Saunders- assessment

A client who has been hospitalized with a paranoid disorder refuses to turn off the lights in the room at night and states, "My roommate will steal me blind." Which is the appropriate response by the nurse? 1. "Why do you believe this?" 2. "Tell me more about the details of your belief." 3. "I hear what you are saying, but I don't share your belief." 4. "If you want a pass for tomorrow evening's movie, you'd better turn that light off this minute."

"I hear what you are saying, but I don't share your belief." Paranoid beliefs are coping mechanisms used by the client and therefore are not easily relinquished. It is important not to support the belief and not to ridicule, argue, or criticize it. Option 1 places the client in a defensive position by asking "why." Option 2 encourages the client to expound on the belief when discussion should instead be limited. Option 4 threatens the client.

The nurse is preparing to administer furosemide (Lasix) 40 mg by intravenous (IV) injection (IV push) to a client. The nurse should administer the medication over which time period? 1. 10 seconds 2. 30 seconds 3. 1 minute 4. 5 minutes

1 minute Rationale: When furosemide is administered by IV injection, each 40 mg or fraction thereof should be given over a 1- to 2-minute period. Options 1 and 2 identify administration times that are too rapid and could cause adverse effects. Option 4 is too slow of a time period for administration and may affect effectiveness of the IV medication.

The nurse is assessing a client's postoperative pain using the PQRSTU method. Using this method, which questions would the nurse ask the client? Select all that apply. Click on the Question Video button to view a video showing preparation procedures. 1."Where is the pain located?" 2."Does pain medication help?" 3."What does the pain feel like?" 4."How does the pain affect you?" 5."Do you have the pain when you sleep?" 6. "What makes your pain better or worse?"

1."Where is the pain located?" 3."What does the pain feel like?" 4."How does the pain affect you? 6. "What makes your pain better or worse?" The PQRSTU method is one method of assessing pain. With this method, the nurse asks about the following: Precipitating factors (option 6); Quality of the pain (option 3); Region or Radiation of the pain (option 1); Severity of the pain; Timing of the pain (continuous or intermittent); and How the pain affects yoU (option 4). Options 2 and 5 may be questions that would be asked; however, these are not a part of the PQRSTU method.

The nurse is preparing to administer 30 mEq of liquid potassium chloride (KCL) to an adult client. The label on the medication bottle reads 40 mEq of KCL per 15 mL. The nurse should prepare how many milliliters of KCL to administer the correct dose of medication? Fill in the blank. Round the answer to the nearest whole number.

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A nurse is assessing a woman in the second trimester of pregnancy who was admitted to the maternity unit with a suspected diagnosis of abruptio placentae. Which finding would the nurse expect to note if abruptio placentae is present? 1. Soft uterus 2. Abdominal pain 3. Nontender uterus 4. Painless vaginal bleeding

Abdominal pain Classic signs and symptoms of abruptio placentae include vaginal bleeding, abdominal pain, and uterine tenderness and contractions. Mild to severe uterine hypertonicity is present. Pains is mild to severe and either localized or diffuse over one region of the uterus, with a board-like abdomen. Painless vaginal bleeding and a soft, nontender uterus in the second or third trimester of pregnancy are signs of placenta previa.

A nurse provides instructions to a preoperative client about the use of an incentive spirometer. The nurse determines that the client needs further instruction if the client indicates that he or she will take which action? 1. Sit upright when using the device. 2. Inhale slowly, maintaining a constant flow. 3. Place the lips completely over the mouthpiece. 4. After maximal inspiration, hold the breath for 10 seconds and then exhale.

After maximal inspiration, hold the breath for 10 seconds and then exhale. For optimal lung expansion with the incentive spirometer, the client should assume a semi-Fowler's or high Fowler's position. The mouthpiece should be covered completely and tightly while the client inhales slowly, with a constant flow through the unit. When maximal inspiration is reached, the client should hold the breath for 2 or 3 seconds and then exhale slowly.

Insulin glargine (Lantus) is prescribed for a client with diabetes mellitus. The nurse should tell the client that it is best to take the insulin at which time? 1. At bedtime 2. 1 hour after each meal 3. 15 minutes before the morning and evening meal 4. Before each meal, on the basis of the blood glucose level

At bedtime Rationale: Insulin glargine is a long-acting recombinant DNA human insulin that is used to treat type 1 and type 2 diabetes mellitus. It has a 24-hour duration of action and is administered once a day, usually at bedtime. Therefore, options 2, 3, and 4 are incorrect times.

A postpartum woman with mastitis in the right breast complains that the breast is too sore for her to breast-feed her infant. The nurse should tell the client to implement which measure? 1. Pump both breasts and discard the milk. 2. Bottle-feed the infant on a temporary basis. 3. Breast-feed from the left breast and gently pump the right breast. 4. Stop breast-feeding from both breasts until this condition resolves.

Breast-feed from the left breast and gently pump the right breast. In most cases, the mother can continue to breast-feed with both breasts. If the affected breast is too sore, the mother can pump the breast gently. Regular emptying of the breast is important to prevent abscess formation. If an abscess forms and ruptures into the ducts of the breast, breast-feeding will need to be discontinued and a pump should be used to empty the breast (but the milk should be discarded). Options 1, 2, and 4 are incorrect.

A client whose cardiac rhythm was normal sinus rhythm suddenly exhibits a different rhythm on the monitor. The nurse should take which action? Refer to Figure. 1. Continue to watch the monitor. 2. Contact the health care provider. 3. Check to see if cardiac medications are due. 4. Call respiratory therapy to do a respiratory treatment.

Contact the health care provider. Rationale: Atrial fibrillation is characterized by multiple rapid impulses from many atrial foci in a totally disorganized manner at a rate of 350 to 600 times per minute. The atria quiver in fibrillation. As a result, thrombi can form within the right atrium and move through the right ventricle to the lungs. This can be a life-threatening situation requiring pharmacological therapy. Therefore, the health care provider needs to be contacted. Options 1 and 3 delay necessary and required interventions. Option 4 is not useful for this client.

A nurse in the labor room is caring for a client who is in the first stage of labor. On assessing the fetal patterns, the nurse notes an early deceleration of the fetal heart rate (FHR) on the monitor strip. Based on this finding, which is the appropriate nursing action? 1. Contact the health care provider. 2. Place the mother in a Trendelenburg position. 3. Administer oxygen to the client by face mask. 4. Document the findings and continue to monitor fetal patterns.

Document the findings and continue to monitor fetal patterns. Early deceleration of the FHR refers to a gradual decrease in the heart rate, followed by a return to baseline, in response to compression of the fetal head. It is a normal and benign finding. Because early decelerations are considered benign, interventions are not necessary. Therefore, options 1, 2, and 3 are unnecessary.

