Unit 7- Reduction of Risk Potential

The nurse is preparing a laboring client for internal electronic fetal monitoring (EFM). Which finding requires nursing intervention?

The membranes are intact. Internal EFM can be used only after the client's membranes rupture, when the cervix is dilated at least 2 cm, and when the presenting part is at least at -1 station. Anesthesia is not required for internal EFM.

A primigravid client has just completed a difficult, forceps-assisted birth of a 9-lb (4.08-Kg) neonate. Her labor was unusually long and required oxytocin augmentation. The nurse who's caring for her should stay alert for uterine

atony. A large fetus, extended labor, stimulation with oxytocin, and traumatic birth commonly are associated with uterine atony, which may lead to postpartum hemorrhage. Uterine inversion may precede or follow birth and commonly results from apparent excessive traction on the umbilical cord and attempts to deliver the placenta manually. Uterine involution and some uterine discomfort are normal after childbirth.

Which symptom should the nurse teach the client with unstable angina to report immediately to the health care provider (HCP)?

a change in the pattern of the chest pain The client should report a change in the pattern of chest pain. It may indicate increasing severity of coronary artery disease. Pain occurring during stress or sexual activity would not be unexpected, and the client may be instructed to take nitroglycerin to prevent this pain. Pain during or after an activity such as lawn mowing also would not be unexpected; the client may be instructed to take nitroglycerin to prevent this pain or may be restricted from doing such activities.

An agitated, confused client arrives in the emergency department. The client's history includes type 1 diabetes, hypertension, and angina pectoris. Assessment reveals pallor, diaphoresis, headache, and intense hunger. A stat blood glucose sample measures 42 mg/dl, (2.3 mmol/L) and the client is treated for an acute hypoglycemic reaction. After recovery, the nurse teaches the client to treat hypoglycemia by ingesting

15 g of a simple carbohydrate. To reverse hypoglycemia, the American Diabetes Association (Canadian Diabetes Association) guidelines recommend ingesting 15 g of a simple carbohydrate, such as 15 g of glucose tablets, 3 teaspoons (15 mL) or 3 packets of table sugar dissolved in water, 3/4 cup (175 mL) of juice or regular soft drink, 6 LifeSavers (1 = 2.5 g carbohydrate), or a 1 tablespoon (5 mL) of honey. Then the client should check their blood glucose after 15 minutes. If necessary, this treatment may be repeated in 15 minutes. Ingesting only 2 to 5 g of a simple carbohydrate may not raise the blood glucose level sufficiently. Ingesting more than 15 g may raise it above normal, causing hyperglycemia.

A nurse is evaluating the parents' comprehension of their child's diagnosis of celiac disease. Which statements indicate a need for further teaching?

"We will need to bring our child in for regular blood work to monitor the disease." Teaching is effective if the parents say that their child must maintain the dietary restrictions for life, because the child needs to avoid recurrence of the disease's clinical manifestations. Celiac disease is an autoimmune disorder that can cause vitamin deficiencies and neurological manifestations. The symptoms can vary from person to person. However, regular lab work is not needed.

Several days before admission, a client reports finding a small lump in the left breast near the nipple. What should the nurse tell the client to do?

Inform the physician immediately. The client should notify the physician immediately because a breast lump may be a sign of breast cancer. The client shouldn't squeeze the nipple to check for drainage until the physician examines the area. The client shouldn't wait until after the next menstrual period to inform the physician of the breast lump because prompt treatment may be necessary. Placing a heating pad on the area would have no effect on a breast lump.

When measuring gastric residual volume in a client receiving continuous tube feeding through a gastrostomy tube, the nurse attaches a large syringe to the tube and withdraws all fluid remaining in the stomach. After noting the amount of fluid, what should the nurse do?

Readminister the aspirated fluid through the feeding tube The aspirated fluid should be readministered to the client through the feeding tube when measuring gastric residual volumes. This prevents the loss of fluids, electrolytes, nutrients and medications that are in that gastric fluid. Discarding the aspirated fluid, either into a biohazard container or down the toilet, results in the loss of important fluids, electrolytes, nutrients and possibly medications, putting the client at risk for a wide variety of complications. Adding the aspirated fluid to the bag of formula would contaminate the entire bag of formula, making it spoil quicker than normal, and could also put the client at risk for infection or complications from spoiled formula.

A client at term arrives in the labor and delivery unit experiencing contractions every 4 minutes. After a brief assessment, the client is admitted, and an electronic fetal monitor is applied. Which assessment finding would be most concerning to the nurse?

blood pressure of 146/90 mm Hg A blood pressure of 146/90 mm Hg may indicate gestational hypertension. Over time, gestational hypertension reduces blood flow to the placenta and can cause intrauterine growth restriction, and other problems that reduce the fetus's ability to tolerate the stress of labor. A weight gain of 30 lb (13.6 kg) is within expected parameters for a healthy pregnancy. A woman over age 30 doesn't have a greater risk of complications if her general condition is healthy before pregnancy. Syphilis that has been treated does not pose an additional risk.

The nurse is teaching an adolescent with celiac disease about dietary changes that will help maintain a healthy lifestyle. Which of the following foods can the nurse safely recommend as part of the adolescent's diet? Select all that apply.

potatoes apples corn Celiac disease is an intolerance to the gluten factor of protein found in grains. Specific grains to be removed from the diet include wheat, rye, oats, and barley. Clients with a diagnosis of celiac disease can tolerate corn, fruits, and vegetables.

The nurse teaches the client with a demand pacemaker that the device functions by providing stimuli to the heart muscle:

when the heart rate falls below a specified level. A demand pacemaker functions only when the heart rate falls below a certain level. A fixed-rate pacemaker stimulates heart contractions at a constant rate independent of the client's heart rate. Fixed-rate pacemakers are much less common than demand pacemakers.A pacemaker is not used to provide cardioversion or defibrillation for cardiac arrhythmias (i.e., when the heart begins to beat irregularly).For a client with ventricular fibrillation, a potentially life-threatening arrhythmia, an implanted defibrillator is used.

A client taking furosemide and digoxin for exacerbation of heart failure reports weakness and heart fluttering. What would be the priority action by the nurse?

Investigate the symptoms further with the client and suggest contacting the physician. Furosemide is a potassium-wasting diuretic. A low potassium level may cause weakness and palpitations. Telling the client to rest does not address the priority. Telling the client to stop the digoxin is out of scope of practice. Addressing the diet does not answer the question.

Which finding will the nurse assess in a client diagnosed with peritonitis?

abdominal wall rigidity Abdominal wall rigidity is a common manifestation of peritonitis. Bowel sounds may or may not be present in peritonitis. A positive Cullen's sign is a manifestation of acute pancreatitis, and Battle's sign is a manifestation of skull fractures.

A nurse is assessing a client with bipolar disorder. Findings include coarse hand tremors, muscle twitching, and mental confusion. These findings suggest:

lithium toxicity. Symptoms of lithium toxicity include muscle twitching, mental confusion, incoordination, and coarse hand tremors. Symptoms of severe lithium toxicity include ataxia, giddiness, blurred vision, and severe hypotension. These findings don't indicate hypomania or manic behaviors.

A client who has been using a combination of drugs and alcohol is admitted to the emergency unit. Behavior has been combative and disoriented. The client has now become uncoordinated and incoherent. What is the priority action by the nurse?

Complete a thorough assessment, including a Glasgow Coma Scale, and place the client in a location for frequent monitoring. This client has been ingesting an unknown amount of drugs and alcohol and is now exhibiting a change in neurologic status. It is a priority to carefully assess and closely monitor for any deterioration. The other choices are incorrect because a family member is not qualified to monitor the client. The client would eventually be referred to an addiction team but is not medically stable. Sedation is not appropriate at this time.

To help minimize calcium loss from a hospitalized client's bones, the nurse should

encourage the client to walk in the hall. Calcium absorption diminishes with reduced physical activity because of decreased bone stimulation. Therefore, encouraging the client to increase physical activity, such as by walking in the hall, helps minimize calcium loss. Turning or repositioning the client every 2 hours wouldn't increase activity sufficiently to minimize bone loss. Providing dairy products and supplemental feedings wouldn't lessen calcium loss — even if the dairy products and feedings contained extra calcium — because the additional calcium doesn't increase bone stimulation or osteoblast activity.

The correct landmark for obtaining an apical pulse is the

left fifth intercostal space, midclavicular line. The correct landmark for obtaining an apical pulse is the left fifth intercostal space in the midclavicular line. This area is the point of maximum impulse and the location of the left ventricular apex. The left second intercostal space in the midclavicular line is where the nurse auscultates pulmonic sounds. The apical pulse isn't obtained at the midaxillary line or the seventh intercostal space in the midclavicular line.

The nurse is instructing the client about postoperative care following cataract removal. What position should the nurse teach the client to use?

Remain in a semi-Fowler's position. The nurse should instruct the client to remain in a semi-Fowler's position or on the nonoperative side. Positioning the feet higher than the body does not affect the operative eye; placing the head in a dependent position could increase pressure within the eyes.

