureus (MRSA)

a client diagnosed with tuberculosis a client diagnosed with chicken pox The clients with tuberculosis and chicken pox need airborne precautions. The clients with respiratory syncytial virus, new onset of diarrhea, and positive wound culture for Methicillin resistant Staphylococcus aureus (MRSA) will need contact precautions.

The charge nurse is assessing assignments for staffing on a medical-surgical floor. Which client(s) will the nurse place in droplet precautions? Select all that apply. a client with bacterial meningitis an older adult client with influenza a client with a positive staphylococcus wound culture a client receiving antibiotics for a fever after surgery a client with a critically low white blood cell count

a client with bacterial meningitis an older adult client with influenza Droplet precautions are used for clients with bacterial meningitis and influenza. The client with a positive staphylococcus wound culture needs contact precautions. The client receiving antibiotics for a fever after surgery will not require precautions. The client with the low white blood cell count will need neutropenic precautions.

The caregiver of a child with a history of ear infections calls the nurse and reports that her son has just told her his urine "looks funny." He also has a headache, and his mother reports that his eyes are puffy. Although he had a fever 2 days ago, his temperature is now down to 100℉ (37.8℃). The nurse encourages the mother to have the child seen by the care provider because the nurse suspects the child may have: a urinary tract infection. lipoid nephrosis (idiopathic nephrotic syndrome). acute glomerulonephritis. rheumatic fever.

acute glomerulonephritis. Acute glomerulonephritis is a condition that appears to be an allergic reaction to specific infections, most often group A beta-hemolytic streptococcal infections such as rheumatic fever. Presenting symptoms appear 1 to 3 weeks after the onset of a streptococcal infection such as strep throat, otitis media, tonsillitis, or impetigo. Usually the presenting symptom is grossly bloody urine. Periorbital edema may accompany or precede hematuria. Fever may be 103℉ to 104℉ (39.4℃ to 40℃) at the onset, but decreases in a few days to about 100℉ (37.8℃). Slight headache and malaise are usual, and vomiting may occur.

A nurse is caring for a client 1 hour post-laparotomy who reports abdominal pain rating 5/10. What will the nurse prioritize when administering the ordered morphine? administer the medication before the pain becomes severe administer the medication when the pain is reported as 9/10 administer the medication every 3 hours around the clock minimize medication administration to avoid dependency

administer the medication before the pain becomes severe For greatest analgesic effectiveness, the nurse should administer an opioid agonist, such as morphine, before the client's pain becomes severe. If the nurse waits until the pain becomes severe, the medication will be less effective, taking longer to provide relief. Giving morphine every 3 hours around the clock whether or not the client has pain would be inappropriate because the client may have increased side effects of the medication such as respiratory depression. Minimizing medication administration to avoid dependency would cause needless suffering for the client.

A female client has been taking prednisone for her asthma for 1 month. The nurse will teach her to gradually decrease her dose of prednisone to avoid: hypokalemia. gastrointestinal problems. adrenal insufficiency. menstrual irregularities.

adrenal insufficiency. Explanation: The client may develop adrenal insufficiency (addisonian crisis), which is characterized by glucocorticoid insufficiency without mineralocorticoid insufficiency. Hypokalemia occurs as a result of hyperaldosteronism. Gastrointestinal distress and menstrual irregularities are common adverse effects of the drug, but these effects are not as serious as preventing adrenal insufficiency.

The nurse would recognize which client as being particularly susceptible to impaired wound healing? an obese woman with a history of type 1 diabetes a client whose breast reconstruction surgery required numerous incisions a man with a sedentary lifestyle and a long history of cigarette smoking A client who is NPO (nothing by mouth) following bowel surgery

an obese woman with a history of type 1 diabetes Explanation: Obese people tend to be more vulnerable to skin irritation and injury. More significant, however, is the role of diabetes in creating both susceptibility to skin breakdown and impairment of the healing process. This is a greater risk factor for impaired healing than are smoking and sedentary lifestyle. Large incisions in and of themselves do not necessarily complicate the healing process. Short-term lack of food intake is not as significant as longer-term lack of nutrition.

The nurse assesses that a client is shivering. Which intervention is most appropriate to prevent further stress on the body? applying a cooling blanket applying a blanket raising the room temperature providing warm fluids

applying a blanket Explanation: Covering prevents heat loss, and the shivering will not stop until the hypothalamus readjusts to a higher set point. A cooling blanket will make the shivering worse, because it will make the client feel cold. Raising the room temperature warms the body surface and is only appropriate for subnormal temperatures. Warm fluids conduct heat to internal organs and this client is febrile; the goal is to reduce to heat.

The nurse planning care for a menopausal woman should include interventions to decrease risk for: atherosclerosis. tachycardia. irregular heartbeat. bradycardia.

atherosclerosis. Consequences of long-term estrogen deprivation include an increased risk for cardiovascular disease (atherosclerosis is accelerated), which is the leading cause of death for women after menopause.

Which option is an example of a primary preventive measure? participating in a cardiac rehabilitation program having an annual physical examination practicing monthly breast self-examination avoiding overexposure to the sun

avoiding overexposure to the sun Primary prevention involves promoting health and helping clients achieve maximum wellness. Primary preventive measures are designed to prevent or delay the onset of specific illnesses; these measures typically include lifestyle changes such as avoiding overexposure to the sun to prevent skin cancer. Participating in a cardiac rehabilitation program is an example of a tertiary preventive measure, which attempts to prevent complications of an existing disease. Annual physical examinations and monthly breast self-examinations are examples of secondary preventive measures, which promote early detection and treatment of disease.

The nurse is assessing a client with chronic bronchitis. For which finding should the nurse suspect that the client is developing right-sided heart failure? dyspnea on exertion bilateral crackles that clear with coughing clubbing of the fingernails on both hands bilateral edema of the feet and ankles

bilateral edema of the feet and ankles A client with chronic bronchitis, a form of chronic obstructive pulmonary disease (COPD), may experience symptoms that are similar to those of left-sided heart failure, such as dyspnea on exertion. However, without other risk factors, the client with COPD is at risk for right-sided, not left-sided, heart failure. Bilateral edema of the feet and ankles would not occur with chronic bronchitis but is evidence of right-sided heart failure due to the resistance to venous return to the right side of the heart. Bilateral crackles that clear with coughing would occur with chronic bronchitis. Note that pulmonary edema is not expected with right-sided heart failure. Nail clubbing develops in chronic bronchitis because of chronic oxygen deprivation and is not evidence of heart failure.

A nurse is providing dietary instructions to a client with hypoglycemia. To control hypoglycemic episodes, the nurse should recommend: increasing saturated fat intake and fasting in the afternoon. increasing intake of vitamins B and D and taking iron supplements. eating a candy bar if light-headedness occurs. consuming a low-carbohydrate, high-protein diet and avoiding fasting.

consuming a low-carbohydrate, high-protein diet and avoiding fasting. To control hypoglycemic episodes, the nurse should instruct the client to consume a low-carbohydrate, high-protein diet, avoid fasting, and avoid simple sugars. Increasing saturated fat intake and increasing vitamin supplementation wouldn't help control hypoglycemia.

A nurse who has diagnosed a client as having "fluid volume excess" related to compromised regulatory mechanism (kidneys) may have been alerted by what symptom? muscle twitching distended neck veins fingerprinting over sternum nausea and vomiting

distended neck veins Explanation: Fluid volume excess causes the heart and lungs to work harder, leading to the veins in the neck becoming distended. Muscle twitching, and nausea and vomiting may signify electrolyte imbalances. The sternum is not an area assessed during fluid volume excess.

