367Qw/exp-Leadership in Nursing: NCLEX Quiz Review - ALL QUESTIONS

The clinic nurse observes that a 3-day-old baby girl is jaundiced. A bilirubin level is 11.4 mg/dL (194.99 umol/L). What causes this bilirubin level? 1. Physiologic jaundice 2. Hemolytic disease of the newborn 3. Erythroblastosis fetalis 4. Sepsis

1 Approximately 40% to 60% of all term babies develop jaundice between the second and fourth days of life. In the absence of disease or a specific cause, it is referred to as physiologic jaundice. It is most often due to the breakdown of excessive red blood cells and increased destruction of immature red cells. Hemolytic disease of the newborn caused by maternal/newborn blood group incompatibility is the most common cause of pathologic jaundice. Erythroblastosis fetalis and kernicterus are associated with pathologic jaundice. Sepsis does not normally cause an elevated bilirubin level. (Hockenberry & Wilson, 10 ed., p. 315)

A client is confined to bed with a fracture of the left femur. He begins receiving subcutaneous low-molecular-weight heparin (LMWH) injections. What is the purpose of this medication? 1. To prevent thrombophlebitis and pulmonary emboli associated with immobility 2. To promote vascular perfusion by preventing formation of micro emboli in the left leg 3. To prevent venous stasis, which promotes vascular complications associated with immobility 4. To decrease the incidence of fat emboli associated with long bone fractures

1 Because of the high risk of venous thromboembolism (VTE) after a femur or hip fracture, prophylactic anticoagulant drugs such as warfarin and low-molecular-weight heparin such as enoxaparin may be ordered to prevent thromboembolic complications in the immobilized client. It is not effective in preventing fat emboli or venous stasis or promoting vascular perfusion. (Lewis et al., 10 ed., p. 1468)

What is the priority assessment information to obtain from a client who is being admitted with a tentative diagnosis of fractured hip? 1. Circulation and sensation distal to the fracture 2. Amount of swelling around the fracture site 3. Degree of bone healing that has occurred 4. Amount of pain that the fracture and healing are causing

1 Circulation and neurosensory status distal to the fracture are always priorities for clients with fractures. The amount of swelling is important, but the primary concern regarding swelling is circulatory and neurosensory deficits. The amount of bone healing cannot be assessed. There is concern regarding pain, but circulatory and neurologic checks are the priority actions. (Lewis et al., 10 ed., p. 1468)

What is significant about the development of proteinuria in a client with type 1 diabetes mellitus? 1. Chronic kidney disease may eventually develop. 2. It indicates that the client's diabetes is uncontrolled. 3. Serum creatinine will diminish as albuminuria increases. 4. Insulin maintenance dose should be lowered.

1 Diabetic nephropathy is the primary cause of end-stage kidney failure. A microscopic amount of albumin in the urine is one of the earliest indications of kidney abnormality and is asymptomatic, which is the purpose of annual albumin-to-creatinine ratios being collected on random urine samples for albumin. Control of hypertension is paramount to delaying the progression of nephropathy. Serum creatinine elevates along with the increased albumin in the urine. Measure of diabetic control is the HbA1c laboratory test. Insulin therapy should not be altered due to proteinuria. (Lewis et al., 10 ed., p. 1079)

What is important to include in the discharge teaching plan for a 38-year-old client who has had a vaginal hysterectomy? 1. Use of birth control is no longer required. 2. Refrain from sexual intercourse for 2 months. 3. Take hormone replacement therapy. 4. Anticipate heavy vaginal bleeding.

1 It will no longer be possible to become pregnant, and birth control is no longer required. On her postoperative visit to the doctor, he or she will evaluate the healing of the cervical area and will advise her regarding sexual intercourse. There is no mention in the question that the client had her ovaries removed, so hormone replacement therapy is not necessary. Heavy vaginal bleeding might indicate hemorrhage. The client may experience a moderate amount of serosanguineous drainage immediately postoperative; once healed, she will not experience menses. (Ignatavicius & Workman, 7 ed., p. 1620)

What evaluation is important in the preoperative nursing assessment of a client with a severely herniated lumbar disk? 1. Movement and sensation in the lower extremities 2. Leg pain that radiates to both lower extremities 3. Reflexes in the upper extremities 4. Pupillary reaction to light

1 The movement and sensation should be evaluated before surgery to serve as a baseline for comparison during the postoperative recovery period. Movement of the legs and assessment of sensation should be unchanged compared with the preoperative status. Radiating leg pain is diagnostic of the condition, and assessing it before surgery is not as beneficial as determining movement and sensation. (Lewis et al., 10 ed., p. 1504)