A pregnant client's hepatitis B report reads "HBsAg = positive." Which correctly describes the client's hepatitis B status?

infected The presence of HBsAg in serum (i.e., HBsAg = positive) identifies an infected person in either an acute or chronic carrier state. To be considered immune, the presence of Anti-HBs with a negative HBsAg is identified in the serum. A carrier refers to those clients who have had a positive serum HBsAg for longer than 6 months but are often unaware they are a carrier because they display no signs or symptoms, do not develop chronic hepatitis, and do not require treatment.

A client asks a nurse a question about the tuberculin skin test for tuberculosis. The nurse should base their response on the fact that the

skin test doesn't differentiate between active and dormant tuberculosis infection. The tuberculin skin test doesn't differentiate between active and dormant infections. If a positive reaction occurs, a sputum smear and culture as well as a chest X-ray are necessary to provide more information. Although the area of redness is measured in 3 days, a second test may be needed; neither test indicates that tuberculosis is active. In the tuberculin skin test, an induration 5 to 9 mm in diameter indicates a borderline reaction; a larger induration indicates a positive reaction. The presence of a wheal within 2 days doesn't indicate active tuberculosis.

The nurse is monitoring a client who was given midazolam during a moderate sedation procedure. In the immediate postprocedure phase, the client becomes unresponsive to painful stimuli and apneic. The nurse should give which medication?

flumazenil Flumazenil is a benzodiazepine antagonist and is used to reverse benzodiazepines such as midazolam, and the nurse should give flumazenil to this client who is showing symptoms of a benzodiazepine overdose. Propofol is a sedation medication, and would not be indicated for central nervous system depression and apnea. Ketorolac is a nonsteroidal antiinflammatory pain medication and would not be helpful for this client. Naloxone is an opioid antagonist, and reverses the effects of narcotic pain medications, but does not reverse midazolam because it is a benzodiazepine, not an opioid.

A client is experiencing contractions every 3 minutes, right occiput posterior (ROP) position, intact membranes, and a moderate amount of bloody show. The quality of the tracing on the external fetal monitor is poor, and the nurse would like to place an internal fetal scalp electrode (FSE) to assess the baby better. Which of these prevents the nurse from being able to complete this activity?

the intact membranes An FSE may not be applied with intact amniotic membranes. In order to reach the fetal scalp and apply the electrode, the membranes must be ruptured, the cervix must be dilated a minimum of 2 cm, and the presenting part must be accessible by vaginal exam. An amniotomy must be performed instead. Bloody show may be present and uterine contractions may occur regardless of whether the membranes are ruptured.

The nurse reviews the plan of care for the child with leukemia who is at risk for bleeding. Which intervention would the nurse question?

IM injections For a child with leukemia who is at risk for bleeding, all treatments should be performed gently. However, all injections should be limited or avoided as much as possible to reduce the risk of tissue injury and subsequent bleeding and bruising.Stool softeners are used to facilitate bowel elimination by preventing the passage of hard stool that may damage the rectal mucosa and subsequently lead to bleeding.Frequent position changes in bed help maintain skin integrity and minimize the risk of trauma to the skin, thereby reducing the possibility of bleeding and bruising secondary to this trauma.Visits with friends and siblings are important for adequate growth and development of the child. Visitation would be curtailed if the child were at risk for possible infection secondary to a decreased neutrophil count.

The nurse is monitoring a client who is receiving moderate sedation for a procedure. The client begins to display signs of restlessness and agitation. What assessment does the nurse perform first?

oxygen saturation When a client has received sedation, hypoxemia is a potential complication and should be suspected and assessed for immediately at the first signs of restlessness and agitation, as these can be early signs of hypoxemia. Hypoxemia can cause rapid decompensation and lead to respiratory or cardiopulmonary arrest if not rapidly identified and corrected. Fear and pain are also possible causes of restlessness and agitation, and should be assessed for, but not until after the nurse has ascertained that the client is not hypoxemic. The level of consciousness will be altered due to the moderate sedation and being too alert could be a sign of undersedation. This should be assessed but is not a priority over the oxygen level.

The pediatric client was given ketamine for moderate sedation. As the client recovers from the procedure, what intervention should the nurse implement based on knowledge of this medication? Select all that apply.

Maintain a calm, quiet environment. Allow the primary caregiver to be present. Speak in a reassuring, kind tone of voice. Ketamine can cause emergence reactions, due to its dissociative and amnesic properties, causing vivid dreams, hallucinations, and floating feelings. Maintaining a calm environment, speaking in a reassuring, kind tone of voice, and allowing the primary caregiver to be present would all be caring interventions to help the client recover from ketamine administration in a positive way, relieving stress and anxiety in the client. Providing a lot of stimulation to help the client wake up could cause fear and anxiety in the client still partially under the effects of ketamine. Following any moderate sedation procedure, the nurse should monitor respiratory status, but also airway, cardiovascular status, pain, level of consciousness, the procedural site, and more.

A client with type I diabetes mellitus is scheduled to have surgery. The client has been nothing-by-mouth (NPO) since midnight. In the morning, the nurse notices the client's daily insulin has not been prescribed. Which action should the nurse do first?

Obtain the client's blood glucose at the bedside. The nurse should first obtain the blood glucose level and then contact the health care provider to clarify whether the client's usual insulin dose should be given before surgery; having the blood glucose level is objective information that the health care provider may need to know before making a final decision as to the insulin dosage. The nurse should not assume that the usual insulin dose is to be given. It is not appropriate for the nurse to defer decision-making on this issue until after the surgery.

The mother calls the nurse to report that her toddler has just been burned on the arm. What should the nurse should advise the mother to first?

Run cool water over the burned area, and then wrap it in a clean cloth. The best advice for the nurse to give the child's mother is to run cool water over the burned area to stop the burning process. Then the area should be wrapped in a clean cloth. Once these initial actions are completed, the mother can call the child's HCP. Packing the arm in ice may cause more damage to the burned area because cold can cause burns just as heat can. For most burns, it is not advised to apply ointment until the area has been evaluated.

The nurse is helping to prepare a client for nonemergency surgery. What should the nurse do?

Verify the client understands the informed consent form. The surgeon is responsible for explaining the surgical procedure to be performed and the risks of the procedure, as well as for obtaining the informed consent from the client. A nurse may be responsible for obtaining and witnessing a client's signature on the consent form. The nurse is the client's advocate, verifying that a client (or family member) understands the consent form and its implications, and that consent for the surgery is truly voluntary.

Which choice demonstrates best nursing practice when performing tracheostomy care on a client who is 8 hours post new insertion?

Use sterile gloves during the procedure. The tracheotomy site is a portal of entry for microorganisms. Sterile technique must be used within the first 24-48 hours because the site is a new source of infection. Monitoring the client's temperature is not reflected in application of this question. Povidone-iodine destroys new cellular growth, so it is not used on open wounds. The client should be in high Fowler's, not semi-Fowler's position.

Which statement by a caregiver of a toddler with nephrotic syndrome indicates that the nurse's discharge teaching was effective?

"I have been checking the urine for protein so I will be able to do it at home." The caregiver stating that a check of the toddler's urine for protein indicates effective teaching because such testing helps detect the progression of nephrotic syndrome. Home care instructions include having the urine checked for protein regularly while the toddler is on medications for treatment. The toddler only needs to be on salt and water restriction during the edema phase of the illness. Once this has passed the toddler can resume a regualr diet. The caregiver would not need special dietary foods for the toddler at home. Staying on a low-sodium diet is not necessary or required to prevent damage to the kidneys. The toddler may need to be treated more than once for nephrotic syndrome as relapses can occur.

A nurse is caring for a client in skeletal traction to the left leg. The client reports pain of 8 on the 0- to-10 pain scale while the nurse is in the client's room. Which action would the nurse take first?

Assess the client's alignment in bed. The client in traction who reports moderate-to-severe pain may need realignment in bed. This also requires assessment of the client, which is completed prior to all other options. The traction weight is prescribed and the nurse will not change this independently. The health care provider would not be notified until an assessment is completed. Retrieving the medication means leaving the client's bedside. The nurse should assess the client's position first while at the bedside.

What is the priority nursing intervention in the postictal phase of a seizure?

Assess the client's breathing pattern. A priority for the client in the postictal phase (after a seizure) is to assess the client's breathing pattern for effective rate, rhythm, and depth. The nurse should apply oxygen and ventilation to the client as appropriate. Other interventions, to be completed after the airway has been established, include reorientation of the client to time, person, and place. Determining the client's level of sleepiness is useful, but it is not a priority. Positioning the client comfortably promotes rest but is of less importance than ascertaining that the airway is patent.

A 6-month-old child is discharged with a urinary stent after a procedure to repair a hypospadias. What instructions should the nurse give the parents?

Avoid tub baths until the stent is removed. The parents should keep the penis as dry as possible until the stent is removed. Soaking in a tub bath is not recommended. Children this age typically go home voiding directly into a diaper. Infants may be started on juice at 6 months of age. Parents are advised to keep their child well hydrated after a hypospadius repair. Therefore, there is no reason to avoid juice. Cleaning the tip of the penis three times a day may cause unnecessary irritation.