A nurse is administering a mumps vaccine to an adolescent. Which medication should be available when administering an immunization? diphenhydramine hydroxyzine physostigmine epinephrine

epinephrine The administration of vaccines for immunization possesses the risk of an allergic reaction and anaphylaxis. The nurse should have aqueous epinephrine available in the event of an anaphylactic reaction. The administration of diphenhydramine or hydroxyzine will reduce the allergic reaction but will not be effective in the event of anaphylaxis. Physostigmine is not administered.

A nurse is speaking to a group of women about early detection of breast cancer. The average age of the women in the group is 47. Following the American Cancer Society (Canadian Cancer Society) guidelines, the nurse should recommend that the women perform breast self-examination annually. have a mammogram annually. have a hormonal receptor assay annually. have a physician conduct a clinical examination every 2 years.

have a mammogram annually. The American Cancer Society (Canadian Cancer Society) guidelines state that women age 40 and older should have a mammogram annually and a clinical examination at least annually (not every 2 years). All women should perform breast self-examination monthly (not annually). The hormonal receptor assay is done on a known breast tumor to determine whether the tumor is estrogen- or progesterone-dependent.

A severely dehydrated adolescent admitted to the hospital with hypotension and tachycardia undergoes evaluation for electrolyte disturbances. The client's history includes anorexia nervosa and a 20-lb (9.1-kg) weight loss in the past month. She is 5′ 7″ (1.7 m) tall and weighs 80 lb (36.3 kg). Which nursing intervention takes highest priority? initiating caloric and nutritional therapy as ordered instituting behavioral modification therapy as ordered addressing the client's low self-esteem monitoring vital signs and weight regularly

initiating caloric and nutritional therapy as ordered A client with anorexia nervosa is at risk for death from self-starvation. Therefore, initiating caloric and nutritional therapy takes highest priority. Behavioral modification (in which client privileges depend on weight gain) and psychotherapy (which addresses the client's low self-esteem, guilt, anxiety, and feelings of hopelessness and depression) are important aspects of care but are secondary to stabilizing the client's physical condition. Monitoring vital signs and weight is important in evaluating nutritional therapy but doesn't take precedence over providing adequate caloric intake to ensure survival.

A nurse may use self-disclosure with a client if: the nurse has experienced the same situation as the client. the client asks directly about the nurse's experience. it helps the client to talk more easily. it achieves a specific therapeutic goal.

it achieves a specific therapeutic goal. Self-disclosure (making personal statements about oneself) can be a useful nursing tool. However, a nurse should use self-disclosure judiciously and with a specific therapeutic purpose in mind. The nurse should listen closely to the client and remember that the experiences of different people are sometimes similar but never identical. Using too many self-disclosures is unethical and can shift the focus from the client to the nurse. Self-disclosure that distracts the client from treatment issues doesn't benefit the client and may alienate the client from the nurse.

The nurse conducts discharge education for a client who is to go home with parenteral nutrition (PN). The nurse determines the client understands the education when the client indicates a sign and/or symptom of metabolic complications is loose, watery stools. increased urination. elevated blood pressure. decreased pulse rate.

loose, watery stools. When the client indicates that loose, watery stools are a sign/symptom of metabolic complications, the nurse evaluates that the client understands the teaching of metabolic complications. Signs and symptoms of metabolic complications from PN include neuropathies, changes in mental activity, diarrhea, nausea, skin changes, and decreased urine output.

Different medications are used to treat the differing causes of nausea and vomiting. Antihistamines may be effective in the treatment of nausea and vomiting created by: motion sickness. drugs. surgery. radiation therapy.

motion sickness. Antihistamines are usually effective in preventing or treating nausea and vomiting induced by motion sickness. Not all antihistamines are effective as antiemetic agents.

A client is administered cyclosporine to prevent rejection of a kidney transplant. Which is a major adverse effect of cyclosporine? congestive heart failure nephrotoxicity anaphylaxis respiratory arrest

nephrotoxicity The major adverse effect of cyclosporine is nephrotoxicity. Congestive heart failure is not noted as an adverse effect of cyclosporine. Anaphylaxis and respiratory arrest are not adverse effects of cyclosporine.

The nurse is caring for a client who has been admitted to the hospital with a leg ulcer that is infected with vancomycin-resistant s. aureus (VRSA). Which nursing actions can be delegated to a licensed practical/vocational nurse (LPN/VN)? teaching the client about the care of the leg ulcer planning the client's diet to improve protein intake assessing the risk of further skin breakdown obtaining a wound culture during a dressing change

obtaining a wound culture during a dressing change A LPN/VN's scope of practice includes obtaining wound cultures and changing dressings. Teaching, assessment, and planning of care are complex actions that should be carried out only by the RN.

The nurse recognizes that Premature ventricular contractions (PVCs) are considered precursors of ventricular tachycardia (VT) when they: occur at a rate of more than six per minute occur during the QRS complex have the same shape are paired with a normal beat

occur at a rate of more than six per minute Explanation: When PVCs occur at a rate of more than six per minute, they indicate increasing ventricular irritability and are considered forerunners of VT. PVCs are dangerous when they occur on the T wave. PVCs are dangerous when they are multifocal (have different shapes). A PVC that is paired with a normal beat is termed bigeminy.

A 25-year-old woman is being treated with penicillin G as prophylaxis to prevent bacterial endocarditis prior to a dental procedure. The nurse should question the client concerning her the use of: alcohol. oral contraceptives. fats in her diet. nicotine.

oral contraceptives. The nurse should document the method of birth control used by a woman of childbearing age because antibiotics, such as penicillin G, can counteract the effects of an oral contraceptive. The client should be advised to use a backup method of birth control for the duration of the therapy. Excess fats in the diet, alcohol, and nicotine should be avoided, but pose no special risk when used along with penicillin G.

The focus of a hospital's current quality assurance program is a comparison of the health status of clients on admission and with that at the time of discharge. This form of quality assurance is characteristic of: outcome evaluation. structure evaluation. process evaluation. nursing audit.

outcome evaluation. Outcome evaluation focuses on measurable changes in the health status of the client or the end results of nursing care. Whereas the proper environment for care and the right nursing actions are important aspects of quality care, the critical element in evaluating care is demonstrable changes in client health status. Process evaluation addresses performance expectations during the various stages of the nursing process. Structure evaluation addresses the environment of care. A nursing audit focuses on the review of records.

NORMAL ABG VALUES

pH: 7.35-7.45 PCO2: 35-45mm Hg PO2: 80 to 100 mm Hg HCO3: 22-28 mEq/L

A client who is a performer expends a tremendous amount of energy while on stage, but his body is not harmed by the added stress. Protection against the harmful effects of stress is primarily a result of: anatomic characteristics. physiologic reserve. cultural factors. immune system compensation.

physiologic reserve. The ability of body systems to increase their function in response to the need to adapt is the physiologic reserve. Anatomic reserve is attributed to organ structure; immune system compensation may be a component of physiologic reserve.

The nurse is reviewing laboratory data for a client with pancreatic cancer. Which finding does the nurse prioritize as requiring notification of the healthcare provider? creatinine: 2.0 mg/dl (176.8 µmol/L) sodium: 136 mEq/L (136 mmol/L) glucose, fasting: 204 mg/dl (11.32 mmol/L) potassium: 2.2 mEq/L (2.2 mmol/L)

potassium: 2.2 mEq/L (2.2 mmol/L) The nurse should identify potassium 2.2 mEq/L as critical because a normal potassium level is 3.8 to 5.5 mEq/L. Severe hypokalemia can cause cardiac and respiratory arrest, possibly leading to death. Hypokalemia also depresses the release of insulin and results in glucose intolerance. The glucose level is above normal (normal is 75 to 110 mg/dl). The sodium level is also above normal (135-145 mEq/L). Although these levels should be reported, neither is life-threatening. The creatinine is elevated (normal is 0.8 to 1.4 mg/dl), but this would not be a priority to report at this time.