The nurse receives a telephone call from the admissions office and is told that a child with acute bacterial meningitis will be admitted to the pediatric unit. The nurse prepares for the child's arrival and plans to implement which type of precautions? 1. Enteric 2. Contact 3. Droplet 4. Neutropenic

Droplet A major priority in nursing care for a child with suspected meningitis is to administer the appropriate antibiotic as soon as it is prescribed. The child will be placed in a private room, with droplet transmission precautions, for at least 24 hours after antibiotics are given. Enteric, contact, and neutropenic precautions are not associated with the mode of transmission of meningitis. Enteric precautions are instituted when the mode of transmission is through the gastrointestinal tract. Contact precautions are instituted when contact with infectious items or materials is likely. Neutropenic precautions are instituted when the client has a low neutrophil count.

The nurse notes that a client is receiving lamivudine (Epivir). The nurse determines that this medication has been prescribed to treat which condition? 1. Pancreatitis 2. Pharyngitis 3. Tonic-clonic seizures 4. Human immunodeficiency virus (HIV)

Human immunodeficiency virus (HIV) Lamivudine is a nucleoside reverse transcriptase inhibitor and antiviral medication. It slows HIV replication and reduces the progression of HIV infection. It also is used to treat chronic hepatitis B and provide prophylaxis in health care workers who are at risk of acquiring HIV infection after occupational exposure to the virus. This medication is not used to treat the conditions identified in options 1, 2, and 3.

A client who is receiving intravenous (IV) fluid therapy complains of burning and a feeling of tightness at the IV insertion site. On assessment, the nurse detects coolness and swelling at the site and notes that the IV rate has slowed. The nurse determines that which complication has occurred? 1. Infection 2. Phlebitis 3. Infiltration 4. Thrombosis

Infiltration An infiltrated IV line is one that has dislodged from the vein and is lying in subcutaneous tissue. Pallor, coolness, and swelling at the IV site result when IV fluid is deposited in the subcutaneous tissue. When the pressure in the tissues exceeds the pressure in the tubing, the flow of IV solution will slow down or stop. The corrective action is to remove the catheter and start a new IV line at another site. The conditions identified in options 1, 2, and 4 are likely to be accompanied by warmth at the site, not coolness.

A child seen in the clinic is found to have rubeola (measles), and the mother asks the nurse how to care for the child. The nurse should tell the mother to implement which action? 1. Keep the child in a room with dim lights. 2. Give the child warm baths to help prevent itching. 3. Allow the child to play outdoors because sunlight will help the rash. 4. Take the child's temperature every 4 hours and administer 1 baby aspirin for fever.

Keep the child in a room with dim lights. Rationale: A nursing consideration in rubeola is eye care. The child usually has photophobia, so the nurse should suggest that the parent keep the child out of brightly lit areas. Warm baths and sunlight will aggravate itching. Additionally, the child needs to rest. Children with viral infections are not to be given aspirin because of the risk of Reye's syndrome.

A nurse is monitoring a 7-year-old child who sustained a head injury in a motor vehicle crash for signs of increased intracranial pressure (ICP). The nurse should assess the child frequently for which early sign of increased ICP? 1. Nausea 2. Papilledema 3. Decerebrate posturing 4. Alterations in pupil size

Nausea Nausea is an early sign of increased ICP. Late signs of increased ICP include a significant decrease in level of consciousness, Cushing's triad (increased systolic blood pressure and widened pulse pressure, bradycardia, and irregular respirations), and fixed and dilated pupils. Other late signs include decreased motor response to command, decreased sensory response to painful stimuli, posturing, Cheyne-Stokes respirations, and papilledema.

The clinic nurse reads the results of a tuberculin skin test performed on a 5-year-old child who is at low risk for contracting tuberculosis. The results indicate an area of induration measuring 10 mm. How would the nurse interpret these results? 1. Positive 2. Negative 3. Inconclusive 4. Definitive and requiring a repeat test

Negative Induration measuring 15 mm or greater is considered a positive result in a child 4 years of age or older who has no associated risk factors. Options 1, 3, and 4 are incorrect interpretations.

The nurse is preparing to administer furosemide (Lasix) to a client with a diagnosis of heart failure. Which is the most important laboratory test result for the nurse to check before administering this medication? 1. Blood urea nitrogen 2. Cholesterol level 3. Potassium level 4. Creatinine level

Potassium level Furosemide is a loop diuretic. The medication causes a decrease in the client's electrolytes, especially potassium, sodium, and chloride. Administering furosemide to a client with low electrolyte levels could precipitate ventricular dysrhythmias. Options 1 and 4 reflect renal function. The cholesterol level is unrelated to the administration of this medication.

After a tonsillectomy, a child is brought to the pediatric unit. The nurse should appropriately place the child in which position? 1. Prone 2. Supine 3. High Fowler's 4. Trendelenburg

Prone The child should be placed in a prone or side-lying position after tonsillectomy to facilitate drainage. Options 2, 3, and 4 will not achieve this goal.

A nurse caring for a client with a diagnosis of gastrointestinal (GI) bleeding reviews the client's laboratory results and notes a hematocrit level of 30%. Which action should the nurse take? 1. Report the abnormally low level. 2. Report the abnormally high level. 3. Inform the client that the laboratory result is normal. 4. Place the normal report in the client's medical record.

Report the abnormally low level. The normal hematocrit level in a male ranges from 42% to 52%, and 35% to 47 % in a female, depending on age. A hematocrit level of 30% is a low level and would be reported to the health care provider because it indicates blood loss; therefore options 2, 3, and 4 are incorrect.

A registered nurse (RN) asks a licensed practical nurse (LPN) to set up a hospital room for a client who is being admitted with a diagnosis of tonic-clonic seizures and asks the LPN to institute seizure precautions. The RN checks the client's room before the arrival of the client and determines that which item placed in the room by the LPN is unsafe? 1. Restraints 2. Nasal cannula 3. Suction catheter 4. Padding for side rails

Restraints Rationale: Seizure precautions include keeping side rails up and padded if the client has tonic-clonic seizures, ensuring that suction and oxygen equipment is available, and disabling the locks on the bathroom and room doors. Restraints are not used and can result in client injury.

A nurse provides dietary instructions to a client who will be taking warfarin sodium (Coumadin). The nurse should tell the client to avoid which food item? 1. Grapes 2. Spinach 3. Watermelon 4. Cottage cheese

Spinach Warfarin sodium is an anticoagulant. Anticoagulant medications act by antagonizing the action of vitamin K, which is needed for clotting. When a client is taking an anticoagulant, foods high in vitamin K often are omitted from the diet. Vitamin K-rich foods include green leafy vegetables, fish, liver, coffee, and tea.

The nurse provides dietary instructions to a client with Ménière's disease. The nurse should tell the client that which food or fluid item is acceptable to consume? 1. Tea 2. Coffee 3. Cold-cut meats 4. Sugar-free Jell-O

Sugar-free Jell-O Rationale: The underlying pathological changes of Ménière's disease include overproduction and defective absorption of endolymph. This increases the volume and pressure within the membranous labyrinth until distention results in rupture and mixing of the endolymph and perilymph fluids. Dietary therapy frequently is quite helpful in controlling the symptoms associated with Ménière's disease. The nurse encourages the client to follow a low-salt diet and to avoid caffeine, sugar, monosodium glutamate, and alcohol.