Following a splenectomy, a client has a hemoglobin (Hb) level of 7.5 g/dl and has vertigo when getting out of bed. The nurse suspects abnormal orthostatic changes. What vital sign values most support the nurse's analysis?

Blood pressure of 80/40 mm Hg and pulse of 130 beats per minute. The client had blood loss during the splenectomy and developed subsequent anemia. With a subnormal Hb level and vertigo when getting out of bed, the nurse is accurate in suspecting orthostasis. Orthostatic changes develop from hypovolemia and cause a drop in blood pressure (evidenced by a blood pressure of 80/40 mm Hg) and a compensatory rise in the heart rate (evidenced by a pulse of 130 beats per minute) when the client rises from a lying position.

The home health nurse is visiting an 80-year-old client diagnosed with Alzheimer's dementia. During the visit, the nurse notes bruising on the client's face and upper arms in various shades of healing. The client is unable to communicate effectively because of the disease progression. What is the nurse's responsibility in this situation? Select all that apply.

Bring up the suspected physical abuse with a trusted authority figure. Report the suspicion to the local Adult Protective Services Agency within 24 hours. A nurse is a mandated reporter of abuse. If the nurse suspects abuse, they must report it to the local Adult Protective Services Agency. You can protect seniors by bringing up the issue of abuse with a trusted authority member. Trying to convince a client with dementia to report the abuse themselves is inappropriate and since the nurse is a mandated reporter, monitoring, or doing nothing is not an appropriate nursing action.

The nurse is caring for a primagravida in active labor. The provider performs an amniotomy to augment labor. What is the nurse's priority action after the procedure is completed?

Check the fetal heart rate for bradycardia. After a client has an amniotomy, the nurse should ensure that the cord is not prolapsed and that the fetus tolerated the procedure well. The most effective way to do this is to check the fetal heart rate. Fetal well-being is assessed via a nonstress test. Fetal position is determined by vaginal examination. Artificial rupture of membranes does not indicate an imminent birth.

A client has nephropathy. The health care provider (HCP) prescribes a 24-hour urine collection for creatinine clearance. Which action is necessary to ensure proper collection of the specimen?

Collect the urine in a preservative-free container and keep it on ice. All urine for creatinine clearance determination must be saved in a container with no preservatives and refrigerated or kept on ice. The first urine voided at the beginning of the collection is discarded, not the last. A self-report of weight may not be accurate. It is not necessary to have an indwelling urinary catheter inserted for urine collection.

Which information would the nurse include in the teaching plan for a 32-year-old female client requesting information about using a diaphragm for family planning?

Diaphragms should not be used if the client develops acute cervicitis. The teaching plan should include a caution that a diaphragm should not be used if the client develops acute cervicitis, possibly aggravated by contact with the rubber of the diaphragm. Some studies have also associated diaphragm use with increased incidence of urinary tract infections. Douching after use of a diaphragm and intercourse is not recommended because pregnancy could occur. The diaphragm should be inspected and washed with mild soap and water after each use. A diaphragm should be left in place for at least 6 hours but no longer than 24 hours after intercourse. More spermicidal jelly or cream should be used if intercourse is repeated during this period.

A client arrives at the emergency department with chest and stomach pain and a report of black, tarry stools for several months. Which diagnostic testing would the nurse anticipate?

ECG (electrocardiogram), complete blood count, testing for occult blood, and comprehensive serum metabolic panel Diagnostic testing is one source of information leading to a medical diagnosis. It is correct to anticipate cardiac and gastrointestinal studies due to the client's signs and symptoms. An ECG evaluates the report of chest pain, laboratory tests determine anemia, and the test for occult blood determines blood in the stool. Cardiac monitoring, oxygen, and creatine kinase, and LD levels are appropriate for a primary cardiac problem. A basic metabolic panel and alkaline phosphatase and aspartate aminotransferase levels assess liver function. PT, PTT, fibrinogen, and fibrin split products are measured to verify bleeding dyscrasias. An EEG evaluates brain electrical activity.

A client on prolonged bed rest has developed a pressure ulcer. The wound shows no signs of healing even though the client has received skin care and has been turned every 2 hours. What is the best action by the nurse?

Evaluate client protein levels. Clients on bed rest suffer from lack of movement and a negative nitrogen balance. Therefore, inadequate protein intake impairs wound healing. The nurse would evaluate the client's protein status by reviewing laboratory data. If protein stores are low, a dietician consult would be warranted. Increasing viatimin D and overall caloric intake will have little effect on a client's wound healing. A pressure ulcer should never be massaged.

The nurse is providing preoperative instructions to a client who is deaf. Which strategy is most effective in assuring that the client understands the information?

Give the client written material to read, and follow up with time for questions. A client who is deaf benefits most from reading information and then having an opportunity to ask questions and follow up. Verbal communication, while appropriate, may not be sufficient. The spouse can be included in the teaching, but the nurse is responsible for ensuring that the client understands the instructions. DVDs may be helpful, but unless they have closed captioning, key points may be missed in the audio portion.

When developing a teaching plan for the parent of an asthmatic child concerning measures to reduce allergic triggers, which suggestion should the nurse include?

Have the child bring his or her own pillow when sleeping away from home. Down pillows and exposure to dust mites are common allergic triggers. The family can reduce exposure to bedding related allergens during travel or sleeps overs by having the child bringing a pillow from home. Typically, the child with asthma should sleep in the top bunk bed to minimize the risk of exposure to dust mites. The risk of exposure to dust mites increases when the child sleeps in the bottom bunk bed because dust mites fall from the top bed, settling in the bottom bed. Scented sprays should be avoided because they may trigger an asthmatic episode. Ideally, carpeting should be avoided in the home if the child has asthma. However, if it is present, carpeting in the child's room should be vacuumed often, possibly daily, to remove dust mites and dust particles.

The nurse is preparing a client for surgery. Although the client can speak English, English is the client's second language. The client has completed high-school level education. When the nurse asks the client what type of surgery is scheduled, the client is unable to provide an answer. What should the nurse do next?

Notify the health care provider that the client cannot explain the scheduled surgery. The nurse should ask the health care provider to explain the surgery to the client again and ensure the client understands the procedure and the risks. If necessary, the nurse can call an interpreter. It is the role of the health care provider to explain the surgical procedure, not the nurse. The nurse cannot continue to prepare the client until the health care provider has explained the surgery and the client agrees to proceed. The nurse should then document the client's response and nurse's action after notifying the health care provider of the need to reexplain the procedure to the client.

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

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

The nurse is assessing for blood return from a client's implanted port. Which nursing intervention is appropriate to assure that the needle will be flushed with pure saline?

Prevent blood from entering the saline flush syringe. To assure that the needle will be flushed with pure saline, the nurse does not allow blood to enter the saline flush syringe when assessing for blood return from an implanted port. Washing hands prevents contamination, drawing the least amount of blood prevents overwasting, and flushing with heparin prevents clots.

A client is scheduled for an appendectomy. What is the nurse's highest priority when planning preoperative teaching for this client?

The client should begin coughing and deep-breathing exercises as soon as the client is able to follow instructions. The nurse should encourage the client to cough and breathe deeply as soon as possible after surgery to help prevent atelectasis and pneumonia. The nurse shouldn't encourage the client to take food or fluids until bowel sounds are present (usually 24 hours postoperatively). Wound infection is a concern, but usually not during the first postoperative day. The nurse should assess the client's skin every 2 hours when made to either change position or get out of bed.

What measure should the nurse take that will be most helpful in preventing wound infection when changing a client's dressing after coronary artery bypass surgery?

Wash hands before changing the dressing. Many factors help prevent wound infections, including washing hands carefully, using sterile prepackaged supplies and equipment, cleaning the incisional area well, and disposing of soiled dressings properly. However, most authorities say that the single most effective measure in preventing wound infections is to wash the hands carefully before and after changing dressings. Careful hand washing is also important in reducing other infections often acquired in hospitals, such as urinary tract and respiratory tract infections.

A client is taking clozapine and complains of a sore throat. This symptom may be an indication of which adverse reaction?

agranulocytosis The complaint of a sore throat may indicate an infection caused by agranulocytosis, a depletion of white blood cells. Although extrapyramidal reaction and tardive dyskinesia may occur, a sore throat isn't an indication of these conditions. Reye's syndrome is caused by a virus unrelated to clozapine.

A pregnant woman states that she frequently ingests laundry starch. The nurse should assess the client for which condition?

anemia all pregnant clients should be screened for pica, or the ingestion of nonfood substances, such as clay, dirt, or laundry starch. Commonly, clients who practice pica are anemic.Muscle spasms are not associated with the ingestion of laundry starch. However, they may be related to seizure disorder or seizure activity or a calcium deficiency.Lactose intolerance is not associated with the ingestion of laundry starch. Lactose intolerance would occur when the client ingests milk or milk products.Diabetes mellitus is not associated with the ingestion of laundry starch. Diabetes mellitus is associated with abnormal glucose levels, excessive thirst, and frequent voiding.