An adolescent, age 14, is hospitalized for nutritional management and drug therapy after experiencing an acute episode of ulcerative colitis. Which nursing intervention is appropriate? administering digestive enzymes before meals as ordered providing small, frequent meals administering antibiotics with meals as ordered providing high-fiber snacks

providing small, frequent meals Explanation: Clients with ulcerative colitis, an inflammatory bowel disorder (IBD), tolerate small, frequent meals better than a few large meals daily. Eating large amounts of food may exacerbate the abdominal distention, cramps, and nausea IBD typically causes. Frequent meals also provide the additional calories needed to restore nutritional balance. This adolescent doesn't lack digestive enzymes and therefore doesn't need enzyme supplementation. Antibiotics are contraindicated because they may interfere with the actions of other ordered drugs and because ulcerative colitis isn't caused by bacteria. High-fiber foods may irritate the bowel further.

The community health nurse is teaching a health care group levels of prevention. What is the nurse's foci with primary prevention? Select all that apply. self-care promotion prevention of illness continuity of care collaboration with health care providers health screening

self-care promotion prevention of illness continuity of care collaboration with health care providers The primary concepts of community-based nursing care are self-care and preventive care within the context of culture and community. Two other important concepts are continuity of care and collaboration. Although health screening and health risk appraisal are two components of secondary prevention with which the community-based nurse is involved, they are not primary concepts with primary prevention.

The parent of a young client with severe hearing loss is quite concerned about the child's future independence because of impaired hearing. Which type of hearing loss is usually irreversible? sensorineural conductive tinnitus noise exposure

sensorineural

A client has been diagnosed with otosclerosis. The nurse explains to the client that this is a common cause of hearing impairment among adults and is the result of a bony overgrowth of the: stapes labyrinth tympanic membrane incus

stapes Otosclerosis is the result of a bony overgrowth of the stapes and a common cause of hearing impairment among adults.

Successful treatment with bacteriostatic antibiotics depends upon: the ability of the host's immune system to eliminate the inhibited bacteria and an adequate duration of drug therapy. stopping drug therapy when symptoms have subsided. using broad-spectrum antibacterial drugs to treat viral infections. the type of drug-resistant bacterial strains that can reproduce in the presence of antimicrobial drugs.

the ability of the host's immune system to eliminate the inhibited bacteria and an adequate duration of drug therapy. Successful treatment with bacteriostatic antibiotics depends on the ability of the host's immune system to eliminate the inhibited bacteria and an adequate duration of drug therapy. Stopping an antibiotic prematurely can result in rapid resumption of bacterial growth.

A nurse is teaching a nursing student about surgical drains and their purposes. The nursing student understands that the purpose for a T-tube drain is: to provide a sinus tract for drainage. to provide drainage for bile. to decrease dead space by decreasing drainage. to divert drainage to the peritoneal cavity.

to provide drainage for bile. A T-tube is used to drain bile, such as after a cholecystectomy. A Penrose drain provides a sinus tract for drainage. Hemovac and Jackson-Pratt drains both decrease dead space by decreasing drainage. A ventriculoperitoneal shunt diverts drainage to the peritoneal cavity.

An immunocompromised patient in a critical care setting has developed a respiratory infection that has been attributed to methicillin-resistant Staphylococcus aureus (MRSA). The nurse should anticipate that the patient will require treatment with ciprofloxacin. clindamycin. vancomycin. an antistaphylococcic penicillin.

vancomycin. Vancomycin is the drug of choice to manage infections caused by MRSA. MRSA is resistant to all of the antistaphylococcic penicillins, as well as to ciprofloxacin and clindamycin.

A nurse is conducting procedures to determine the extent of a client's left-sided heart failure. What adventitious lung sounds would the nurse expect to hear during auscultation of the lungs to support the diagnosis? Select all that apply. wheezes wet lung sounds stridor labor

wheezes wet lung sounds Explanation: With left-sided heart failure, auscultation reveals a crackling sound and possibly wheezes and gurgles. Wet lung sounds are accompanied by dyspnea and an effort to sit up to breathe.

A pregnant patient asks the nurse if it is all right for her take the varicella immunization for entrance into nursing school. What is the best response by the nurse? "If you will be working in the health care field, you must take the immunization." "It is not recommended that pregnant women take the live virus. You should wait until after your child is born." "It is not a live virus, so it should be fine." "You will have to delay entrance into the nursing program if they force you to take it."

"It is not recommended that pregnant women take the live virus. You should wait until after your child is born." Some live vaccines (e.g., varicella, MMR [against measles, mumps, and rubella], yellow fever) are contraindicated for people who are severely immunosuppressed or pregnant.

A 71-year-old male has been recently diagnosed with a stage III tumor of colorectal cancer, and is attempting to increase his knowledge base of his diagnosis. Which statement about colorectal cancer demonstrates a sound understanding of the disease? "If accurate screening test for this type of cancer existed, it could likely have been caught earlier." "The NSAIDs and aspirin that I've been taking for many years probably contributed to my getting cancer." "While diet is thought to play a role in the development of colorectal cancer, the ultimate causes are largely unknown." "A large majority of clients who have my type of colon cancer survive to live many more years."

"While diet is thought to play a role in the development of colorectal cancer, the ultimate causes are largely unknown." The etiology of cancer of the colon and rectum remains largely unidentified, though dietary factors are thought to exist. The prognosis, especially with stage III tumors, is poor. Simple and accurate screening tests do exist for colorectal cancer, while drugs are not implicated in the etiology.

Which clinical finding among older adults is most likely to be viewed as a normal part of age-related changes? 81-year-old client whose serum creatinine level has increased sharply since the last blood work 78-year-old client whose glomerular filtration rate (GFR) has been steadily declining over several years 90-year-old client whose blood urea nitrogen (BUN) is rising 80-year-old client whose dipstick urine reveals protein is present

78-year-old client whose glomerular filtration rate (GFR) has been steadily declining over several years A gradual decrease in GFR is considered a normal age-related change. Sudden increase in creatinine or BUN would warrant follow up, as would the presence of protein in a client's urine.

A nurse is preparing to assess a family which recently went through a divorce. The family now consists of a 40-year-old female, her 16-year-old son and 5-year-old daughter. The mother will continue as the primary wage earner with her current employment and has full custody of the children. Which action should the nurse prioritize with this family? Assess the son for emotional trauma. Assess the daughter for emotional trauma. Educate the mother on community supports. Educate the mother on the risks of intimate partner violence.

Assess the son for emotional trauma. The first priority should be to assess each individual and determine if there are any concerns which need to be addressed. Boys generally have more emotional trauma from divorce than girls, probably because they lose their gender role model as the mother is most apt to become the parent with custody. Thus, the son is more likely to need assessment and treatment for emotional trauma. The nurse can then act as an advocate and find community resources which may be appropriate for this family (e.g., Big Brother/Big Sister would be appropriate for the children). There is no evidence in the scenario of intemate partner violence.

A nurse volunteers to serve on the hospital ethics committee. Which action should the nurse expect to take as a member of the ethics committee? Assist in decision making based on the client's best interests. Decide the care for a client who is unable to voice an opinion. Convince the family to choose a specific course of action. Present options about the type of care.

Assist in decision making based on the client's best interests. One reason an ethics committee convenes is when a client is unable to make an end-of-life decision and the family cannot come to a consensus. In this case, the committee members are there to advocate for the best interest of the client and to promote shared decision making between the client (or surrogates, if the client is decisionally incapacitated) and the clinicians. The committee would not convince, decide, or present options about the type of care. This is not the role of an ethics committee.