The nurse is preparing to care for a client who will be arriving from the recovery room after an above-the-knee amputation. The nurse ensures that which is in the client's hospital room as a priority item? 1. Over-bed trapeze 2. Dry sterile dressings 3. Surgical tourniquet 4. Incentive spirometer

Surgical tourniquet Monitoring for complications is an important aspect of initial postoperative care. Vital signs and pulse oximetry values are monitored closely until the client's condition stabilizes. The wound and any drains are monitored closely for excessive bleeding because hemorrhage is the primary immediate complication of amputation. Therefore a surgical tourniquet is kept at the bedside in case of acute bleeding. An over-bed trapeze increases the client's independence in self-care activities but is not a priority in the immediate postoperative period. An incentive spirometer and dry sterile dressings also should be available, but these are not priority items considering the surgical procedure that the client underwent.

A woman in the third trimester of pregnancy with a diagnosis of mild preeclampsia is being monitored at home. The home care nurse teaches the woman about the signs that need to be reported to the health care provider. The nurse should tell the woman to call the health care provider if which occurs? 1. Urine tests negative for protein. 2. Fetal movements are more than four per hour. 3. Weight increases by more than 1 pound in a week. 4. The blood pressure reading is ranging between 122/80 and 132/88 mm Hg.

Weight increases by more than 1 pound in a week. The nurse would instruct the client to report any increase in blood pressure, protein in the urine, weight gain greater than 1 pound per week, or edema. The client also is taught how to count fetal movements and is instructed that decreased fetal activity (three or fewer movements per hour) may indicate fetal compromise and should be reported.

A health care provider writes a prescription for digoxin (Lanoxin), 0.25 mg daily. The nurse teaches the client about the medication and tells the client that it is most important to be sure to implement which measure? 1. Count the radial and carotid pulses every morning. 2. Check the blood pressure every morning and evening. 3. Stop taking the medication if the pulse is faster than 100 beats/min. 4. Withhold the medication, and call the health care provider if the pulse is slower than 60 beats/min.

Withhold the medication, and call the health care provider if the pulse is slower than 60 beats/min. Rationale: An important component of taking digoxin is monitoring the pulse rate; however, it is not necessary for the client to take both radial and carotid pulses. It is also unnecessary for the client to check the blood pressure every morning and evening because the medication does not directly affect blood pressure. It is most important for the client to know the guidelines related to withholding the medication and calling the health care provider. The client should not stop taking the medication.

A nurse provides home care instructions to a client undergoing hemodialysis with regard to care of a newly created arteriovenous (AV) fistula. Which client statement would indicate understanding of the instructions? 1. "I should check the fistula every day by feeling it for a vibration." 2. "I am glad that the laboratory will be able to draw my blood from the fistula." 3. "I should wear a shirt with tight arms to provide some compression on the fistula." 4. "I should check my blood pressure in the arm where I have my fistula every week."

"I should check the fistula every day by feeling it for a vibration." Rationale: An AV fistula provides access to the client's bloodstream for the dialysis procedure. The client is instructed to monitor fistula patency daily by palpating for a thrill (vibration feeling). The client is instructed to avoid compressing the fistula with tight clothing or when sleeping, and that blood pressure measurements and blood draws should not be performed on the arm with the fistula. The client also is instructed to assess the fistula for signs and symptoms of infection, including pain, redness, swelling, and excessive warmth.

A client who has just received a diagnosis of asthma says to the nurse, "This condition is just another nail in my coffin." Which response by the nurse is therapeutic? 1. "Do you think that having asthma will kill you?" 2. "You seem very distressed over learning you have asthma." 3. "I'm not going to work with you if you can't view this as a challenge rather than a 'nail in your coffin.'" 4. "Asthma is a very treatable condition. It is important to properly administer your medications. Let's practice with your inhalant."

"You seem very distressed over learning you have asthma." Clients who have learned that they have a chronic illness may exhibit denial, anger, or sarcasm because of fear associated with the chronic illness. It is important for the nurse to convey an accepting attitude to enhance mutual respect and trust. Option 1 reflects and paraphrases the client's words but is somewhat sarcastic. Option 3 is punitive in its approach, threatens the client, and sarcastically quotes the client's words. Option 4 lectures the client and does not deal directly with expressed concerns.

A client in the postpartum unit complains of sudden, sharp chest pain. The client is tachycardic, and the respiratory rate is increased. The health care provider diagnoses a pulmonary embolism. Which actions should the nurse plan to take? Select all that apply. 1. Administer oxygen. 2. Assess the blood pressure. 3. Start an intravenous (IV) line. 4. Prepare to administer morphine sulfate. 5. Place the client on bed rest in a supine position. 6. Prepare to administer warfarin sodium (Coumadin).

1. Administer oxygen. 2. Assess the blood pressure. 3. Start an intravenous (IV) line. 4. Prepare to administer morphine sulfate. Rationale: If pulmonary embolism is suspected, oxygen is administered to decrease hypoxia. The client also is kept on bed rest, with the head of the bed slightly elevated to reduce dyspnea. Morphine sulfate may be prescribed for the client to reduce pain and apprehension. An IV line also will be required, and vital signs must be monitored. Heparin therapy (not warfarin sodium) is administered.

A health care provider prescribes 1 unit of packed red blood cells to be infused over 4 hours. The unit of blood contains 250 mL. The drop factor is 15 drops (gtt)/1 mL. The nurse should set the flow rate at how many drops per minute? Fill in the blank. Round the answer to the nearest whole number.

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A nulliparous woman asks the nurse when she will begin to feel fetal movements. The nurse responds by telling the woman that the first recognition of fetal movement will occur at approximately how many weeks of gestation? 1. 5 weeks 2. 9 weeks 3. 13 weeks 4. 18 weeks

18 weeks The first recognition of fetal movements, or feeling life, by the multiparous woman may occur as early as 14 to 16 weeks' gestation. The nulliparous woman may not notice these sensations until the 18 weeks' gestation or later. The first recognition of fetal movement is called quickening.

A client is taking ticlopidine hydrochloride (Ticlid). The nurse should tell the client to avoid which substance while taking this medication? 1. Vitamin C 2. Vitamin D 3. Acetaminophen (Tylenol) 4. Acetylsalicylic acid (aspirin)

Acetylsalicylic acid (aspirin) Rationale: Ticlopidine hydrochloride is a platelet aggregation inhibitor. It is used to decrease the risk of thrombotic stroke in clients with precursor symptoms. Because it is an antiplatelet agent, other medications that precipitate or aggravate bleeding should be avoided during its use. Therefore, aspirin or any aspirin-containing product should be avoided. The substances in options 1, 2, and 3 are safe to consume.