When teaching the parents about an echocardiogram scheduled for their child, the nurse should explain that the primary reason for this procedure is to determine which factor?

cardiac muscle structure An echocardiogram records the structure of the heart muscle and provides a graphic representation of the heart working.An echocardiogram does not provide information about the pressure or amount of the blood in the heart. Cardiac catheterization is used to measure the pressure in the heart chambers and major vessels and the amount of blood entering the heart.Auscultation with a stethoscope is required to detect the various sounds made with each heartbeat. A phonocardiogram provides a graphic representation of heart sounds.

When taking a diet history from the mother of a 7-year-old child with phenylketonuria, a report of an intake of which food should cause the nurse to gather additional information?

diet cola Foods with low phenylalanine levels include vegetables, fruits, and juices. Foods high in phenylalanine include meats and dairy products, which must be restricted or eliminated. Diet colas contain more phenylalanine than the fruits listed.

A client with type 2 diabetes mellitus who is taking metformin is scheduled for a computed tomography (CT) with contrast of the abdomen tomorrow. Which priority nursing assessment is done before the procedure?

ensuring that the metformin has been withheld for 48 hours prior to the scan Iodine-based CT contrast can cause kidney damage in clients taking metformin. To prevent possible renal failure, metformin needs to be discontinued 48 hours prior to the scan. A CT of the abdomen with contrast does not require NPO status or an empty colon.

To protect a client's skin under a back brace, the nurse should:

have the client wear a close-fitting thin cotton shirt under the back brace. Having the client wear a thin cotton shirt that is close fitting to avoid having extra folds that could cause pressure under a back brace helps to protect the skin and to keep the brace free of skin oils and perspiration.Using padding may increase pressure points.Lubricating or powdering the skin under the back brace will not provide protection from irritation by the brace.

A client with a history of hypertension has been prescribed a new antihypertensive medication and is reporting dizziness. Which is the best way for the nurse to assess blood pressure?

in the supine, sitting, and standing positions By assessing the client's blood pressure in these positions, the nurse can calculate the client's postural pressure, understanding the increase or decrease in blood pressure from a lying to sitting or sitting to standing position. Ambulating the client and taking in the left and then again in the right arm are not accurate assessment tools. Assessing at the beginning and end of the exam is incorrect because this measures a deficit and is not a tool for hypotension.

After a child undergoes nephrectomy for a Wilms' tumor, the nurse should assess the child postoperatively for which early sign of a complication?

increased abdominal distention Children who have undergone abdominal surgery are at risk for intestinal obstruction from a dynamic ileus. Indications of intestinal obstruction include abdominal distention, decreased or absent bowel sounds, and vomiting. Later signs of intestinal obstruction include tachycardia, fever, hypotension, increased respirations, shock, and decreased urinary output.

Which finding in a client diagnosed with asthma would require a nurse to take immediate action?

lethargy Lethargy can be a manifestation of status asthmaticus. Anhidrosis, cough, and diaphoresis should be further assessed.

Three hours postpartum, a primiparous client's fundus is firm and midline. On perineal inspection, the nurse observes a small, constant trickle of blood. Which condition should the nurse assess further?

perineal lacerations A small, constant trickle of blood and a firm fundus are usually indicative of a vaginal tear or cervical laceration. If the client had retained placental tissue, the fundus would fail to contract fully (uterine atony), exhibiting as a soft or boggy fundus. Also, vaginal bleeding would be evident. Uterine inversion occurs when the uterus is displaced outside of the vagina and is obvious on inspection. Bladder distention may result in uterine atony because the pressure of the bladder displaces the fundus, preventing it from fully contracting. In this case the fundus would be soft, possibly boggy, and displaced from midline.

The nurse is admitting a client with acute appendicitis to the emergency department. The client has abdominal pain of 10 on a pain scale of 1 to 10. The client will be going to surgery as soon as possible. The nurse should:

place the client on nothing-by-mouth (NPO) status. The nurse should place the client on NPO status in anticipation of surgery.The nurse can initiate pain relief strategies, such as relaxation techniques, but the surgeon will likely not prescribe narcotic medication prior to surgery.The nurse can place the client in a position that is most comfortable for the client.Heat is contraindicated because it may lead to perforation of the appendix.

The health care provider (HCP) prescribes pulse assessments through the night for a school- age child with rheumatic fever who has a daytime heart rate of 120 bpm. The nurse explains to the mother that this is to evaluate if the elevated heart rate is caused by which factor?

routine activity during waking hours An above-average pulse rate that is out of proportion to the degree of activity is an early sign of heart failure in a client with rheumatic fever. The sleeping pulse is used to determine whether the mild tachycardia persists during sleep (inactivity) or whether it is a result of daytime activities. The environmental temperature would need to be quite warmer before it could influence the heart rate. Digitalis lowers the heart rate, so the rate would be decreased during the daytime.

The nurse is conducting an admission interview with a client and is assessing for risk factors related to the client's safety. The nurse should include which targeted assessments? Select all that apply.

suicide or self-harm ideation recent use of substances of abuse allergic reactions or adverse drug reactions When assessing client safety, the nurse assesses suicide thoughts or plan, recent use of illicit drugs (as they may cause impaired judgment or thought processes), and previously experienced allergic reactions and adverse reactions to medications. Note that safety involves many aspects of care. Incentives and diet preferences (allergies would be previously noted) are not directly related to safety, although they may be part of an overall assessment.

During the fourth stage of labor, the client should be assessed carefully for

uterine atony. Uterine atony should be carefully assessed during the fourth stage. The second stage of labor begins with complete cervical dilation and ends with birth. The third stage begins immediately after birth and ends with the separation and expulsion of the placenta. Immediately after delivery, the placenta is evaluated carefully for completeness, and the client is assessed for excessive bleeding or a relaxed uterus. After delivery of the placenta is the fourth stage and assessing for relaxed uterus helps determine uterine atony. Umbilical cord prolapse, displacement of the umbilical cord to a position at or below the fetus's presenting part, occurs most commonly when amniotic membranes rupture before fetal descent. The client should be assessed for a visible or palpable umbilical cord in the birth canal, violent fetal activity, or fetal bradycardia with variable deceleration during contractions. The presence of umbilical cord prolapse requires an emergency delivery.

A client undergoes an amniotomy. Shortly afterward, the nurse detects large variable decelerations in the fetal heart rate (FHR) on the external electronic fetal monitor (EFM). These findings signify:

umbilical cord prolapse. After an amniotomy, a significant change in the FHR may indicate umbilical cord prolapse; an EFM may show large variable decelerations during cord compressions. Infection, the start of the second stage of labor, and the need for labor induction aren't associated with FHR changes. An infection causes temperature elevation. The second stage of labor starts with complete cervical dilation. Labor induction is indicated if the client's labor fails to progress.

A client's pulmonary function tests note an increased residual volume and a decreased vital capacity. Which is the best nursing diagnosis?

risk for activity intolerance These findings indicate respiratory disease; this client will have shortness of breath with exertion because of the trapped air. The client may have impaired physical mobility because of the inability to tolerate activities. Altered health maintenance or risk for fluid volume deficit are not supported by the test results.

The nurse is giving preoperative instructions to a client who will be undergoing rhinoplasty. What should the nurse tell the client?

"Do not take aspirin-containing medications for 2 weeks before surgery." Aspirin-containing medications should be discontinued for 2 weeks before surgery to decrease the risk of bleeding. Nasal packing is usually removed the day after surgery. Normal saline nose drops are not routinely administered preoperatively. The results of the surgery will not be obvious immediately after surgery because of edema and ecchymosis.

A nurse is providing discharge teaching for a client who had a laryngectomy. Which instruction should the nurse include in the teaching?

"Cover the stoma with a loose plastic cloth whenever you shower or bathe." The nurse should instruct the client to gently cover the stoma with a loose plastic bib when showering or bathing to prevent water from entering the stoma. The client should cover the stoma with a loose-fitting, not tight, cloth to protect it. Covering the stoma with the hand is not practical and short term at best. The client should keep the house humidified to prevent irritation of the stoma that can occur in low humidity. The client should avoid swimming at at all; the activity is too risky, because it's possible for water to enter the stoma and then enter the client's lung, causing drowning without submerging the face.

An adolescent is receiving chemotherapy for lymphoma. Which statement by the adolescent supports a nursing diagnosis of Deficient knowledge related to mouth care?

"I remove white patches from my tongue and cheeks with my toothbrush." White patches on the tongue and oral mucosa indicate infection; the adolescent should report the patches, not remove them. Using a soft toothbrush is appropriate because it prevents injury to the fragile oral mucosa. Rinsing the mouth every 2 to 4 hours with a nonirritating solution, such as baking soda and water or normal saline solution helps prevent stomatitis. Avoiding commercial mouthwashes is appropriate because they may contain alcohol, which may dry the oral mucosa.

The student nurse is caring for a client with a suspected respiratory infection. Which statement by the nursing student indicates that the student will facilitate the best time to collect this specimen?

"I will instruct the client to give the specimen in the morning, as soon as the client awakens." Because sputum accumulates in the lungs during sleep, the nurse should collect a sputum specimen in the morning, as soon as the client awakens. This specimen will be concentrated, increasing the likelihood of an accurate culture. Sputum specimens collected at other times during the day are not concentrated and may not provide an accurate culture.

A client is admitted to the emergency department following an overdose of barbiturates. What should the nurse do first?