A nurse working night shift understands the importance of enhancing the sleep patterns of his clients. In order to do so, he should: only wake them for the 12:00 AM and 4:00 AM vital signs. allow the client time to sit at the desk to enhance better rest. evaluate the sleep response of the client with polysomnogram. cluster activities to allow 90 to 120 minutes of sleep.

Cluster Activities When possible, the nurse should cluster activities at night to provide periods of 90 to 120 minutes of uninterrupted sleep.

A 15-year-old client has been brought to the clinic by their mother and is suspected of having an immune system disorder. What tests would you expect to be ordered for this young client? Plasmapheresis Sedimentary rate Complete blood count with differential Complete chemistry panel

Complete blood count with differential Laboratory tests are used to identify immune system disorders. They usually include a complete blood count with differential. Protein electrophoresis screens for diseases associated with a deficiency or excess of immunoglobulins. T-cell and B-cell assays (or counts) and the enzyme-linked immunosorbent assay may be performed. Options A, B, and D are not diagnostic of immune disorders.

A family has lost a member who was treated for leukemia at a nursing unit. The nurse provides emotional support to the family and counsels them to cope with their loss. Which quality should the nurse use in this situation? Indifference Pity Sympathy Empathy

Empathy The nurse should empathize with the family for their loss. Empathy helps the nurse to provide effective care and support without being emotionally distraught by the family's condition. If the nurse becomes indifferent to the family's condition, the nurse may not be able to assess their needs. The nurse should not pity, or provide sympathy to, the family for their loss, as it would involve the nurse emotionally.

The nurse identifies a nursing diagnosis of Imbalanced nutrition: less than body requirements for a terminally ill client who is near the end of life. Which of the following would the nurse expect to include in the client's plan of care? Suggestions that the family offer the client foods that are hot. Encouragement of the family to serve the client meat, especially beef. Advice for the family to have fruit juices readily available at the client's bedside. Arrangements for the client to eat meals while others are out of the home.

Encourage family to provide fruit juices To promote nutrition in the terminally ill, the nurse would encourage the family to have fruit juices and milkshakes readily available at the bedside so that the client can access them frequently. Cool foods may be better tolerated than hot foods. Cheese, eggs, peanut butter, mild fish, chicken, and turkey are often better choices than meat such as beef that may taste bitter and unpleasant. Meals should be scheduled when family members are present to provide company and stimulation.

What education should the nurse give to a male client older than age 50 to help ensure early identification of prostate cancer? Have a digital rectal examination and prostate-specific antigen (PSA) test done yearly. Have a transrectal ultrasound every 5 years. Perform monthly testicular self-examinations, especially after age 50. Have a complete blood count (CBC) and blood urea nitrogen (BUN) and creatinine levels checked yearly.

Have a digital rectal examination and prostate-specific antigen (PSA) test done yearly. The incidence of prostate cancer increases after age 50. The digital rectal examination, which identifies enlargement or irregularity of the prostate, and PSA test, a tumor marker for prostate cancer, are effective diagnostic measures that should be done yearly. Testicular self-examinations won't identify changes in the prostate gland because of its location in the body. A transrectal ultrasound, CBC, and BUN and creatinine levels are usually done after diagnosis to identify the extent of the disease and potential metastasis.

A 78-year-old male client begins an immunosuppressant therapy for his rheumatoid arthritis. The nurse is concerned because this client is at greater risk for what complication, compared with younger adults using the same treatment modality? Falls Infections Mental status changes Self-care deficit

Infections Immunosuppressants are used for the same purposes and produce similar therapeutic and adverse effects in older adults as in younger adults. Because older adults often have multiple disorders and organ impairments, it is especially important that drug choices, dosages, and monitoring tests be individualized. In addition, infections occur more commonly in older adults, and this tendency is increased with immunosuppressant therapy.

A nurse is instructing a class for people with newly diagnosed asthma to encourage healthy lifestyle choices. The nurse explains that stimulation of certain lung receptors with things such as smoke, cigarette smoke, inhaled dust, or cold air can lead to constriction of the conducting airways resulting in rapid, shallow breathing. How does the nurse identify these receptors? J receptors Noxious receptors Stretch receptors Irritant receptors

Irritant receptors It is believed that the irritant receptors protect the lower airways and respiratory tissues from damage. The receptors cause airway constriction and rapid, shallow breathing. It would be beneficial for people living with asthma to avoid these triggers.

To avoid the side effects of corticosteroids, which medication classification is used as an alternative to treat inflammatory conditions of the eyes? Miotics NSAIDs Mydriatics Cycloplegics

NSAIDs NSAIDs are used as an alternative in controlling inflammatory eye conditions and postoperatively to reduce inflammation. Miotics are used to cause the pupil to constrict. Mydriatics cause the pupil to dilate. Cycloplegics cause paralysis of the iris sphincter.

When a nurse is assessing a client with osteoarthritis, which factor poses a risk for the disease? Sedentary life style Obesity Smoking Hypertension

Obesity Obesity is a particular risk factor for OA of the knee in women and a contributory biomechanical factor in the pathogenesis of the disease; OA is a problem occurring in weight-bearing joints.

The nursing instructor is teaching a session on the increase of health care costs associated with the advancement of modern technology. The instructor determines the session is successful when the students correctly choose which focus of community-based health care that has been implemented to combat the increased cost? Providing care for the client as an individual Tracking reportable diseases Keeping clients with chronic illnesses in their homes Preventing disease and its sequelae

Preventing disease and its sequelae Community-based nursing focuses on prevention and is directed toward persons and families within a community. Community-based nursing is holistic in nature and provides care for the client as part of a family and community, not just as an individual. It strives to keep clients with chronic illnesses in their homes, but that is not the focus of the care provided. A function of community-based nursing is reporting and tracking reportable diseases; again, that is not the focus of community-based nursing.

Which sets professional standards of care? States Provinces Professional nursing organizations Hospitals

Professional nursing organizations States and provinces grant the legal authority to practice nursing, but professional nursing organizations set standards of care and professional nursing activities.

The nurse is assessing a client who was involved in a neighborhood shooting. The client's vital signs show that his body is attempting to adapt to the stressor. What stage of the general adaptation syndrome is this client experiencing? Alarm reaction Resistance Exhaustion Homeostasis

Resistance The general adaptation syndrome (GAS) describes the body's general response to stress, a concept essential in all areas of nursing care. Having perceived a threat and mobilized its resources, the body attempts to adapt to the stressor during the resistance stage; vital signs, hormone levels, and energy production return to normal during this stage. The alarm reaction is initiated when a person perceives a specific stressor and various defense mechanisms are activated. Exhaustion results when the adaptive mechanisms can no longer provide defense. Homeostasis is when the body's internal environment is in a balanced state.

A client with neurological infection develops cerebral edema from syndrome of inappropriate antidiuretic hormone (SIADH). Which is an important nursing action for this client? Maintaining adequate hydration Administering prescribed antipyretics Restricting fluid intake and hydration Hyperoxygenation before and after tracheal suctioning

Restricting fluid intake and hydration Fluid restriction may be necessary if the client develops cerebral edema and hypervolemia from SIADH. Antipyretics are administered to clients who develop hyperthermia. In addition, it is important to maintain adequate hydration in such clients. A client with neurological infection should be given tracheal suctioning and hyperoxygenation only when respiratory distress develops.

A young child is in the emergency department with swelling and pain in the right ankle. The client states that while playing soccer, the client somehow twisted the ankle, and could not walk off the field. The health care provider tells the client that it is a sprain. Which type of pain is this client experiencing? Chronic Cutaneous Somatic Visceral

Somatic Pain is classified in two categories. Acute pain has a rapid onset, usually as a result of tissue injury and it resolves with the injury healing. The other type of pain is chronic. This type does not end when the injury heals and affects a client's activities of daily living. One type of acute pain is somatic pain. Somatic pain originates from deep body structures, such as muscles or blood vessels. The pain of a sprained ankle is somatic pain. Visceral pain is pain occurring in the organs. Cutaneous pain affects the skin.