A client who has been receiving total parenteral nutrition (TPN) by way of a central venous access device complains of chest pain and dyspnea. The nurse quickly assesses the client's vital signs and notes that the pulse rate has increased and the blood pressure has dropped. The nurse determines that the client is most likely experiencing which problem? 1. Sepsis 2. Air embolism 3. Fluid overload 4. Fluid imbalance

Air embolism The signs and symptoms of air embolism include chest pain, dyspnea, hypoxia, anxiety, tachycardia, and hypotension. The nurse also may hear a loud churning sound over the pericardium on auscultation of the client's chest. The signs and symptoms of sepsis include fever, chills, and general malaise. Fluid overload causes increased intravascular volume, which increases the blood pressure and the pulse rate as the heart tries to pump the extra fluid volume. Fluid overload also causes neck vein distention and shifting of fluid into the alveoli, resulting in lung crackles. The signs and symptoms of a fluid imbalance depend on the type of imbalance the client is experiencing.

The nurse is preparing to care for a client with acquired immunodeficiency syndrome (AIDS). In planning infection control for this client, the nurse should implement which form of isolation to prevent the spread of the AIDS virus to others? 1. Strict isolation 2. Enteric precautions 3. Contact precautions 4. Blood and body fluid precautions

Blood and body fluid precautions Rationale: The AIDS virus is transmitted through anal, vaginal, or oral sexual contact with infected semen or vaginal secretions; through contact with infected blood or blood products; from mother to fetus during childbirth; or during breast-feeding. Blood and body fluid precautions will prevent contact with infectious matter from the AIDS virus. Strict isolation is not needed and may contribute to feelings of isolation in the client. Enteric or contact precautions alone are insufficient to prevent transmission of the AIDS virus.

A client with angina pectoris is experiencing chest pain that radiates down the left arm. The nurse administers a sublingual nitroglycerin tablet to the client. The client's pain is unrelieved, and the nurse determines that the client needs another nitroglycerin tablet. Which vital sign is the most important for the nurse to check before administering the medication? 1. Temperature 2. Respirations 3. Blood pressure 4. Radial pulse rate

Blood pressure Rationale: Nitroglycerin acts directly on the smooth muscle of the blood vessels, causing relaxation and dilation. As a result, hypotension can occur. The nurse would check the client's blood pressure before administering the second nitroglycerin tablet. Although the respirations and apical pulse may be checked, these vital signs are not affected by this medication. The temperature also is not associated with administration of this medication.

A nurse is preparing to care for a newborn who has respiratory distress syndrome. Which initial action should the nurse plan to best facilitate bonding between the newborn and the parents? 1. Encourage the parents to touch their newborn. 2. Identify specific caregiving tasks that may be assumed by the parents. 3. Explain the equipment that is used and how it functions to assist their newborn. 4. Give the parents pamphlets that will help them understand their newborn's condition.

Encourage the parents to touch their newborn. Rationale: The best initial action to begin the attachment process and promote bonding is to encourage the parents to touch their newborn. The parents' initial need is to become acquainted with their newborn. Option 2 may be frightening to the parents because of the condition of the newborn and the unfamiliarity of high-risk newborn care practices. This option will be appropriate later, as the newborn's condition becomes stable. Option 3 is important but is not specific to parent-newborn bonding activities. Option 4 is inappropriate initially. Requiring parents to focus on pamphlets or literature does not enhance the parent-newborn bond.

A nurse is performing a vaginal assessment of a pregnant woman who is in labor. The nurse notes that the umbilical cord is protruding from the vagina. The nurse would immediately take which action? 1. Administer oxygen to the woman. 2. Transport the woman to the delivery room. 3. Place an external fetal monitor on the woman. 4. Exert upward pressure against the presenting part using a gloved hand.

Exert upward pressure against the presenting part using a gloved hand. If the umbilical cord is protruding from the vagina, no attempt should be made to replace it because doing so could traumatize it and further reduce blood flow. The nurse would place a gloved hand into the vagina to the cervix and exert upward pressure against the presenting part to relieve compression of the cord. The nurse also would wrap the cord loosely in a sterile towel saturated with warm, sterile normal saline solution. Oxygen, 8 to 10 L/min by face mask, would be administered to the mother to increase fetal oxygenation, and the woman would be prepared for immediate delivery. However, the immediate action is to relieve pressure on the cord. The woman should already have an external fetal monitor in place.

A nurse is monitoring an infant for signs of increased intracranial pressure (ICP). On assessment of the fontanelles, the nurse notes that the anterior fontanelle bulges when the infant is sleeping. Based on this finding, which is the priority nursing action? 1. Increase oral fluids. 2. Document the finding. 3. Notify the health care provider. 4. Place the infant supine in a side-lying position.

Notify the health care provider. The anterior fontanelle is diamond shaped and is located on the top of the head. It should be soft and flat in a normal infant, and it normally closes by 12 to 18 months of age. A larger-than-normal fontanelle may be a sign of increased ICP within the skull. Although the anterior fontanelle may bulge slightly when the infant cries, bulging at rest may indicate increased ICP. Options 1 and 4 are inaccurate interventions and will not be helpful. Although the nurse would document the finding, the priority action would be to report the finding to the health care provider.

A nurse is assessing a dark-skinned client for the presence of petechiae. Which body area is the best for the nurse to check in this client? 1. Sclera 2. Oral mucosa 3. Soles of the foot 4. Palms of the hand

Oral mucosa Rationale: In a dark-skinned client, petechiae are best observed in the conjunctivae and oral mucosa. Jaundice would best be noted in the sclera of the eye. Cyanosis is best noted on the palms of the hands and soles of the feet.

A nurse is providing home care instructions to the mother of an infant who has just been found to have hemophilia. The nurse should tell the mother that care of the infant should include which appropriate measure? 1. Use aspirin for pain relief. 2. Pad crib rails and table corners. 3. Use a soft toothbrush for dental hygiene. 4. Use a generous amount of lubricant when taking a temperature rectally.

Pad crib rails and table corners. Rationale: Establishment of an age-appropriate, safe environment is of paramount importance for hemophiliacs. Providing a safe environment for an infant includes padding table corners and crib rails, providing extra padding on clothes to protect the joints, observing a mobile infant at all times, and keeping items that can be pulled down onto the infant out of reach. Use of a soft toothbrush is an appropriate measure for a child with hemophilia but is not typically necessary for an infant. Rectal temperature measurements and the use of aspirin are contraindicated in hemophiliacs because of the risk of bleeding.

The nurse reviews a client's arterial blood gas results and notes that the pH is 7.30, the Pco2 is 52 mm Hg, and the HCO3 is 22 mEq/L. The nurse interprets these results as indicating which condition? 1. Metabolic acidosis, compensated 2. Respiratory alkalosis, compensated 3. Metabolic alkalosis, uncompensated 4. Respiratory acidosis, uncompensated

Respiratory acidosis, uncompensated Rationale: Normal pH is 7.35 to 7.45. In a respiratory condition, the pH and the Pco2 will exhibit opposite effects; in this case, the pH is low and the Pco2 is increased. In an acidotic condition, the pH is decreased. Therefore the values identified in the question indicate a respiratory acidosis. Compensation occurs when the pH returns to a normal value. Because the pH is not within the normal range, the condition is uncompensated.