Assess ventilation and assist ventilation as needed. Barbiturates can cause significant respiratory depression. The nurse's first action is to immediately assess the respiratory status and assist in bag-mask-valve ventilation as needed. Monitoring the vital signs is important, but respiratory care takes precedence over the blood pressure. Without other injury, blood products are not necessary. Placing the client in the Trendelenburg position will put pressure from the abdominal contents onto the diaphragm and further impair breathing.

When assessing a client with chest trauma, the nurse notes that the client is taking small breaths at first, then bigger breaths, and then a couple of small breaths, then 10 to 20 seconds of no breaths. How should the nurse should record the breathing pattern?

Cheyne-Stokes respiration Cheyne-Stokes respiration is defined as a regular cycle that starts with normal breaths, which increase and then decrease followed by a period of apnea. It can be related to heart failure or a dysfunction of the respiratory center of the brain. Hyperventilation is associated with an increased rate and depth of respirations. Obstructive sleep apnea is recurring episodes of upper airway obstruction and reduced ventilation. Biot's respiration, also known as "cluster breathing," is periods of normal respirations followed by varying periods of apnea.

A nurse is assessing a client with a urinary tract infection who takes an antihypertensive drug. The nurse reviews the client's urinalysis results (see chart). What should the nurse do next?

Encourage the client to increase fluid intake. The client's urine specific gravity is elevated. Specific gravity is a reflection of the concentrating ability of the kidneys. This level indicates that the urine is concentrated. By increasing fluid intake, the urine will become more dilute. Antihypertensives do not make urine more concentrated unless there is a diuretic component within them. The nurse should not hold a dose of antihypertensive medication. Sodium tends to pull water with it; by restricting sodium, less water, not more, will be present. Bananas do not aid in the dilution of urine.

The nurse teaches the parents of an infant with developmental dysplasia of the hip how to handle their child in a Pavlik harness. Which care is most appropriate?

Fit the diaper under the straps. The Pavlik harness is worn over a diaper. Knee socks are also worn to prevent the straps and foot and leg pieces from rubbing directly on the skin. For maximum results, the infant needs to wear the harness continuously. The skin should be inspected several times a day, not every other day, for signs of redness or irritation. Lotions and powders are to be avoided because they can cake and irritate the skin.

A client with eclampsia begins to experience a seizure. Which intervention should the nurse do immediately?

Maintain a patent airway. The priority for the pregnant client having a seizure is to maintain a patent airway to ensure adequate oxygenation to the mother and the fetus. Additionally, oxygen may be administered by face mask to prevent fetal hypoxia.Because the client is diagnosed with eclampsia, she is at risk for seizures. Thus, seizure precautions, including padding the side rails, should have been instituted prior to the seizure.Placing a pillow under the client's left buttock would be of little help during a tonic-clonic seizure.Inserting a padded tongue blade is not recommended because injury to the client or nurse may occur during insertion attempts.

The client is admitted to the telemetry unit due to chest pain. The client has polysubstance abuse, and the nurse assesses that the client is anxious and irritable and has moist skin. What should the nurse do in order of priority from first to last? All options must be used.

Position electrodes on the chest. Take vital signs. Administer the prescribed dose of morphine. Obtain a history of which drugs the client has used recently. The nurse should first connect the client to the monitor by attaching the electrodes. Electrocardiography can be used to identify myocardial ischemia and infarction, rhythm and conduction disturbances, chamber enlargement, electrolyte imbalances, and the effects of drugs on the client's heart. The nurse next obtains vital signs to establish a baseline. Next, the nurse should administer the morphine; morphine is the drug of choice in relieving myocardial infarction (MI) pain; it may cause a transient decrease in blood pressure. When the client is stable, the nurse can obtain a history of the client's drug use.

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

Report a heart rate greater than 120 beats/minute to the health care provider. Because terbutaline can cause tachycardia, the client should be taught to monitor her radial pulse and call the health care provider for a heart rate greater than 120 beats/minute. Terbutaline must be taken every 4 to 6 hours around-the-clock to maintain an effective serum level that will suppress labor. A fetus normally moves 10 to 12 times per hour. The client does not need to contact the health care provider if such movement occurs. The client experiencing premature labor must maintain bed rest at home.

The nurse is preparing to infuse a unit of packed red blood cells. What safety precautions will the nurse follow? Select all that apply.

Review hemoglobin and hematocrit levels. Note client allergies. Confirm the client is wearing a name band. The nurse will review hemoglobin and hematocrit levels to note the client status. The nurse checks for allergies as a safety mechanism in case of impending orders or possible reactions. The nurse will confirm the client is wearing a name band prior to the transfusion to ensure that there is no delay in the start of the packed red blood cells. The pharmacist does not need to be aware of the transfusion. The client's weight is not necessary for a transfusion.

The nurse is preparing a client for a thoracentesis. How should the nurse position the client for the procedure?

Sitting forward with the arms supported on the bedside table. In preparation for a thoracentesis, the client should be asked to sit forward and place his arms on the bedside table for support. This position provides access to the chest wall and intercostal spaces for insertion of the needle. The supine, Sims', or prone position would not provide adequate access to the chest wall or separate the intercostal spaces sufficiently for needle insertion.

When caring for a client with head trauma, a nurse notes a small amount of clear, watery fluid oozing from the client's nose. What should the nurse do first?

Test the nasal drainage for glucose. Because cerebrospinal fluid (CSF) contains glucose, testing nasal drainage for glucose helps determine whether it's CSF. The nurse should look for a halo sign only if the drainage is blood tinged. A client with a suspected CSF leakage shouldn't blow their nose; doing so could increase the risk of injury. The nurse should contact the physician after completing the assessment.

A client, age 50, visits the physician for a routine checkup. The history reveals that the client was diagnosed with a spinal curvature at age 45. The nurse knows that life-threatening complications can occur if the progressive spinal curvature exceeds 65 degrees. Which region of the spine should the nurse assess for complications?

Thoracic The nurse should assess the thoracic region of the spine because a progressive curvature of more than 65 degrees in this region may lead to cardiopulmonary failure as well as less serious signs and symptoms, such as fatigue, back pain, decreased height, and cosmetic deformity. Although a curvature may affect any part of the spine, life-threatening complications aren't associated with curvature of the cervical, lumbar, or sacral regions.

A nasogastric tube inserted during surgical correction of infant's intussusception is no longer freely removing gastric secretions. What should the nurse do next?

Verify the tube placement. The first action is to check the placement of the tube to ensure that it is in the correct position. To check tube position, the nurse should aspirate the tube with a syringe. A return of gastric contents indicates that the end of the tube is in the stomach. Another method is to inject a small amount of air while auscultating with a stethoscope over the epigastric area. The tube is irrigated only after the position of the tube is confirmed. The suction level should not be increased because doing so could damage the mucosa. Rotating the tube could irritate or traumatize the nasal mucosa.

A nurse is caring for a client who required chest tube insertion for a pneumothorax. To assess for pneumothorax resolution, the nurse can anticipate that the client will require

a chest X-ray. Chest X-ray confirms diagnosis by revealing air or fluid in the pleural space. SaO2 values may initially decrease with a pneumothorax but typically return to normal within 24 hours. ABG studies may show hypoxemia, possibly with respiratory acidosis and hypercapnia but these are not necessarily related to a pneumothorax. Chest auscultation will determine overall lung status but it's difficult to determine if the chest has reexpanded sufficiently.

Which behavior should cause the nurse to suspect that a client's labor is moving quickly and that the physician should be notified?

an increased sense of rectal pressure An increased sense of rectal pressure indicates that the client is moving into the second stage of labor. The nurse should be able to discern that information by the client's behavior. Contractions don't decrease in intensity, there isn't a change in fetal heart rate variability, and nausea and vomiting don't usually occur.

A client is admitted with a possible diagnosis of osteomyelitis. Based on the documentation, which laboratory result is the priority for the nurse to report to the physician?

blood culture Osteomyelitis is a bacterial infection of the bone and soft tissue that occurs by extension of soft tissue infection, direct bone contamination following surgery, or spreading from other infection sites in the body. A positive blood culture would be reported immediately to the physician so that specific antibiotic therapy can begin or be adjusted based on the positive culture. A negative rheumatoid factor would be expected in a possible diagnosis of osteomyelitis. An alkaline phosphatase level of 60 IU/L (1.0 nkat/L) is within the normal range, and an ESR of 10 mm/hour is also within the normal range.

A client who had a cholecystectomy has a T-tube for drainage. The nurse measures the amount of bile drainage from the T tube at the end of each shift. How should the nurse record the drainage?

charting it separately on the output record T-tube bile drainage is recorded separately on the output record. Adding the t-tube drainage to the urine output or wound drainage makes it difficult to accurately determine the amounts of bile, urine, or drainage. The client's total intake will be incorrect if drainage is subtracted from it.