Which level of prevention focuses on minimizing deterioration and improving quality of life? Primary Secondary Tertiary Outpatient

Tertiary Tertiary prevention focuses on minimizing deterioration and improving quality of life, including rehabilitation to assist patients in achieving their maximum potential by working through their physical or psychological challenges. Primary prevention focuses on health promotion and prevention of illness or disease. Secondary prevention centers on health maintenance and is aimed at early detection and prompt intervention to prevent or minimize loss of function and independence. Outpatient is not a level of prevention.

A client who is enrolled in Medicare and who has been recovering in the hospital from a stroke has developed a pressure injury on the coccyx, an event that the Centers for Medicare & Medicaid Services (CMS) has identified as a "never event." The nurse should recognize what implication of this CMS designation? The hospital must bear any costs incurred for treating the client's injury. The hospital will be fined by CMS because the client developed a pressure injury. CMS will bear the hospital's costs if the client chooses to sue the hospital. CMS may choose to divert clients to other health care facilities in the future.

The hospital must bear any costs incurred for treating the client's injury. If "never events" occur while a client is hospitalized, the cost of the care associated with that event will not be paid by CMS, but will be borne by the hospital. Fines are not levied against the hospital, however, and CMS does not actively divert clients to other facilities. CMS does not pay damages on behalf of hospitals.

A nurse is teaching parents of preschoolers about growth and development of their children. Which teaching point would the nurse include? The pace of growth and development is specific for each person. Growth and development occur at similar stages and rates for each age group. Aspects of growth and development cannot be modified. Growth and development do not follow regular predictable trends.

The pace of growth and development is specific for each person. The pace of growth and development is specific and individualized for each person. Growth and development follow regular predictable trends, as noted by various developmental theorists. Growth and development do not occur at similar stages and rates for each age group. Aspects of growth and development can be modified.

A nurse is teaching a female client about preventing osteoporosis. Which teaching point is correct? Obtaining an X-ray of the bones every 3 years is recommended to detect bone loss. To prevent fractures, the client should avoid strenuous exercise. The recommended daily allowance of calcium may be found in a wide variety of foods. Obtaining the recommended daily allowance of calcium requires taking a calcium supplement.

The recommended daily allowance of calcium may be found in a wide variety of foods. Premenopausal women require 1,000 mg of calcium per day. Postmenopausal women require 1,500 mg per day. Clients usually can get the recommended daily requirement of calcium by eating a varied diet. Osteoporosis doesn't show up on ordinary X-rays until 30% of bone has been lost. Bone densitometry, however, can detect bone loss of 3% or less. This test is sometimes recommended routinely for women older than 35 who are at risk for osteoporosis. Strenuous exercise won't cause fractures. Although supplements are available, they aren't always necessary.

A client admitted with a gunshot wound to the abdomen is transferred to the intensive care unit after an exploratory laparotomy. IV fluid is being infused at 150 mL/hour. Which assessment finding suggests that the client is experiencing acute renal failure (ARF)? Blood urea nitrogen (BUN) level of 22 mg/dl Serum creatinine level of 1.2 mg/dl Temperature of 100.2° F (37.8° C) Urine output of 250 ml/24 hours

Urine output of 250 ml/24 hours ARF, characterized by abrupt loss of kidney function, commonly causes oliguria, which is characterized by a urine output of 250 ml/24 hours. A serum creatinine level of 1.2 mg/dl isn't diagnostic of ARF. A BUN level of 22 mg/dl or a temperature of 100.2° F (37.8° C) wouldn't result from this disorder.

When an ethical decision is made based on the reasoning of the "greatest good for the greatest number," what theory is the nurse following? Deontological theory Formalist theory Moral-justification theory Utilitarian theory

Utilitarian theory One classic theory in ethics is teleologic theory or consequentialism, which focuses on the ends or consequences of actions. The best-known form of this theory, utilitarianism, is based on the concept of "the greatest good for the greatest number." Another theory in ethics is the deontologic or formalist theory, which argues that ethical standards or principles exist independently of the ends or consequences.

A mother rooming-in with her 10-month-old infant appears upset following the visit of a consultant physician. The mother has questions but states, "The doctor is always so busy." The nurse will: assist the mother in preparing a list of questions for the physician's next visit. explain to the mother the limits on the consultant's time. encourage the mother to remain at the infant's bedside so as not to miss any future consultant visits. ask the mother for her questions so that the nurse can relay them to the medical team.

assist the mother in preparing a list of questions for the physician's next visit. Empowering parents so that they can be active partners in their child's care is part of family-centered care. Helping the mother state and write her questions will provide information to which the nurse can respond plus help the mother interact more effectively with the consultant and other health team members. Relaying the mother's questions may be helpful on limited occasions but places the nurse between the parent and provider relaying information in a "third party" manner. Keeping the mother at the bedside watching and waiting causes unnecessary watchfulness and stress. Supporting the "busyness" of the consultant burdens the mother further.

The nurse is teaching a client about the importance of adhering to a medication regimen. The client does not believe that it is important. The nurse is communicating which ethical principle? beneficence justice veracity paternalism

beneficence According to the principle of beneficence, the health care provider uses knowledge of science and incorporates the art of caring to develop an environment in which individuals achieve their maximum health care potential. Justice is the duty to treat all fairly, distributing the risk and benefits equally. Veracity is the duty to tell the truth. Paternalism is the belief that knowledge and education authorize professionals to make decisions for the good of the client.

Which assessment should be conducted by the nurse before the nurse administers tuberculin intradermal injection? checking for documented allergies to food or drugs preparing the syringe with the medication cleaning the area with an alcohol swab gathering all the equipment needed

checking for documented allergies to food or drugs Checking for documented allergies to food or drugs is done to ensure safety and is therefore correct. Preparing the syringe with the medication is incorrect because this is considered planning, not assessment. Cleaning the area with an alcohol swab is implementing, not assessing. Gathering all the equipment needed is also considered planning.

To encourage adequate nutritional intake for a client with Alzheimer's disease, a nurse should stay with the client and encourage them to eat. help the client fill out their menu. give the client privacy during meals. fill out the menu for the client.

stay with the client and encourage them to eat. Staying with the client and encouraging them to feed themself will ensure adequate food intake. A client with Alzheimer's disease can forget how to eat. Allowing privacy during meals, filling out the menu, or helping the client to complete the menu doesn't ensure adequate nutritional intake.

A nurse working in a community clinic is discussing lifestyle modifications with a client. The client has been advised to lose weight because of a BMI greater than 25. Which statement by the nurse would be most therapeutic in helping the client? "Losing weight is a challenge that I can help you with." "It will be important for you to stop having between-meal snacks." "I can offer you some information outlining a variety of ways to lose weight." "There are herbal preparations for weight loss that are very effective."

"I can offer you some information outlining a variety of ways to lose weight." The therapeutic response would put the client in a position to make an individual choice. The nurse would offer options to allow for choice. Telling the client that losing weight is a challenge the nurse can help with puts the focus on the nurse and does not offer options. Many weight loss plans include meals plus snacks as well as limiting options. Offering herbal preparation also limits the options given to the client.

While a client admitted to the medical-surgical unit is in the radiology department, a visitor claiming to be the client's cousin arrives on the medical-surgical unit and asks the nurse to provide a brief outline of the client's illness. Which response by the nurse would be most appropriate, both legally and professionally? "I will call the client and ask for permission to share this infomation with you." "I cannot give you that information due to client confidentiality." "Do you have any identification proving that you are related to the client?" "I'm busy right now but can talk later."