The nurse is monitoring a client who has a closed chest tube drainage system. The nurse notes fluctuation of the fluid level in the water-seal chamber during inspiration and expiration. On the basis of this finding, the nurse should make which interpretation? 1. There is a leak in the system. 2. The chest tube is functioning as expected. 3. The amount of suction needs to be decreased. 4. The occlusive dressing at the insertion site needs reinforcement.

The chest tube is functioning as expected. The presence of fluctuation of the fluid level in the water-seal chamber indicates a patent drainage system. With normal breathing, the water level rises with inspiration and falls with expiration. Fluctuation stops if the tube is obstructed, if the suction is not working properly, or if the lung has re-expanded. Options 1, 3, and 4 are incorrect interpretations of the finding. An air leak may cause excessive bubbling in the water seal chamber. Excessive and vigorous bubbling in the suction control chamber may indicate that the amount of suction needs to be decreased. The status of the dressing is not specifically related to the presence of fluctuation of the fluid level in the water-seal chamber.

The nurse is monitoring a woman with a diagnosis of depression. Which behavior, if observed by the nurse, indicates that suicide precautions should be implemented for this client? 1. The woman refuses to attend group therapy. 2. The woman asks to meet with a lawyer to take care of unfinished business. 3. The woman has an argument with her significant other during visiting hours. 4. The woman swears at her roommate because she takes too much time in the bathroom.

The woman asks to meet with a lawyer to take care of unfinished business. Rationale: Warning signs of suicide include talking about suicide, preoccupation with death and dying, behavioral changes, giving away special possessions and making arrangements to take care of unfinished business, decreased appetite and difficulty with sleep, and a loss of interest in usual activities. Options 1, 3, and 4 deal with anger and "acting-out" behaviors.

A nurse performs an assessment of a pregnant woman who is receiving intravenous magnesium sulfate for management of preeclampsia and notes that the woman's deep tendon reflexes are absent. On the basis of this finding, the nurse should make which interpretation? 1. The infusion rate needs to be increased. 2. The magnesium sulfate is effective. 3. The woman is experiencing cerebral edema. 4. The woman is experiencing magnesium excess.

The woman is experiencing magnesium excess. Magnesium toxicity can occur as a result of magnesium sulfate therapy. Signs of magnesium sulfate toxicity relate to the central nervous system depressant effects of the medication and include respiratory depression, loss of deep tendon reflexes, sudden decrease in fetal heart rate or maternal heart rate or both, and sudden drop in blood pressure. An absence of reflexes indicates magnesium excess. The infusion rate therefore would not be increased. Hyperreflexia indicates increased cerebral edema.

A nurse is preparing to administer digoxin (Lanoxin) to an infant with heart failure. Before administering the medication, the nurse double-checks the dose, counts the apical heart rate for 1 full minute, and obtains a rate of 88 beats/minute. Based on this finding, which is the appropriate nursing action? 1. Withhold the medication. 2. Administer the medication. 3. Double-check the apical heart rate and administer the medication. 4. Check the blood pressure and respirations and administer the medication.

Withhold the medication. Digoxin is a cardiac glycoside that is used to treat heart failure. A primary concern is digoxin toxicity and the nurse needs to monitor closely for signs of toxicity and monitor digoxin blood levels. The medication is effective within a narrow therapeutic digoxin range (1.0 to 2.0 ng/mL). Safety in administration is achieved by double-checking the dose and counting the apical heart rate for 1 full minute. If the heart rate is less than 100 beats/minute in an infant, the nurse would withhold the dose and contact the health care provider. Therefore, options 2, 3, and 4 are incorrect actions; it would be harmful to administer the medication.

A nurse notes that a client is taking lansoprazole (Prevacid). On assessment of the client, the nurse should ask which question to determine the effectiveness of this medication? 1. "Has your appetite increased?" 2. "Are you experiencing any heartburn?" 3. "Do you have any problems with vision?" 4. "Do you experience any leg pain when walking?"

"Are you experiencing any heartburn?" Lansoprazole is a gastric acid pump inhibitor that is used to treat gastric and duodenal ulcers, erosive esophagitis, and hypersecretory conditions. It also is used to treat gastroesophageal reflux disease (GERD). It is not used to treat problems with appetite, visual problems, or leg pain.

A nurse reviews the medication history of a client and notes that the client is taking leflunomide (Arava). During assessment of the client, the nurse should ask which question to determine the effectiveness of this medication? 1. "Do you have any joint pain?" 2. "Are you having any diarrhea?" 3. "Are you experiencing heartburn?" 4. "Do you have frequent headaches?"

"Do you have any joint pain?" Leflunomide is an immunomodulatory agent and has an anti-inflammatory action. The medication provides symptomatic relief of rheumatoid arthritis. Diarrhea can occur as a side effect of the medication. Options 2, 3, and 4 are unrelated to the action, use, or effectiveness of the medication.

A hospitalized client with a diagnosis of schizophrenia who is experiencing delusions says to the nurse, "I know that the doctor is talking to the top man in the mob to get rid of me." Which response should the nurse make to the client? 1. "I don't believe this is true." 2. "The doctor is not talking to the mob." 3. "What makes you think the doctor wants to get rid of you?" 4. "I don't know anything about the top man in the mob. Do you feel afraid that people are trying to hurt you?"

"I don't know anything about the top man in the mob. Do you feel afraid that people are trying to hurt you?" Rationale: When delusional, a client truly believes what he or she thinks to be real is real. The client's thinking often reflects feelings of great fear and aloneness. It is most therapeutic for the nurse to empathize with the client's experience. Disagreeing with delusions may make the client more defensive, and the client may cling to the delusions even more. Encouraging discussion regarding the delusions is inappropriate.

A client who has received a kidney transplant is taking azathioprine (Imuran), and the nurse provides instructions about the medication. Which statement by the client would indicate a need for further instruction? 1. "I need to watch for signs of infection." 2. "I need to discontinue the medication after 14 days of use." 3. "I can take the medication with meals to minimize nausea." 4. "I need to call the health care provider if more than one dose is missed."

"I need to discontinue the medication after 14 days of use." Rationale: Azathioprine is an immunosuppressant medication that is taken for life. Because of the effects of the medication, the client must watch for signs of infection, which are to be reported immediately to the health care provider. The medication may be taken with meals to minimize nausea. The client should also call the health care provider if more than one dose is missed.

A nurse reinforces medication instructions to a client who has received a kidney transplant about therapy with cyclosporine (Sandimmune). Which statement by the client would indicate a need for further instruction? 1. "I need to obtain a yearly influenza vaccine." 2. "I need to have dental checkups every 3 months." 3. "I need to self-monitor my blood pressure at home." 4. "I need to call the health care provider if my urine volume decreases or it becomes cloudy."

"I need to obtain a yearly influenza vaccine." Rationale: Cyclosporine is an immunosuppressant medication. Because of the effects of the medication, the client should not receive any vaccinations without first consulting the health care provider. The client should report decreased urine output or cloudy urine, which could indicate kidney rejection or infection, respectively. The client needs meticulous oral care and dental cleaning every 3 months to help prevent gingival hyperplasia. The client must be able to self-monitor blood pressure to check for the side effect of hypertension.