The nurse receives the preoperative blood work report for a client who is scheduled to undergo surgery. Which laboratory finding should the nurse report to the surgeon and anesthesiologist?

creatinine, 2.6 mg/dL (230 µmol/L) The nurse should call the surgeon for a serum creatinine level of 2.6 mg/dL (230 µmol/L), which is higher than the normal range of 0.1 to 0.4 mg/dL (9 to 35 µmol/L). An elevated serum creatinine value indicates that the kidneys are not filtering effectively and has important implications for the surgical client because many anesthesia and analgesia medications need to be filtered out through the renal system. The red blood cell count, hemoglobin level, and blood urea nitrogen level are within normal limits and do not need to be reported to the surgeon.

The nurse is assessing the client's bowel sounds (see the accompanying image). The nurse should:

expect to hear 5 to 35 sounds in 1 minute for normal bowel sounds. Normal bowel sounds occur at a rate of 5 to 35 sounds per minute. The nurse should use the diaphragm of the stethoscope and listen for 5 minutes, moving the stethoscope in all four quadrants. The client should empty the bladder prior to auscultation, and not drink water, which might increase the frequency of the sounds.

A client with peripheral vascular disease has poor circulation. The nurse should assess the client for changes in: (Select all that apply.)

nail bed color. skin temperature. pain in extremity. Maintaining circulation is critical in individuals with peripheral vascular disease. Skin and nail bed color and temperature will reveal the degree to which the extremity is receiving blood flow. Clients with peripheral vascular disease also usually have a certain amount of pain, especially when the oxygen demand becomes greater than oxygen supply, such as with walking or exercising. Fluid intake and nausea are unrelated to peripheral circulation.

The nurse is caring for a multigravid client in active labor when the nurse detects variable fetal heart rate decelerations on the electronic monitor. The nurse interprets this as the compression of which structure?

umbilical cord Variable decelerations are associated with compression of the umbilical cord. The nurse should alter the client's position and increase the IV fluid rate. Fetal head compression is associated with early decelerations. Severe compression of the fetal chest, such as during the process of vaginal birth, may result in transient bradycardia. Compression or damage to the placenta, typically from abruptio placentae, results in severe, late decelerations.

A 21-year-old client undergoes bone marrow aspiration at the clinic to establish a diagnosis of possible lymphoma. Which statement made by the client demonstrates proper understanding of discharge teaching? Select all that apply.

"I will take acetaminophen for pain." "I will not be able to play basketball for the next 2 days." "I can apply an ice pack or a cold compress to the puncture site." Acetaminophen is a safer analgesic than aspirin in order to avoid bleeding. Contact sports or trauma to the site should be avoided. Cool compresses should limit swelling and bruising. The puncture site should be inspected every 2 hours for bleeding or bruising during the first 24 hours.

A nurse is educating a client recently diagnosed with early glaucoma. Which client statement indicates further teaching is necessary?

"I will take my latanoprost eye drops as soon as I start to feel pain." Treatments for glaucoma include medicated eye drops that help drain fluid in the eye, thereby decreasing the intraocular pressure. Latanoprost is a prostaglandin agonist that should be administered daily. This medication is ineffective if the client takes it only when feeling pain. Constipation or straining to have a bowel movement can increase intraocular pressure; therefore clients should increase their fluids and fiber intake. It's important for the client to attend all healthcare provider appointments and get routine eye examinations to monitor the extent of the disease. Glaucoma presents with increased intraocular pressure that can damage the optic nerve, leading to visual disturbances.

A client newly diagnosed with diabetes mellitus asks why they need ketone testing when the disease affects their blood glucose levels. How should the nurse respond?

"Ketones will tell us if your body is using other tissues for energy." The nurse should tell the client that ketones are a byproduct of fat metabolism and that ketone testing can determine whether the body is breaking down fat to use for energy. The spleen doesn't release ketones when the body can't use glucose. Although ketones can damage the eyes and kidneys and help the physician evaluate the severity of a client's diabetes, these responses by the nurse are incomplete.

A neonate born at 38 weeks' gestation is admitted to the neonatal nursery for observation. The neonate's mother, who is positive for human immunodeficiency virus (HIV) infection, has received no prenatal care. The mother asks the nurse if her neonate is positive for HIV. The nurse can tell the mother which information?

"We will test your baby now, but testing will need to be repeated for an accurate diagnosis." New recommendations state that virologic diagnostic testing at birth should be considered for infants at high risk of HIV infection, but it may take several months before an accurate diagnosis can be made. New guidelines suggest that infants should be tested at 2 to 3 weeks, 1 to 2 months, and again 4 to 6 months. It is estimated that 15% to 30% of all HIV-positive mothers without treatment will give birth to HIV-positive infants. With appropriate drug intervention to the mother during pregnancy, 95% of these neonates can be born unaffected. An enlarged liver at birth is associated with erythroblastosis fetalis, not HIV infection. Virologic testing, such as deoxyribonucleic acid polymerase chain reaction, viral culture, or ribonucleic acid plasma assay, can diagnose HIV infection by 6 months of age and commonly in the first month.

A child admitted to the hospital with a serum sodium level of 160 mEq/L (160mmol/L) is receiving 5% dextrose with 0.45 normal saline solution. The mother asks the child's nurse why the child is receiving sodium. What is the nurse's best reply?

"Your child's sodium is high; but if the serum sodium level is decreased too rapidly, it may cause seizures." The normal serum sodium level for a child is 138 to 146 mmol/L. The value given is high. A rapid decrease in serum sodium level, however, can cause fluid shifts that will result in a rapid increase in intracranial pressure, increasing the risk of seizures. Therefore, the child's sodium level is monitored carefully and decreased slowly. There is no need to stop the infusion or question the primary care provider as this treatment is designed to slowly lower the sodium level.

A nurse is caring for a client with a chest tube connected to a three-chamber drainage system without suction. On the illustration below, identify which chamber the nurse will mark to record the current drainage level.

A chest tube drains blood, fluid, and air from around the lungs. The drainage system, which the nurse measures each shift, is on the right. It has three calibrated chambers that show the amount of drainage collected. When the first chamber fills, drainage empties into the second; when the second chamber fills, drainage flows into the third. The water seal chamber is located in the center. The suction control chamber is on the left.

Caregivers of an infant with a feeding button style gastrostomy tube mention to the nurse there is leaking present. What action should the nurse take?

Assess if the leakage is coming from valve failure or from the peristomal area. The nurse should assess the source of the leakage because intervention will vary depending on the cause. Leakage should not be treated as normal until interventions have failed to remedy the source of the leaking. Therefore, simply applying barrier cream or gauze does not properly address the problem. How the caregivers attach the tubing could be explored after the nurse assesses the infant's gastrostomy site but the technique would not explain leakage that occurs between feedings.

For a primigravid client with the fetal presenting part at -1 station, what would be the nurse's priority immediately after a spontaneous rupture of the membranes?

Check the fetal heart rate. Immediately after a spontaneous rupture of the membranes, the nurse should listen to the fetal heart rate to detect bradycardia. With the fetus at -1 station, the cord may prolapse as amniotic fluid rushes out. Fetal heart rate should be monitored because it will indicate if cord prolapse or cord compression has occurred. The color, amount, and odor of the amniotic fluid should be noted.Although the optimal position for the client is side lying, this is not a priority at this time.The client is not having a precipitous birth with the fetal head at ?1 station. Therefore, preparing the client for a cesarean birth is unnecessary.Although maternal blood pressure should be monitored throughout labor, this is not a priority at this time.

The nurse is caring for a client 1 day after having a colectomy. The client is lethargic and difficult to arouse; the temperature is 101.5°F (38.6°C), blood pressure is 92/36 mm Hg (MAP 55 mm Hg), and heart rate is 114 bpm with SpO2 of 88% on oxygen at 2 L/min per nasal cannula (previously 94%). A saline lock has been established and is patent. Which prescription should the nurse implement first?

Draw blood cultures. This client has signs and symptoms of severe sepsis. Blood cultures should be drawn prior to administering the antibiotic (vancomycin); and the antibiotics should be administered within the first 45 minutes after recognition of these signs in order to try to prevent septic shock. Obtaining a chest X-ray and inserting a urinary catheter to accurately measure intake and output are also important actions but are not first priority for this client.

An adolescent client is being admitted with an eating disorder. Which initial assessment finding is of greatest concern for the nurse?

a potassium level of 2.5 meq/L (2.5 mmol/L) Hypokalemia can result from excessive vomiting or laxative use in clients with eating disorders. Potassium levels of 2.5 meq/L (2.5 mmol/L) or less are considered life-threatening and in need of urgent attention. A 10% weight loss over 6 months indicates gradual rather than rapid weight loss. Depending on the client's height and exact age, a systolic blood pressure of 100 mm Hg can be with normal limits. Low heart rates are frequently seen in clients with very restricted calorie intakes. While a heart rate of 57 bpm indicates bradycardia, if there are no other signs of poor perfusion, it is not immediately life-threatening.

A toddler is brought to the clinic with symptoms of weakness and sores at the corners of the mouth. The parent states that the child eats poorly and will drink only cow's milk. Based on this information, which of the following laboratory tests would be a priority for the nurse to evaluate?

ferriten level Iron deficiency anemia is commonly caused by an insufficient dietary intake of iron. The parent indicates that the child's diet may be deficient in iron. The ferriten level would be essential in helping to determine whether the child has iron deficiency anemia. Testing for vitamin B-12 is done to determine megaloblastic anemia. The Coombs test is used to determine hemolytic anemia. Neutrophils are white blood cells that are elevated in infection.