"I cannot give you that information due to client confidentiality." Sharing a client's information without the client's consent is an invasion of privacy. The nurse should not give out the information even if the visitor provides proof of a relationship without the client's consent. It is inappropriate to call the client to ask for permission. The nurse claiming to be busy and offering to talk later does not address the issue but only delays it, perhaps leading the visitor to assume that the nurse will disclose information then.

A client asks the nurse what the difference is between osteoarthritis (OA) and rheumatoid arthritis (RA). Which response is correct? "OA is a noninflammatory joint disease. RA is characterized by inflamed, swollen joints." "OA and RA are very similar. OA affects the smaller joints and RA affects the larger, weight-bearing joints." "OA affects joints on both sides of the body. RA is usually unilateral." "OA is more common in women. RA is more common in men."

"OA is a noninflammatory joint disease. RA is characterized by inflamed, swollen joints." OA is a degenerative arthritis, characterized by the loss of cartilage on the articular surfaces of weight-bearing joints with spur development. RA is characterized by inflammation of synovial membranes and surrounding structures. OA may occur in one hip or knee and not the other, whereas RA commonly affects the same joints bilaterally. RA is more common in women; OA affects both sexes equally.

A nurse is interviewing a parent regarding the 2-year-old child's recent illness. The nurse would like the parent to elaborate about any symptoms of the illness noticed. Which would be the mosteffective question for the nurse to ask the parent in this situation? "What symptoms has your child exhibited?" "Has your child exhibited any symptoms?" "Has your child exhibited a fever and vomiting?" "Your child hasn't exhibited a fever, has she?"

"What symptoms has your child exhibited?" An open-ended question, such as, "What symptoms has your child exhibited?" allows a parent to elaborate, which is what the nurse desires in this case. A closed-ended question, such as, "Has your child exhibited any symptoms?" does not allow the parent to elaborate, and thus would be inappropriate in this case. Compound questions, such as, "Has your child exhibited a fever and vomiting?" should be avoided because the information they elicit is often inaccurate and must be clarified. Likewise, leading questions, such as, "Your child hasn't exhibited a fever, has she?" should be avoided.

The nurse is teaching a prenatal class illustrating the steps that are used to keep families safe. The nurse determines the session is successful when the parents correctly choose which precaution to follow after the birth of their infant? Send a family member to accompany the infant when leaving the room. Check the name on the baby's identification bracelet. Provide a list of approved visitors who came spend time with the infant. Check the identification badge of any health care worker before releasing baby from room.

Check the identification badge of any health care worker before releasing baby from room. Infant abduction is a concern, and all personnel should wear identification badges and introduce themselves to the parents before they enter the room or take the infant. If at any time the mother is suspicious, she has the right to not allow an individual to take the infant. There may not always be a family member around to accompany the infant and they may not be allowed admittance to treatment rooms or other such areas. Checking the name on the baby's identification bracelet will not stop abduction. Providing a list of approved visitors may help prevent abduction from individuals outside the medical facility but will not stop someone posing as an employee from abducting the infant.

Based on the Patient Protection and Affordable Care Act (ACA), nurses are to assume an important new role in health care. Which is an example of this new role? Identifying individuals who are at risk of developing diabetes mellitus Collaborating with all agencies to provide for the client's home health needs Verifying that all documentation is updated prior to surgery Providing client education related to colostomy care

Collaborating with all agencies to provide for the client's home health needs As the various components of the ACA are phased in, nurses have begun to play an influential role in the implementation of new health policy. The newest opportunity is collaborating with all agencies to provide for the client's home health needs. Nurses have already been involved in screening individuals for type 2 diabetes mellitus and providing postoperative teaching for ostomy care. Nurses recheck paperwork for consent prior to surgery, but this is not just limited to nurses. Other health care providers also review consent prior to surgery.

What is the best nursing intervention to promote health in a client at risk for heart disease? Emphasizing a client's strengths to encourage weight loss Informing the client that the client must lose weight Instructing the client to adhere to a high-sodium diet Taking the client's pulse rate daily

Emphasizing a client's strengths to encourage weight loss Nurses promote health by identifying, analyzing, and maximizing each client's own individual strengths as components of preventing illness, restoring health, and facilitating coping with disability or death. Emphasizing the client's strengths to encourage weight loss is the most effective way to promote this client's health. Informing the client that the client must lose weight would not help the client use his or her strengths to accomplish the goal. Low-sodium diets can prevent heart disease. Taking the pulse daily would not prevent heart disease.

A nurse is working in a support group for clients with acquired immunodeficiency syndrome (AIDS). Which point is most important for the nurse to stress? Avoiding the use of recreational drugs and alcohol Refraining from telling anyone about the diagnosis Following safer-sex practices Telling potential sex partners about the diagnosis, as required by law

Following safer-sex practices It's essential for clients with AIDS to follow safer-sex practices to prevent transmission of the human immunodeficiency virus. Although it's helpful if clients with AIDS avoid using recreational drugs and alcohol, it's more important that I.V. drug users use clean needles and dispose of used needles for purposes of avoiding transmission. Whether the client with AIDS chooses to tell anyone about the diagnosis is his decision; there is no legal obligation to do so.

During a follow-up visit 3 months after a new diagnosis of type 2 diabetes, a client reports exercising and following a reduced-calorie diet. Assessment reveals that the client has only lost 1 pound and did not bring the glucose-monitoring record. Which value should the nurse measure? Fasting blood glucose level Glucose via a urine dipstick test Glycosylated hemoglobin level Glucose via an oral glucose tolerance test

Glycosylated hemoglobin level Glycosylated hemoglobin is a blood test that reflects the average blood glucose concentration over a period of approximately 2 to 3 months. When blood glucose is elevated, glucose molecules attach to hemoglobin in red blood cells. The longer the amount of glucose in the blood remains above normal, the more glucose binds to hemoglobin and the higher the glycosylated hemoglobin level becomes.

The nurse that ascribes to the gate control theory of pain would be most likely to prescribe which of the following for the relief of pain? (Select all that apply.) Heat Massage Cold Percocet Acetaminophen

Heat Massage Cold The gate theory supports that the signals at the gate in the spinal cord determine which impulses eventually reach the brain. A limited amount of sensory information can be processed by the nervous system at any given moment. When there is too much information sent through, certain cells in the spinal column interrupt the signal as if closing a gate. The theory appears to explain why mechanical and electrical interventions such as heat, cold, pressure, and massage provide effective pain relief. Percocet and acetaminophen are medications that can be used for pain.

When approaching health care holistically, which of the following would the nurse do?

Holistic care involves the promotion of the total health of mind, body, and spirit. This approach integrates the client's physical, emotional, and social elements of health. Complementary and alternative practices are included with holistic health but are not the primary focus. Active participation and capitalizing on the client's personal strengths are part of holistic health. Holistic health includes a balance and integration of traditional medicine and advanced technology in conjunction wtih the influence of the mind and spirit on healing.

A client recovering from gastric bypass surgery accidentally removes the nasogastric tube. What is the best action by the nurse?

If the nasogastric tube is removed accidently in a client who has undergone esophageal or gastric surgery, it is usually replaced by the health care provider. Care is taken to avoid trauma to the suture line. The nurse will not insert the tube to the esophagus or to the stomach in this situation. The nurse needs to do more than just document its removal. The nurse needs to notify the health care provider who will make a determination of leaving out or inserting a new nasogastric tube.

What is the rationale for not administering tetracycline to children under the age of 8 years? It will not treat the infection effectively. It will increase the risk of heart failure. It will interfere with enamel development. It will increase the risk for future infections.

It will interfere with enamel development. Tetracyclines should not be used in children younger than 8 years because of their effects on teeth and bones. In teeth, the drugs interfere with enamel development. Without existing contraindications, tetracycline can be used in children to treat infections without increasing the risk of heart failure. The administration of tetracycline will not increase the risk of future infections in children.