A nurse provides home care instructions to a client who has undergone cataract removal and placement of an intraocular implant in the right eye. Which statement by the client would indicate a need for further instruction? 1. "I need to avoid lying on my right side." 2. "I need to wear the metal eye shield at night when I sleep." 3. "I should take stool softeners to prevent becoming constipated." 4. "I need to remove the eye dressing as soon as I get home and place a warm pack on my eye."

"I need to remove the eye dressing as soon as I get home and place a warm pack on my eye." Rationale: After cataract surgery, a dressing is applied to the eye. It usually is removed later on the day of surgery or on the following day by the health care provider. The client should not place a warm pack on the eye unless this is specifically prescribed because of the risk of infection and increased edema in the surgical area. The client is instructed not to sleep on the side of the body that was operated on, to prevent pressure and edema in the affected eye. The client is instructed to wear a metal or plastic eye shield to protect the eye from accidental injury and is instructed not to rub the eye. Glasses may be worn during the day. The use of stool softeners is recommended to prevent constipation and straining.

An older client says to the home care nurse, "I can't believe that my wife died yesterday. I keep expecting to see her everywhere I go in this house, ready to plan our activities for the day." Which is the therapeutic nursing response? 1. "It must be hard to accept that she has passed away." 2. "Are you saying that she made all the social plans for you?" 3. "Focus on the fact that her suffering is over and that she had a good life with you." 4. "Try to focus on the fact that you have three wonderful children and that you and your wife loved one another for years."

"It must be hard to accept that she has passed away." The therapeutic nursing response is the one that recognizes the difficulties of grieving the loss of a loved one and facilitates expression of feelings. Options 2, 3, and 4 are not therapeutic because they do not encourage expression of feelings.

A 63-year-old woman whose husband died 2 months ago says to the visiting nurse, "My daughter came over yesterday to help me move my husband's things out of our bedroom, and I was so angry with her for moving his slippers from where he always kept them under his side of our bed. She doesn't know how much I'm hurting." Which statement by the nurse would be therapeutic? 1. "I know just how you feel because I lost my husband last summer." 2. "It's OK to grieve and be angry with your daughter and anyone else for a time." 3. "You need to focus on the many good years you both enjoyed together and move on." 4. "Although it's a troubling time for you, try to focus on your children and grandchildren."

"It's OK to grieve and be angry with your daughter and anyone else for a time." The therapeutic statement is the one that gives the client permission to grieve and acknowledges that anger is part of loss and that it may be aimed at the people who are trying most to help and are closest. Options 1, 3, and 4 are all nontherapeutic. They do not encourage the client to express feelings.

The nurse is performing an admission assessment on a client who has been admitted to the hospital with a diagnosis of suspected gastric ulcer. The nurse is asking the client questions about pain. Which statement, if made by the client, would support the diagnosis of gastric ulcer? 1. "The pain doesn't usually come right after I eat." 2. "The pain gets so bad that it wakes me up at night." 3. "The pain that I get is located on the right side of my chest." 4. "My pain comes shortly after I eat, maybe a half-hour or so later."

"My pain comes shortly after I eat, maybe a half-hour or so later." Gastric ulcer pain often occurs in the upper epigastrium, with localization to the left of the midline, and may be exacerbated by intake of food. The pain occurs 30 to 60 minutes after a meal and rarely occurs at night. Duodenal ulcer pain is usually located to the right of the epigastrium. The pain associated with a duodenal ulcer occurs 90 minutes to 3 hours after eating and often awakens the client at night.

The mother of 6-year-old twins says to the nurse, "My mother-in-law doesn't think our children should come to the funeral service for their grandfather. What do you advise?" The nurse most appropriately responds by making which statement? 1. "What do you and your husband believe is the right thing for your children?" 2. "By all means have them attend. Not to do so would promote postmortem grief." 3. "It's a difficult decision, but given their young age, perhaps omitting the wake and just including the funeral would be best." 4. "I agree with your mother-in-law. Your mother-in-law is upset enough as it is. Tell your children that their grandfather is in heaven."

"What do you and your husband believe is the right thing for your children?" The most therapeutic response is the one that encourages open expression of feelings and empowers the grieving relative. Values, beliefs, and practices differ depending on the client's ethnic and spiritual backgrounds, and the nurse should not push a decision based on the nurse's own belief system. Options 2, 3, and 4 are nontherapeutic. Option 2 provides incorrect information related to postmortem grieving. Options 3 and 4 offer the nurse's opinion and impose the nurse's own beliefs.

A nurse is assigned to care for a client who is experiencing episodes of postural hypotension. Which action should the nurse take to ensure safety while transferring the client from the bed to the chair? 1. Arrange for a transfer board to be used. 2. Perform the transfer using a hydraulic lift only. 3. Put the client's shoes on so that the client will not slip on the floor during the transfer. 4. Allow the client to dangle the legs in a sitting position on the bed before transfer to a chair.

Allow the client to dangle the legs in a sitting position on the bed before transfer to a chair. Rationale: Having the client sit on the side of the bed before transfer allows the body to adjust to position changes, thereby avoiding a fall resulting from postural hypotension. The nurse should remain with the client and assist in the transfer to the chair. Options 1 and 2 are not necessary. Although option 3 is an important measure, it is not related to preventing postural hypotension.

A woman in the third trimester of pregnancy visits the clinic for a scheduled prenatal appointment. The woman tells the nurse that she frequently has leg cramps, primarily when she is reclining. Once thrombophlebitis has been ruled out, the nurse should tell the woman to implement which measure to alleviate the leg cramps? 1. Apply heat to the affected area. 2. Take acetaminophen (Tylenol) every 4 hours. 3. Self-administer calcium carbonate tablets three times daily. 4. Purchase a chewable antacid that contains calcium and take a tablet with each meal.

Apply heat to the affected area. Leg cramps may be a result of compression of the nerves supplying the legs by the enlarging uterus, a reduced level of diffusible serum calcium, or an increase in serum phosphorus. In the pregnant woman who complains of leg cramps, the nurse would perform further assessments to ensure that the client is not experiencing thrombophlebitis. Once this has been ruled out, the nurse would instruct the woman to place heat on the affected area, dorsiflex the foot until the spasm relaxes, or stand and walk. The health care provider may prescribe oral supplementation with calcium carbonate tablets or calcium hydroxide gel with each meal to increase the calcium level and lower the phosphorus level, but the nurse would not prescribe these or any other medications.

A client has a prescription for continuous monitoring of oxygen saturation by pulse oximetry for a preoperative client. The nurse should perform which best action to ensure accurate readings on the oximeter? 1. Apply the sensor to a finger that is cool to the touch. 2. Apply the sensor to a finger with very dark nail polish. 3. Ask the client to limit motion in the hand attached to the pulse oximeter. 4. Place the sensor distal to an intravenous (IV) site with a continuous IV infusion.