The nurse is caring for a client who is at the beginning of her third trimester of pregnancy. The client has been admitted in preterm labor, and magnesium sulfate is being used. Contractions are occurring about every 4 to 5 minutes and lasting 1 to 11⁄2 minutes; blood pressure is 130/88 mmHg; respirations are 22 breaths/min; pulse is 98 beats/min. What nursing observation would cause the nurse the most concern? 1. Urinary output of a total of 240 mL for the past 8 hours 2. Presence of active 21 deep tendon reflexes 3. Complaints of hot flashes, nausea, and a headache 4. Blood pressure increase to 145/92 mmHg

1 Monitoring during the administration of magnesium sulfate includes urine output, which should be greater than 30 mL per hour, respiratory rate should be greater than 12 breaths/min, and deep tendon reflexes should be 21. The medication should be held or decreased if the urinary output drops to or below 30 mL per hour, as magnesium sulfate is excreted through the urine and toxicity can develop if urine output is not sufficient. Deep tendon reflexes are present, and the respiratory rate is normal. Hot flashes may occur after the medication is started, but it is not a primary concern at this time; however, the blood pressure is. The urine output is the priority. Magnesium sulfate will reduce the blood pressure once administration is started. (Lowdermilk et al., 11 ed., p.664)

The nurse is assessing a client who is at 36 weeks' gestation; this client has type 2 diabetes. The client says she is extremely upset that she will not be able to breastfeed her infant. The best nursing response would be based on what information? 1. There are no contraindications to diabetic mothers' breastfeeding their infants; it will be important for the mother to carefully monitor her blood glucose levels and insulin needs. 2. Because the mother's blood sugar level will be controlled by oral hypoglycemics, the medications are excreted in breast milk and would not be good for the baby. 3. Breastfeeding puts increased carbohydrate metabolism demands on the mother and makes it unrealistic to control her blood glucose level. 4. Offer the mother reassurance that there are some very good, nutritious infant formulas that are very close to breast milk and her infant should do well with them.

1 Mothers with diabetes can breastfeed, but they must frequently check their blood glucose levels, and insulin is recommended to maintain good blood glucose control. Oral hypoglycemics are not usually recommended for breastfeeding mothers. Breastfeeding does put an increased demand on the mother's metabolism, but this can be controlled with careful monitoring of blood glucose levels. Multiple formulas are available, but if the mother can breastfeed, that option should be made available to her. (Lowdermilk et al., 11 ed., p. 698)

For a client with severe painful osteoarthritis, a regimen of heat, massage, and exercise will: 1. Help relax muscles and relieve pain and stiffness. 2. Restore range of motion previously lost. 3. Prevent the inflammatory process. 4. Help the client cope with pain effectively.

1 Physical therapy relaxes muscles and relieves the aching and stiffness of the involved joints. It usually does not restore lost range of motion, and it does not prevent inflammation. Physical therapy does make the client more comfortable, but it does not assist in coping with pain. (Lewis et al., 10 ed., p. 1470)

The nurse is caring for an infant with an unrepaired tracheoesophageal fistula. In planning care, the nurse will identify which priority nursing goal? 1. To promote oxygen exchange 2. To prevent lung infection 3. To promote bonding 4. To replace fluids and electrolytes

1 Promoting life-saving oxygen exchange is a priority measure at this time. Prevention of infection will be appropriate after surgical repair. It is important to prevent pulmonary infection, especially aspiration, but oxygen exchange is still a priority. (Hockenberry & Wilson, 10 ed., p. 1110)

The nurse is encouraging a pregnant woman to eat a diet rich in folic acid. Which of the following food sources would provide the most folic acid? 1. Meat and dark green, leafy vegetables 2. Dairy products 3. Carrots and raisins 4. Shellfish

1 Rich dietary sources of folate are dark green, leafy vegetables, whole wheat bread, lightly cooked beans and peas, nuts and seeds, sprouts, oranges and grapefruits, liver and other organ meats, poultry, fortified breakfast cereals, and enriched grain products. Shellfish is rich in iodine. Dairy products are rich in calcium. (Lowdermilk et al., 11 ed., p. 345)

What nursing measure would be included in the plan of care for a client with acute kidney injury? 1. Observe for signs of a secondary infection. 2. Provide a high-protein, low-carbohydrate diet. 3. In-and-out catheterization for residual urine 4. Encourage fluids to 2000 mL in 24 hours.

1 Secondary infections are the cause of death in 50% to 90% of clients with acute renal failure. A low-protein diet is most often offered. Catheterizations are avoided. Fluids may be limited if the client is in acute kidney injury. (Lewis et al., 10 ed., pp. 1073-1075)

Ten days after delivery, a client is diagnosed with mastitis. The nurse would anticipate what assessment findings? 1. Tender, hard, inflamed area on the breast 2. Dimpled skin on the upper outer quadrant of the breast 3. Lack of milk production 4. Nipple burning during feeding

1 Swelling, erythema, and pain are found most often in the upper, outer quadrant of the breast. Dimpled skin (orange peel appearance) is a potential sign of breast cancer. Nipple burning is related to positioning and initiation of the let-down reflex during feeding. Milk production starts about 4 days after delivery and is not related to the development of mastitis. (Lowdermilk et al., 11 ed., p. 625)