A client with chronic obstructive pulmonary disease presents with respiratory acidosis and hypoxemia. The client tells the nurse that they don't want to be placed on a ventilator. What action should the nurse take? Notify the physician immediately to have the physician determine client competency. Have the client sign a do-not-resuscitate (DNR) form. Determine whether the client's family was consulted about this decision. Consult the palliative care group to direct care for the client.

Notify the physician immediately to have the physician determine client competency. Three requirements are necessary for informed decision-making: the decision must be given voluntarily; the client making the decision must have the capacity and competence to understand; and the client must be given adequate information to make the decision. In light of the client's respiratory acidosis and hypoxemia, the client might not be competent to make this decision. The physician should be notified immediately so the physician can determine client competency. The physician, not the nurse, is responsible for discussing the implications of a DNR order with the client. The Patient's Bill of Rights entitles the client to make decisions about the care plan, including the right to refuse recommended treatment. The client's family may oppose the client's decision. Consulting the palliative care group isn't appropriate at this time and must be initiated by a physician order.

Students are reviewing information about community health nursing. The students demonstrate understanding of the term "community-oriented nursing practice" by describing it as which of the following? Nursing interventions that can promote wellness, reduce illness spread, and improve the health status of groups Nursing care directed to specific client groups with identified needs, usually related to illness Provision of primary care services, often with care being provided to underserved populations Nursing care of clients with complex needs who are discharged from acute care institutions early in the recovery process

Nursing interventions that can promote wellness, reduce illness spread, and improve the health status of groups Community-oriented nursing practice focuses on nursing interventions that can promote wellness, reduce the spread of illness, and improve the health status of groups of citizens or the community at large. Community-based nursing and home health care is directed toward specific client groups with identified needs, which usually relate to illness, injury, or disability, resutling most often from advanced age or chronic illness. Community nursing centers are nurse managed and provide primary care, often to underserved populations. Home care nursing is a specialty area that provides care in the home and community to meet the needs of clients who are discharged from acute care institutions to their homes and communities early in the recovery process and with complex needs.

The nurse is caring for a client with a suspected diagnosis of HIV. The nurse is preparing to draw blood for a confirmatory diagnostic test on this client. What is the most important action that the nurse should perform before testing a client for HIV? Advise the client to avoid excess fluid intake. Advise the client to abstain from having intercourse. Advise the client to take off any ornaments and metallic objects. Obtain a written consent from the client.

Obtain a written consent from the client. It is important that the nurse obtain written consent from the client before performing an HIV test and keep the results of HIV test confidential. The nurse may not ask the client to avoid excess fluid intake or abstain from intercourse before the tests. The client also need not take off ornaments and metallic objects worn unless they are likely to interfere with the test results.

A client has glaucoma. The nurse is taking a health history and knows that the most common form of glaucoma is which type? Open angle Angle closure Congential Infantile

Open angle Open-angle glaucoma is the most common form of glaucoma, and is usually asymptomatic and chronic, causing progressive damage to the optic nerve and visual field loss unless it is appropriately treated. Angle-closure glaucoma usually occurs as the result of an inherited anatomic defect that causes a shallow anterior chamber. There are several types of childhood glaucoma, including congenital glaucoma that is present at birth and infantile glaucoma that develops during the first 2 to 3 years of life.

A nurse is working at a community clinic that serves mostly families with young children. What would be a priority intervention for clients in this developmental stage? Setting up parenting classes Providing alcohol and drug information Screening for congenital defects Providing sex education

Setting up parenting classes The question asks about a community clinic that serves mostly families with young children and the priority intervention for clients in this developmental stage. Setting up parenting classes is the only answer that addresses the stated developmental stage. Families with adolescents and young adults would be at the appropriate developmental stage for providing sex education and alcohol/drug information. The community clinic would not focus on screening for congenital defects. Reference:

A nurse, while off-duty, tells the physiotherapist that a client who was admitted to the nursing unit contracted AIDS due to exposure to sex workers at the age of 18. The client discovers that the nurse has revealed the information to the physiotherapist. With what legal action could the nurse be charged? Libel Slander Negligence Malpractice

Slander The nurse can be charged with slander, which is a verbal attack on a person's character. Libel pertains to damaging written statements read by others. Both libel and slander are considered defamation of character—an intentional tort in which one party makes derogatory remarks about another that diminish the other party's reputation. Negligence and malpractice pertain to actions which are committed or omitted, thereby causing physical harm to a client.

A client is diagnosed with human immunodeficiency virus (HIV). What information does the nurse provide to best protect the client from advancing to the acquired autoimmodeficiency syndrome (AIDS) phase of this infection? Engage in safer-sex practices at all times. Strictly adhere to antiviral medication therapy. Practice meticulous infection control. Maintain a generally healthy lifestyle.

Strictly adhere to antiviral medication therapy. Antiretroviral therapy (ART) can control HIV and prevent the progression to AIDS. Missing doses of this therapy greatly increases the risk for increased viral activity. Making healthy lifestyle choices is good general advice but does not control viral activity as ART will. The client is not at high risk for contracting opportunistic infections simply by being HIV positive; the degree of risk depends on current cell counts. Once in the AIDS stage of infection, the client is at high risk for infection and needs to take protective measures. Safe sexual practices protect others from the virus.

A nurse is taking the health history of a newly admitted client. Which of the following conditions would NOT place the client at risk for impaired immune function? Previous organ transplantation Surgical removal of the appendix History of radiation therapy Surgical history of a splenectomy

Surgical removal of the appendix Removal of the appendix would have no direct effect on the immune system. Organ transplantaion requires immunosupressive drugs, which cause impaired immune function. Radiation therapy destroys lymphocytes. The spleen is an important part of the immune system, and removal of it increases the client's risk for poor immune function.

In which situation is the nurse providing tertiary prevention? Teaching rehabilitation exercises to a client after a mastectomy Educating teens on the importance of sunscreen to reduce the risk of skin cancer Providing breast cancer screening information to a high-risk population Evaluating client understanding of discharge instructions

Teaching rehabilitation exercises to a client after a mastectomy Tertiary prevention focuses on minimizing deterioration and improving quality of life, including rehabilitation to assist patients in achieving their maximum potential by working through their physical or psychological challenges. The focus on primary prevention is on health promotion and prevention of illness or disease. Secondary prevention centers on health maintenance and is aimed at early detection and prompt intervention to prevent or minimize loss of function and independence. Evaluating patient understanding of discharge instructions is important, but it does not focus on health promotion and prevention of illness or disease.

The nurse is caring for a patient who is to be discharged from the acute care facility to a rehabilitation unit after having a stroke. What type of prevention is this considered to be? Primary Secondary Tertiary Rehabilitation

Tertiary Nurses in community-based practice provide preventive care at three levels: primary, secondary, and tertiary. Primary prevention focuses on health promotion and prevention of illness or disease, including interventions such as teaching about healthy lifestyles. Secondary prevention centers on health maintenance and is aimed at early detection, with prompt intervention to prevent or minimize loss of function and independence, including interventions such as health screening (Fig. 2-1) and health risk appraisal. Tertiary prevention focuses on minimizing deterioration and improving quality of life, including rehabilitation to assist patients in achieving their maximum potential by working through their physical or psychological challenges. Home care nurses often focus on tertiary preventive nursing care, although they also address primary and secondary prevention.

The client has become confused and attempts to climb out of bed. What interventions will the nurse provide prior to applying restraints? Call the health care provider to prescribe sedation for the patient. Arrange a schedule for staff to sit with the client. Place the client in a chair at the nurses' station with a sheet tied around the client's waist. Place all four side rails of the bed in the upright position.