Ask the client to limit motion in the hand attached to the pulse oximeter. Rationale: Several factors can interfere with the reading of accurate oxygen saturation levels on a pulse oximeter. To ensure accurate readings, the nurse should ask the client to limit motion of the area attached to the sensor. The nurse should apply the device to a warm area because hypotension, hypothermia, and vasoconstriction interfere with blood flow to the area. The nurse needs to know that very dark nail polish (black, brown-red, blue, green) interferes with accurate measurement. The nurse also should avoid placing the sensor distal to any invasive arterial or venous catheters, pressure dressings, or blood pressure cuffs.

A client with portal-systemic encephalopathy is receiving oral lactulose (Chronulac) daily. The nurse should check which item to determine the effectiveness of this medication? 1. Lung sounds 2. Blood pressure 3. Blood ammonia level 4. Serum potassium level

Blood ammonia level Lactulose is a hyperosmotic laxative and ammonia detoxicant. It is used to prevent or treat portal-systemic encephalopathy, including hepatic precoma and coma. It also is used to treat constipation. The medication retains ammonia in the colon (decreases the blood ammonia concentration), producing an osmotic effect. It promotes increased peristalsis and bowel evacuation, expelling ammonia from the colon. This medication has no effect on lung sounds, the blood pressure, or the serum potassium level.

Methylergonovine (Methergine) is prescribed for a woman with postpartum hemorrhage caused by uterine atony. Before administering the medication, the nurse should check which most important client parameter? 1. Lochial flow 2. Urine output 3. Temperature 4. Blood pressure

Blood pressure Methylergonovine is an ergot alkaloid used for postpartum hemorrhage. It stimulates contraction of the uterus and causes arterial vasoconstriction. Ergot alkaloids are avoided in women with significant cardiovascular disease, peripheral disease, hypertension, eclampsia, or preeclampsia. Such conditions are worsened by the vasoconstrictive effects of the ergot alkaloids. The nurse would assess the woman's blood pressure before administering the medication and would follow agency protocols regarding withholding of the medication. Options 1, 2, and 3 are items that are assessed in the postpartum period, but they are unrelated to the use of this medication.

A nurse is providing morning care to a client who has a closed chest tube drainage system to treat a pneumothorax. When the nurse turns the client to the side, the chest tube is accidentally dislodged from the chest. The nurse immediately applies sterile gauze over the chest tube insertion site. Which is the nurse's next action? 1. Call the health care provider. 2. Replace the chest tube system. 3. Obtain a pulse oximetry reading. 4. Place the client in a Trendelenburg position.

Call the health care provider. If the chest drainage system is dislodged from the insertion site, the nurse immediately applies sterile gauze over the site and calls the health care provider. The nurse would maintain the client in an upright position. A new chest tube system may be attached if the tube requires insertion, but this would not be the next action. Pulse oximetry readings would assist in determining the client's respiratory status, but the priority action would be to call the health care provider in this emergency situation.

nurse is performing an admission assessment on a client with tuberculosis (TB) and is collecting subjective and objective data. Which finding would the nurse expect to note? 1. High fever 2. Flushed skin 3. Complaints of weight gain 4. Complaints of night sweats

Complaints of night sweats Rationale: The client with TB usually experiences a low-grade fever, weight loss, pallor, chills, and night sweats. The client also will complain of anorexia and fatigue. Pulmonary symptoms include a cough that is productive of a scant amount of mucoid sputum. Purulent, blood-stained sputum is present if cavitation occurs. Dyspnea and chest pain occur late in the disease.

A nurse is monitoring a newborn infant who has been circumcised. The nurse notes that the infant has a temperature of 100.6° F and that the dressing at the circumcised area is saturated with a foul-smelling drainage. Which is the priority nursing action? 1. Reinforce the dressing. 2. Document the findings. 3. Contact the health care provider. 4. Swab the drainage and send the sample to the laboratory for culture.

Contact the health care provider. Complications after circumcision include bleeding, failure to urinate, displacement of the Plastibell, and infection (indicated by a fever and a purulent or foul-smelling drainage). If signs of infection occur, the health care provider is notified. The nurse would change, not reinforce, the dressing; reinforcing the dressing leaves the foul smelling drainage in contact with the surgical site. The nurse would document the findings, but this is not the priority item. The health care provider will prescribe a culture if it is necessary; it is not within the realm of nursing responsibilities to prescribe a diagnostic test.

The nurse is assessing a client with a suspected diagnosis of hypocalcemia. Which cardiovascular manifestation would the nurse expect to note? 1. Hypotension 2. Increased heart rate 3. Bounding peripheral pulses 4. Shortened QT interval on electrocardiography (ECG)

Hypotension Rationale: Cardiovascular manifestations that occur with hypocalcemia include decreased heart rate, diminished peripheral pulses, and hypotension. On the electrocardiogram (ECG), the nurse would note a prolonged ST interval and a prolonged QT interval.

A nurse provides dietary instructions to a client at risk for hypokalemia about which foods are high in potassium and should be included in the daily diet. The nurse should tell the client that which fruit is highest in potassium? 1. Kiwi 2. Apples 3. Peaches 4. Pineapple

Kiwi Rationale: Foods that are high in potassium include bananas, cantaloupe, kiwi, and oranges. Fruits low in potassium include apples, cherries, grapefruit, peaches, pineapple, and cranberries.

The nurse is monitoring a client who is attached to a cardiac monitor and notes the presence of U waves. The nurse assesses the client and checks his or her most recent electrolyte results. The nurse expects to note which electrolyte value? 1. Sodium 135 mEq/L 2. Sodium 140 mEq/L 3. Potassium 3.0 mEq/L 4. Potassium 5.0 mEq/L

Potassium 3.0 mEq/L Rationale: The normal sodium level is 135 to 145 mEq/L. The normal potassium level is 3.5 to 5.0 mEq/L. A serum potassium level lower than 3.5 mEq/L is indicative of hypokalemia. In hypokalemia, the electrocardiographic (ECG) changes that occur include inverted T waves, ST segment depression, heart block, and prominent U waves.

A client is found to have rape trauma syndrome. The nurse plans care for the client knowing that which occurs in this condition? 1. More than one assault 2. Re-experiencing recollections of the trauma 3. Actively initiating situations in which sex is forced 4. Imagining the use of foreign objects in a sexual situation

Re-experiencing recollections of the trauma Rationale: The major trauma of rape or sexual assault involves the victim's emotional reaction to being physically forced to do something against his or her will. The life-threatening nature of the crime and feelings of helplessness, loss of control, and experiencing the self as an object of the perpetrator's rage combine to produce the victim's overpowering fear and stress. In this syndrome, which has been called rape trauma syndrome, the client re-experiences the trauma, as evidenced by recurrent recollections of the event. Options 1, 3, and 4 are not associated with rape trauma syndrome.

The nurse is preparing to care for a client with immunodeficiency. The nurse should plan to address which problem as the priority? 1. Anxiety 2. Fatigue 3. Risk for infection 4. Need for social isolation

Risk for infection The client with immunodeficiency has inadequate or no immune bodies and is at risk for infection. The priority concern would be risk for infection. The question presents no data indicating that the client is experiencing anxiety. Fatigue may be a problem and the client may need to be placed on protective isolation but these are not the priority problems for this client. Infection can be life-threatening and is the priority.