The nurse is instructing a college student with Addison's disease how to adjust the dose of glucocorticoids. The nurse should explain that the client may need an increased dosage of glucocorticoids in which situation?

having wisdom teeth extracted Adrenal crisis can occur with physical stress, such as surgery, dental work, infection, flu, trauma, and pregnancy. In these situations, glucocorticoid and mineralocorticoid dosages are increased. Weight loss, not gain, occurs with adrenal insufficiency. Psychological stress has less effect on corticosteroid need than physical stress.

A client had a Mantoux test result of an 8-mm induration. When should the nurse interpret the test as positive? When the client:

is immunocompromised. An induration (palpable raised hardened area of skin) of more than 5 to 15 mm (depending upon the person's risk factors) to 10 Mantoux units is considered a positive result, indicating TB infection. An induration of greater than 5 mm is found in HIV-positive individuals, those with recent contacts with persons with TB, persons with nodular or fibrotic changes on chest x-ray consistent with old healed TB, or clients with organ transplants or immunosuppressed. An induration of greater than 10 mm is positive, and the client may be a recent arrival (less than 5 years) from high-prevalent countries, injection drug user, resident or an employee of high-risk congregate settings (e.g., prisons, long-term care facilities, hospitals, homeless shelters), or mycobacteriology lab personnel. Persons with clinical conditions that place them at high risk (e.g., diabetes, prolonged corticosteroid therapy, leukemia, end-stage renal disease, chronic malabsorption syndromes, low body weight), a child less than 4 years of age, or a child or adolescents exposed to adults in high-risk categories.

The nurse is assessing a client with a darker-skin tone in need of emergency care for acute respiratory distress. Which area would the nurse inspect when assessing for cyanosis in this client?

mucous membranes Skin color does not affect the mucous membranes. Therefore, the nurse can assess for cyanosis by inspecting the client's mucous membranes. The lips, nail beds, and earlobes are less-reliable indicators of cyanosis because they are affected by skin color.

Which is most critical for the nurse to communicate to the health care provider (HCP) prior to placing an epidural analgesia catheter? The client:

received enoxaparin 40 mg subcutaneously 1 hour ago. Clients receiving anticoagulation are at high risk for an epidermal hematoma. If the client is taking any anticoagulants, this should be immediately relayed to the HCP scheduled to perform the procedure. Clear liquids may be limited 2 hours prior to the procedure, but this varies by HCP and institutional guidelines. The albumen level is on the lower end of normal and is not a concern. The indwelling urinary catheter is not a concern at this time.

A nurse places electrodes on a collapsed individual who was visiting a hospitalized family member. The monitor exhibits the following. Which interventions would the nurse do first?

Assess the client's airway, breathing, and circulation. The rhythm the client is experiencing is ventricular tachycardia (VT). Although all of the options listed are appropriate for someone with stable VT, it is not yet known whether the client's VT is stable, unstable, or pulseless. Therefore, the nurse must first assess the airway, breathing, circulation, and level of consciousness to establish the client's stability. Different actions are required if the client's VT is unstable or pulseless.

The nurse is preparing to clean around a client's G-tube that was placed 1 week ago and change the gauze dressing. Based on the type of procedure, what type of precautions are needed?

Clean procedure, universal precautions Site care for a recently placed G-tube is a clean procedure, not a sterile procedure. Care should be taken not to introduce bacteria into the fresh site, but sterile gloves and sterile procedure is not necessary or recommended. Universal precautions are required, as the nurse will come into contact with blood and/or bodily fluids while cleaning around the G-tube. Droplet, contact, and airborne precautions are not indicated, because these are for a variety of infectious diseases such as methicillin-resistant Staphylococcus aureus, influenza, measles, meningitis and tuberculosis, not for wound care.

Which equipment should the nurse plan to use to help prevent external rotation of the client's right leg postoperatively?

sandbags It is best to support the client's leg in its proper anatomic position and to prevent external rotation by supporting the leg with sandbags. A trochanter roll can also be used. Sandbags should be placed along the length of the thigh and lower leg.A footboard, rubber air ring, or metal frame will not help prevent external rotation of the leg.

The nurse observes a parent of a child with cystic fibrosis performing chest percussion. The nurse determines that the skill is being done correctly when the parent uses which technique?

firmly but gently striking the chest wall to make a popping sound The parent should firmly yet gently strike the chest wall with the hand cupped to make a hollow popping sound. A slapping sound indicates that an incorrect technique is being used. The area over the rib cage is percussed to loosen mucus from the underlying lung passages. The child should wear a thin piece of clothing (T-shirt) over the chest area to protect the skin without diminishing the effect of the percussion.

The nurse is coaching a client with heart failure about reducing fluid retention. Which strategy will be most effective in reducing a client's fluid retention?

low-sodium diet In clients with fluid retention, sodium restriction may be necessary to promote fluid loss. Increasing exercise will not reduce fluid retention. Exercise will promote circulation, but will not manage the fluid retention. Restricting fluid intake will not reduce retained fluids; increased fluids will increase urine output and promote improved fluid balance. Elevating the client's feet helps promote venous return and fluid reabsorption but in itself will not reduce the volume of excess fluid.

The nurse is caring for a client recovering from moderate sedation for a routine endoscopy without complications. The nurse applies which statement by the client as evidence of understanding the discharge planning?

"I will need a ride home within a few hours of the procedure." Moderate sedation procedures, such as a routine endoscopy, are usually performed in the outpatient setting and are procedures in which rapid recovery and discharge is expected. Longer procedures with more in-depth monitoring and postprocedure care may not be appropriate for moderate sedation. The client should understand that a ride home is needed within a few hours of the procedure; many facilities will not sedate the client unless the person providing a ride home is physically present or readily available. Assuming there are no complications with the procedure, the client would not need to be admitted to the hospital overnight or spend 12 hours in the emergency department being monitored after moderate sedation. Because the medications given can impact decision making, cause drowsiness, and slow reflexes, the client is advised not to drive for 24 hours, and is not allowed to drive home.

The nurse is caring for a client in active labor and notes minimal variability on the external fetal monitor tracing. What are the nurse's priority interventions?

Position to left lateral, O2 per nonrebreather mask at 10 L. Position to left lateral and administering O2 per nonrebreather mask at 10 L will improve fetal hypoxia and increase the amount of maternal circulating oxygen by taking pressure created by the uterus off the aorta and improving blood flow. Positioning to knee-chest will improve circulation and oxygenation, but it is easier and faster to move to left lateral. Increasing IV fluids will support maternal circulation and is recommended, but would not be the priority in this instance. Giving orange juice and using vibroacustic stimulation are used to "wake a baby up" from a sleep state for a nonstress test (NST) and will not improve oxygenation. Administering terbutaline and turning off oxytocin infusion will improve uterine perfusion, but would not be the priority action for decreased variability.

When the nurse is conducting a preoperative interview with a client who is having a vaginal hysterectomy, the client states that she forgot to tell her surgeon that she had a total hip replacement 3 years ago. Why should the nurse communicate this information to the perioperative nurse?

The client should not have her hip externally rotated when she is positioned for the procedure. The nurse should notify the surgery department and document the past surgery in the medical record in the preoperative notes so that the client's hip is not externally rotated and the hip dislocated while she is in the lithotomy position. The prosthesis should not be a problem as long as the perioperative nurse places the return electrode away from the prosthesis site. The perioperative nurse will inform the rest of the team, but the primary reason to inform the perioperative nurse is related to safe positioning of the client. The surgeon should enter this information on the client's medical record at this time.

A nurse is monitoring a client recovering from moderate sedation that was administered during a colonoscopy. Which finding requires the nurse's immediate attention?

oxygen saturation (SaO2) of 89% Normal SaO2 is 95% to 100%. Oxygen saturation below 94% indicates inadequate oxygenation, which may be a consequence of the moderate sedation. Appropriate nursing actions include rousing the client, if necessary, assisting the client with coughing and deep breathing, and evaluating the need for additional oxygen. A heart rate of 84 beats/minute is within normal limits. Colonoscopy doesn't affect cough and gag reflexes, although these reflexes may be slightly decreased from the administration of sedation. These findings don't require immediate intervention. Blood-tinged stools are a normal finding after colonoscopy, especially if the client had a biopsy.

A nurse is obtaining the history of an infant with suspected acute otitis media. What should the nurse ask the parent about?

position of the infant when taking a bottle A significant association between feeding position and otitis media exists. Children fed in a supine position have a high incidence of otitis media because of the reflux of milk into the eustachian tubes during feedings. Keeping the infant's ears covered when out in the cold or thoroughly drying the ears after a bath has not been identified as a contributing factor to an infant's development of ear infections. Although the infant's immunization status is always important to ascertain, other factors, such as the position of the infant when taking a bottle, have more impact.