Arrange a schedule for staff to sit with the client. The nurse should arrange a schedule for the staff to sit with the client. Calling for sedation is not the first step with caring for a client with confusion. The chair with a sheet and the side rails are restraints. The use of restraints (including physical and pharmacologic measures) is another issue with ethical overtones because of the limits on a person's autonomy when restraints are used. It is important to weigh carefully the risks of limiting autonomy and increasing the risks of injury by using restraints against the risks of injury if not using restraints, which have been documented as resulting in physical harm and death. The ANA advocates that restraints only be used when no other viable option is available.The Joint Commission and the Centers for Medicare and Medicaid Services (CMS) have designated standards for the use of restraints.

A nurse is caring for a client who was raped at gunpoint. The client does not want any photos taken of the injuries. The client also does not want the police to be informed about the incident even though state laws require reporting life-threatening injuries. Which intervention should the nurse perform to document and report the findings of the case? Use direct quotes and specific language. Obtain photos to substantiate the client's case in a court of law. Document only descriptions of medical interventions taken. Respect the client's opinion and avoid informing the police.

Use direct quotes and specific language. The nurse should use direct quotes and specific language as much as possible when documenting. The nurse should not obtain photos of the client without informed consent. The nurse should, however, document the refusal of the client to be photographed. Documentation must include details as to the frequency and severity of abuse and the location, extent, and outcome of injuries, not just a description of the interventions taken. The nurse is required by law to inform the police of any injuries that involve knives, firearms, or other deadly weapons or that present life-threatening injuries.

Which tools do case managers commonly rely on to plan and coordinate client care? clinical pathways, practice guidelines, and standards of care clinical pathways and drug formularies standards of care, HIPAA regulations, and electronic medical records practice guidelines, outcome data, and staff rosters

clinical pathways, practice guidelines, and standards of care Case managers make use of tools such as clinical pathways, practice guidelines, and standards of care to help them plan and coordinate care. Hospitals and insurance companies may develop their own or rely on published protocols for guidance. Drug formularies are not tools used by case managers in planning and coordinating care. HIPAA regulations and EMRs are not tools used by case managers in planning and coordinating care. Outcome data and staff rosters are not tools used by case managers in planning and coordinating care.

During a prenatal visit, a pregnant client with cardiac disease and slight functional limitations reports increased fatigue. To help combat this problem, the nurse should advise the client to: eat three well-balanced meals per day. exercise 1 hour before each meal. take a vitamin and mineral supplement. divide daily food intake into five or six meals.

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

Immediately following administering a medication by enteral tube, the nurse will: flush the tube with water. position the child on his left side. elevate the head of the bed. check for signs of nausea or vomiting.

flush the tube with water. It is important to flush the tube to ensure all of the medication reaches the child's digestive tract and to prevent occlusion of the tube. Right (not left) side-lying position will aid in stomach emptying, although it was not specified that the enteral tube was located in the stomach. Elevating the head of the bed is done prior to placing material in the gastrointestinal tract. Checking for signs of nausea and vomiting is always important but not the immediately following nursing action in this situation.

A client is experiencing a stress response each time the family visits the room. What nursing intervention is most appropriate? tell the family they are causing too much stress limit the family visits to once daily explain that family visits and support are important do not intervene and allow the client to work out the family issue

limit the family visits to once daily When a person is experiencing a stressor, it is important for the nurse to reduce or eliminate the stress. In this case, it is appropriate to limit the family visiting time to allow the client to recover without experiencing a stress response. Telling the family they are causing the stress is not therapeutic. Telling the client that the family should be there invalidates the client's feelings. Doing nothing is not an appropriate response to decrease or remove the stressor.

A nurse witnesses a traffic accident and dresses the open wounds sustained by a child. Later, in the hospital, the child develops complications from an infection in the wound. The family holds the nurse responsible for the complications and attempts to file a lawsuit. Which statement is true regarding how the Good Samaritan law applies to this case? The Good Samaritan law will provide legal immunity to the nurse. The Good Samaritan law will not protect the nurse because the nurse did not accept compensation. The Good Samaritan law is not applicable to health care workers. The Good Samaritan law will provide absolute exemption from prosecution.

The Good Samaritan law will provide legal immunity to the nurse. The Good Samaritan laws provide legal immunity to passersby who provide emergency first aid to victims of accidents. Therefore, the law is applicable to the nurse in this scenario; moreover, Good Samaritan laws apply to those who do not accept any compensation for services provided. The law is equally applicable to everyone but does not provide absolute exemption from prosecution in cases of negligence. Paramedics, ambulance personnel, physicians, and nurses who stop to provide assistance are still held to a higher standard of care because they have training above and beyond that of average lay people. In cases of gross negligence, health care workers may be charged with a criminal offense.

A client has been hospitalized for treatment of acute bacterial pneumonia. Which outcome indicates an improvement in the client's condition? The client has a partial pressure of arterial oxygen (PaO2) value of 90 mm Hg or higher. The client has a partial pressure of arterial carbon dioxide (PaCO2) value of 65 mm Hg or higher. The client exhibits restlessness and confusion. The client exhibits bronchial breath sounds over the affected area.

The client has a partial pressure of arterial oxygen (PaO2) value of 90 mm Hg or higher. As the acute phase of bacterial pneumonia subsides, normal lung function returns and the PaO2typically rises, reaching 85 to 100 mm Hg. A PaCO2 of 65 mm Hg or higher is above normal and indicates CO2 retention — common during the acute phase of pneumonia. Restlessness and confusion indicate hypoxia, not an improvement in the client's condition. Bronchial breath sounds over the affected area occur during the acute phase of pneumonia; later, the affected area should be clear on auscultation.

A nurse manager at a home health care agency is reviewing the medical record of a client who is receiving Medicare-based home health services. To ensure reimbursement for services, the nurse manager should consider whether which criteria have been met? Select all that apply. The client is under the care of a physician. The client requires the full-time services of a registered nurse. The client's condition is expected to improve in a reasonable time period. The client is restricted from leaving the house for any reason. The client requires intermittent skilled services.

The client is under the care of a physician. The client's condition is expected to improve in a reasonable time period. The client requires intermittent skilled services. For Medicare to reimburse for home care, the client must be under the care of a physician and be getting services under a care plan established and reviewed regularly by a physician; a physician must certify that the client needs intermittent skilled nursing care (other than just drawing blood) and/or physical therapy, speech-language pathology, or continued occupational therapy services (such that the client's condition must be expected to improve in a reasonable and generally predictable time frame); the client must be homebound, and a physician must certify to that fact. A client may leave home for medical treatment or short, infrequent absences. A client can still get home health care if the client attends adult day care for medical and safety reasons. Leaving the home must require considerable and taxing effort.

A client suffers a musculoskeletal injury while participating in a sporting event. Which treatment is most appropriate initially?

The initial treatment of a musculoskeletal injury involves rest, ice, compression, and elevation. These activities reduce pain, swelling, and further injury. In some injuries, elevation followed by local application of cold may be sufficient. Any immobilization device should be applied in a functional position. If there is a deformity, there should be no attempt to straighten the limb.

In an attempt to best explain the innate immune system to a class of first-year nursing students, the instructor should describe what characteristic? The innate immune system is mediated by molecules called antibodies and is the principal defense against extracellular microbes and toxins. The response of the innate immune system is rapid, usually within minutes to hours, and prevents the establishment of infection and deeper tissue penetration of microorganisms. The innate immune system consists of lymphocytes and their products, including antibodies. The innate immune system is mediated by specific T-cells and defends against intracellular microbes such as viruses.

The response of the innate immune system is rapid, usually within minutes to hours, and prevents the establishment of infection and deeper tissue penetration of microorganisms. The innate immune system is the first line of defense. The adaptive immune system is composed of lymphocytes and their products. Antibodies comprise humoral immunity and T-cells provide cellular immunity.