A nurse is preparing a pregnant woman for a transvaginal ultrasound examination. The nurse should tell the woman that which will occur? 1. She will feel some pain during the procedure. 2. She will be placed in a supine left side-lying position. 3. She will feel some pressure when the vaginal probe is moved. 4. She will need to drink 2 quarts of water to attain a full bladder.

She will feel some pressure when the vaginal probe is moved. Transvaginal ultrasonography, in which a lubricated probe is inserted into the vagina, allows evaluation of the pelvic anatomy. A transvaginal ultrasound examination is well tolerated by most women because it alleviates the need for a full bladder to perform the test. The woman is placed in a lithotomy position or with her pelvis elevated by towels, cushions, or a folded blanket. The procedure is not physically painful, although the woman may feel pressure as the probe is moved.

A nurse is gathering data from a client with a phobia. The client tells the nurse that he consistently avoids attending community functions because he fears that he will be asked to speak publicly to the members. On the basis of this information, the nurse determines that the client is experiencing which condition? 1. Nyctophobia 2. Social phobia 3. Agoraphobia 4. Claustrophobia

Social phobia Rationale: Social phobias are characterized by severe anxiety or fear provoked by exposure to a social situation or a performance situation. Fear of public speaking is the most common social phobia. Nyctophobia is a fear of darkness. Agoraphobia is a fear of open spaces. Claustrophobia is a fear of closed places.

The nurse is caring for a client who is receiving oxytocin (Pitocin) for induction of labor and notes a nonreassuring fetal heart rate (FHR) pattern on the fetal monitor. On the basis of this finding, the nurse should take which action first? 1. Stop the oxytocin infusion. 2. Check the client's blood pressure. 3. Check the client for bladder distention. 4. Place the client in a side-lying position.

Stop the oxytocin infusion. Oxytocin stimulates uterine contractions and is used to induce labor. If uterine hypertonicity or a nonreassuring FHR pattern occurs, the nurse needs to intervene to reduce uterine activity and increase fetal oxygenation. The oxytocin infusion is stopped, the client is placed in a side-lying position, and oxygen by face mask at 8 to 10 L/min is administered. The health care provider is notified. The nurse would monitor the client's blood pressure and intake and output; however, the nurse would first stop the infusion.

An older client is seen in the clinic for a physical examination. Laboratory studies reveal that the hemoglobin and hematocrit levels are low, indicating the need for further diagnostic studies and a blood transfusion. The client is a Jehovah's Witness and refuses to have a blood transfusion. The nurse should take which most appropriate action? 1. Try to convince the client of the need for the transfusion. 2. Speak to the family regarding the need for a blood transfusion. 3. Support the client's decision not to receive a blood transfusion. 4. Discuss with the client the results of the hemoglobin and hematocrit levels compared with normal levels.

Support the client's decision not to receive a blood transfusion. A client's cultural and ethnic background influences the response to health, illness, surgery, and death. Awareness of cultural differences enhances the nurse's knowledge of how a health care experience may be perceived by the client or family. In the Jehovah's Witness religion, the administration of blood and blood products is forbidden; therefore the nurse would support the client's decision. Trying to convince the client of the need for the blood transfusion is inappropriate and does not respect the client's cultural beliefs. Speaking to the family is a violation to the client's right to confidentiality; in addition, it does not respect the client's cultural beliefs. Discussing the results of laboratory values is an indirect way of trying to convince the client of the need for a blood transfusion, which again is inappropriate and does not respect the client's cultural beliefs.

The nurse is providing home care instructions to the mother of a child who has bacterial conjunctivitis. The nurse should provide the mother with which information? 1. The child may attend school if antibiotics have been started. 2. Any unused eye medication should be saved in case a sibling gets the eye infection. 3. The child's towels and washcloths should not be used by other members of the household. 4. Any crusted material should be wiped from the eye with a cotton ball soaked in warm water, starting at the outer aspect of the eye and moving toward the inner aspect.

The child's towels and washcloths should not be used by other members of the household. Bacterial conjunctivitis is highly contagious, and infection control measures should be taught. These include good handwashing and not sharing towels or washcloths with others. The child should be kept home from school until 24 hours after antibiotics are started. Bottles of eye medication should never be shared with others. Crusted material may be wiped from the eye with a cotton ball soaked in warm water, starting at the inner aspect of the eye and moving toward the outer aspect.

The nurse instructs a client regarding pursed-lip breathing and asks the client to demonstrate the breathing technique. Which observation by the nurse would indicate that the client is performing the technique correctly? 1. The client breathes in through the mouth. 2. The client breathes out slowly through the mouth. 3. The client avoids using the abdominal muscles to breathe out. 4. The client puffs out the cheeks when breathing out through the mouth.

The client breathes out slowly through the mouth. Rationale: Pursed-lip breathing facilitates maximal expiration for clients with obstructive lung disease. The client should close the mouth and breathe in through the nose. The client then purses the lips and breathes out slowly through the mouth, without puffing the cheeks. The client should spend at least twice the amount of time breathing out that it took to breathe in. The client should use the abdominal muscles to assist in squeezing out all of the air. The client also is instructed to use this technique during any physical activity, inhale before beginning the activity, and exhale while performing the activity. The client is also instructed that he or she should never hold the breath.

A nurse is checking lochia discharge in a woman in the immediate postpartum period. The nurse notes that the lochia is bright red and contains some small clots. Based on this data, the nurse should make which interpretation? 1. The client is hemorrhaging. 2. The client needs to increase oral fluids. 3. The client is experiencing normal lochia discharge. 4. The client's health care provider needs to be notified of the finding.

The client is experiencing normal lochia discharge. Lochia, the uterine discharge present after birth, initially is bright red and may contain small clots. During the first 2 hours after birth, the amount of uterine discharge should be approximately that of a heavy menstrual period. After that time, the lochial flow should steadily decrease, and the color of the discharge should change to a pinkish red or reddish brown. Because this is a normal, expected occurrence, options 1, 2, and 4 are incorrect.

A nurse in the health care provider's office is performing a postoperative assessment of a client who underwent mastectomy of her right breast 2 weeks ago. The client tells the nurse that she is very concerned because she has numbness in the area of the surgery and along the inner side of the arm from the armpit to the elbow. The nurse should provide which information to the client about her complaint? 1. These sensations are signs of a complication. 2. These sensations probably will be permanent. 3. These sensations dissipate over several months and usually resolve after 1 year. 4. It is nothing to worry about because most women who have this type of surgery experience this problem.

These sensations dissipate over several months and usually resolve after 1 year. Rationale: Numbness in the area of the surgery and along the inner side of the arm from the armpit to the elbow occurs in most women after mastectomy. It is a result of injury to the nerves that provide sensation to the skin in those areas. These sensations may be described as heaviness, pain, tingling, burning, or "pins and needles." These sensations dissipate over several months and usually resolve by 1 year after surgery. These sensations are not a sign of a complication and are not permanent. The nurse would not tell the client that a complaint is nothing to worry about because this is nontherapeutic and avoids the client's concern.