A client who was found unconscious at home is brought to the hospital by a rescue squad. In the intensive care unit, the nurse checks the client's oculocephalic (doll's eye) response by

turning the client's head suddenly while holding the eyelids open. To elicit the oculocephalic response, which detects cranial nerve compression, the nurse turns the client's head suddenly while holding the eyelids open. Normally, the eyes move from side to side when the head is turned; in an abnormal response, the eyes remain fixed. The nurse introduces ice water into the external auditory canal when testing the oculovestibular response; normally, the client's eyes deviate to the side of ice water introduction. The nurse touches the client's cornea with a wisp of cotton to elicit the corneal reflex response, which reveals brain stem function; blinking is the normal response. Shining a bright light into the client's pupil helps evaluate brain stem and cranial nerve III function; normally, the client's pupil responds by constricting.

A client whose cervix is 10 cm dilated begins to push. The nurse notes early decelerations of the fetal heart rate. The nurse should interpret this finding as being caused by which factor?

fetal head compression Early decelerations are usually due to pressure on the fetal head as the fetus progresses through the birth canal. These decelerations mirror the contraction pattern and are usually benign, unless the pattern occurs in early labor. If this pattern is demonstrated in early labor, it may indicate cephalopelvic disproportion.Variable decelerations are associated with cord compression.Fetal bradycardia may occur as a result of analgesia and can occur at any time.Inadequate placental perfusion is associated with late fetal heart rate decelerations.

The nurse is performing a breast examination on a client. Which findings most strongly suggest that a client has breast cancer?

fixed nodular mass, breast pain, dimpling of the skin A fixed nodular mass with dimpling of the overlying skin is the most significant sign of breast cancer. This is common during the late stages of breast cancer. Breast pain may be associated with cancer, but may also be related to a benign condition. Many women have asymmetrical breasts. Nipple discharge, whether bloody or clear, maybe a sign of cancer, but are also commonly associated with benign conditions and are not the most significant sign of cancer. Multiple firm, round, freely movable masses that change with the menstrual cycle indicate fibrocystic breasts, a benign condition. Although metastasis to lymph nodes may occur, fever is not a typical finding of breast cancer.

After completing assessment rounds, which client should the nurse discuss with the health care provider (HCP) first?

a client with hepatitis whose pulse was 84 bpm and regular and is now 118 bpm and irregular A change in a client's baseline vital signs should be brought to the HCP's attention immediately. In this case, the client's heart rate has increased, and the rhythm appears to have changed; the HCP may prescribe an ECG to determine if treatment is necessary. The nurse should also have a complete set of current vital signs as well as a physical assessment before providing the HCP information using the SBAR format. The nutritional as well as psychological needs of a client must be addressed but are not first priority. A rash that develops after a new antibiotic is started must be brought to the HCP attention; however, this client is stable and is not the first priority. The nurse is responsible to facilitate discussion between the client, the client's family, and the HCP but only after all of the immediate physical and psychological needs of all clients have been met.

For a client with a Wilms' tumor, which preoperative nursing intervention takes highest priority?

avoiding abdominal palpation Because manipulating the abdominal mass may disseminate cancer cells to adjacent and distant sites, the most important intervention for a client with a Wilms' tumor is to avoid palpating the abdomen. Restricting oral intake and monitoring acid-base balance are routine interventions for all preoperative clients; they have no higher priority in one with a Wilms' tumor. Isolation isn't required because a Wilms' tumor isn't infectious.

When performing an assessment, the nurse identifies these signs and symptoms in the client: decreased muscle strength, limited range of motion, and reluctance to move. Based on these symptoms, the nurse should perform which interventions? Select all that apply.

encouraging client turning and repositioning every 2 hours having call bell within easy reach initiating hospital fall risk protocols The client with discoordination, decreased muscle strength, limited range of motion, and reluctance to move is at risk for falls and also for pressure ulcers. The nurse should encourage/assist the client in turning and repositioning every 2 hours and ensure that the call bell is within easy reach. The hospital's fall risk protocols should be initiated at this time. Having four-sided rails up is considered a restraint and is not indicated at this time. Gowning and gloving when in the room is appropriate for clients needing isolation precautions—these are not indicated at this time.

On a client's first postpartum day, nursing assessment reveals vital signs within normal limits, a boggy uterus, and saturation of the perineal pad with lochia rubra. Which nursing intervention takes highest priority?

massaging the uterus gently If a postpartum client has a boggy (relaxed) uterus, the nurse should first massage her uterus gently to stimulate contraction (involution). The nurse should reassess the client 15 minutes later to ensure that massage was effective. If the uterus doesn't respond to massage, the nurse should administer oxytocin as ordered. The nurse should notify the physician or nurse-midwife if the client's uterus remains boggy after massage and oxytocin administration or if assessment reveals a rapid, thready pulse or decreased blood pressure.

A client with schizoaffective disorder is brought to the hospital by a family member. The family member states that the client is having an increase in auditory hallucinations and is becoming significantly more withdrawn. The nurse reviewing the admission blood work expects which blood level to be subtherapeutic?

lithium carbonate Lithium carbonate, an antimania drug, is used to treat clients with cyclical schizoaffective disorder, a psychotic disorder once classified under schizophrenia that causes affective symptoms, including manic and depressive activity. Lithium helps control this disorder's affective component. Phenobarbital can cause schizophrenia-like symptoms in some people and would not be prescribed for a person with schizophrenia. Chlordiazepoxide, an antianxiety agent, is generally contraindicated in psychotic clients. Imipramine, primarily considered an antidepressant agent, is also used to treat clients with agoraphobia and those undergoing cocaine detoxification.

An adolescent is at risk for injury related to intracranial pathology following a motor vehicle collision. Which nursing action is the priority?

monitor intrancranial pressure Increased intracranial pressure (ICP) contributes to increasingly severe pathology, including potential for brain stem herniation, so monitoring and maintaining stable intracranial pressure is the priority. Systemic parameters and intracranial parameters are both essential though. The nurse takes actions to keep the intracranial pressure low by controlling factors that can cause elevated ICP; these action include monitoring for changes in oxygenation, temperature, glucose, blood pressure, and heart rhythm and rate. Maintaining the head in a neutral position is essential to keeping ICP within the desired limits.

The client is to have pneumatic compression devices applied. The client is hesitant to have the device applied. What is the best response by the nurse?

"This device will help push blood from the small vessels to the large vessels in your legs and prevent you from developing a blood clot." The purpose of using pneumatic compression devices is to reduce the risk of developing thromboembolism. Intermittent compression from the device pushes blood from the smaller blood vessels into the deeper vessels and into the femoral veins. This action enhances blood flow and venous return and promotes fibrinolysis, deterring venous thrombosis. When a client is hesitant about a treatment, providing appropriate education will help to increase compliance. Telling the client that it is important to wear the device because they are in bed does not explain how the device works or why it is necessary. Pneumatic compression devices do not provide comfort. Telling the client that the healthcare provider wants the client to wear the device does not provide the client teaching.

The nurse is caring for a client admitted for a quadruple coronary artery bypass graft. Which statements by the client indicate that preoperative teaching has not been effective? Select all that apply.

"I will be relieved to have this surgery over with; I have a very busy schedule at work right now." "I had stopped smoking a month before the surgery; however, I will be able to start again once I have recovered." Both of these statements indicate that the client believes the surgery will solve the problem and lifestyle changes are not necessary. There is no demonstration of understanding of preoperative teaching. "I know that I will have to perform deep breathing and coughing exercises to prevent complications," "I will be on a heart monitor and a respirator to help me breathe," and "I understand that I need to change my eating habits and activity levels to keep my heart healthy" are all positive statements that indicate a good understanding of the teaching, indicating the client is an active participant and is following guidelines to help in recovery after the surgery and promote heart health.

An adolescent is to receive radioactive iodine for Graves' disease. Which statement by the client reflects the need for more teaching?

"The advantage of radioactive iodine is that I will not need future medication for my disease." Most clients will need lifelong thyroid replacement after treatments with radioactive iodine. Most clients are treated as outpatients. To reduce the risk of exposure to radioactivity to others, clients are advised to avoid public places for at least 1 day and maintain a prudent distance from others for 2 to 3 days. Additionally, clients are advised to avoid close contact with pregnant women and children for 5 to 11 days. The use of radioiodine to treat Graves' disease has not been found to affect long-term fertility. Clients are taught not to share food, utensils, and towels. Use of a private bathroom is desirable. Clients are also instructed to flush the toilet more than one time after each use.

After teaching the parents of an infant with clubfoot requiring application of a plaster cast how to care for the cast, which statement would indicate that the parents have understood the teaching?

"We will check the color and temperature of the toes of the casted leg frequently." A cast that is too tight can cause a tourniquet effect, compromising the neurovascular integrity of the extremity. Manifestations of neurovascular impairment include pain, edema, pulselessness, coolness, altered sensation, and inability to move the distal exposed extremity. The toes of the casted extremity should be assessed frequently to evaluate for changes in neurovascular integrity. Wetting a plaster cast with water and soap softens the plaster, which may alter the cast's effectiveness. There is no reason to elevate the casted extremities when a child with clubfoot is being treated with nonsurgical measures. The legs would be elevated if swelling were present. Petals, which are applied to cover the rough edges of the cast, are to be left in place to minimize the risk for skin irritation from the cast edges.