The nurse would explain to a patient with genital herpes that he or she is most contagious at what stage? 1. When vesicles rupture and release transudate 2. When superficial, painful ulcers appear 3. When yellow vaginal drainage is present 4. When pustules become inflamed and erythematous

1 The herpes simplex virus (HSV-2) is concentrated in the vesicles, and therefore the infection is highly contagious when this clear fluid is released. The lesions rupture and form shallow, moist ulcerations (not pustules) that eventually crust, allowing epithelialization of the erosions to occur. There is no yellow drainage. The primary infection is associated with local inflammation and pain and is often accompanied by systemic symptoms of fever, headache, malaise, myalgia, and regional lymphadenopathy. (Lewis et al., 10 ed., p. 1232)

Which nursing observations indicate that a male client with a kidney stone is experiencing renal colic? 1. Severe flank pain radiating toward the testicles 2. Stress incontinence with full bladder 3. Hematuria and severe burning on urination 4. Enuresis with hyperalbuminuria

1 The most characteristic symptom of renal colic is sudden, severe pain. The client may also exhibit nausea and vomiting, pallor, and diaphoresis during the acute pain episode. Hematuria and burning on urination are associated with UTIs, although there may be some bleeding with the passage of the renal stone. (Lewis et al., 10 ed., p. 1045)

The nurse is teaching a client with a pelvic inflammatory disease. The nurse instructs the client to sleep with her head elevated about 45 degrees. What is the rationale behind instructing the client to sleep in this position? 1. Assists to localize drainage in the lower abdomen 2. Decreases abdominal muscle tension 3. Makes coughing and deep breathing more effective 4. Prevents scarring of the fallopian tubes

1 The nurse teaches the client to maintain a semi-Fowler's position to prevent or decrease movement of the contaminated fluid to the upper abdomen and the area of the diaphragm. (Lewis et al., 10 ed., p. 1251)

The nurse is assessing a client who had a transurethral resection of the prostate (TURP) 6 hours ago. He has a urinary catheter with continuous bladder irrigation running. What nursing observations would indicate a complication is developing? 1. Catheter drainage of 50 mL in the past hour and increase in suprapubic pain 2. Dark, grossly bloody catheter drainage with pieces of tissue 3. Client states that he feels like he needs to void 4. Moderate amount of bloody discharge from around the catheter

1 The primary complication is the obstruction of the urinary catheter with clots or tissue. There should be a large amount of drainage from the catheter because the irrigating fluid is infusing into the bladder. The catheter drainage should be closer to 300 to 400 mL/ hr. It is not unusual for the drainage to be grossly bloody on the operative day, but it should begin to clear over the next 24 hours. It is common to have a feeling of needing to void with a catheter in place. (Lewis et al., 10 ed., p. 1268)

The nurse assigned to the care of newborn infants understands the importance of keeping these infants swaddled in a warm blanket to prevent heat loss. Why is this important in the care of the newborn? 1. Chilling leads to increased heat production and greater oxygen needs. 2. The newborn's metabolic rate is decreased. 3. Evaporation will affect the newborn's ability to feed. 4. The newborn will sleep more comfortably.

1 The priority is to prevent chilling, which leads to greater oxygen consumption and to an increased utilization of glucose and brown fat. Chilling also increases caloric needs, decreases surfactant production, and promotes a tendency to develop acidosis. Evaporation occurs when the newborn is wet with amniotic fluid. (Hockenberry & Wilson, 10 ed., p. 244)

The nurse is providing discharge teaching to a 20-year-old mother who has had her first male child. Which statement by the mother demonstrates that she understands the discharge teaching regarding his circumcision? 1. "I will observe the whitish yellow drainage on his penis, but I will not remove it." 2. "I will bring him back to the clinic in 3 days to have the drainage removed." 3. "I will use antibiotic ointment on his penis with every diaper change." 4. "I will rub the area briskly with a washcloth to remove the discharge."

1 The whitish yellowish exudate around the glans penis is granulation tissue and is normal. It will usually disappear within 2 to 3 days. It is not an infection; therefore antibiotic ointment is not appropriate. Soap and water cleansing after each diaper change is appropriate. A small sterile petrolatum gauze dressing may be applied to the area during the first 2 to 3 days (Gomco and Mogen clamp). If a PlastiBell was used, keep area clean; application of petrolatum jelly is not necessary; plastic ring will dislodge when area has healed (5 to 7 days). (Hockenberry & Wilson, 10 ed., p. 274)

A 10-lb (4536-g) newborn of a mother with diabetes is admitted to the intensive care unit because of hypoglycemia. The baby's mother is concerned that he will have diabetes. The most appropriate response by the nurse is that the baby: 1. May have an increased risk of acquiring metabolic syndrome in childhood or early adulthood 2. Will not be at risk for developing diabetes 3. Will have to follow a diabetic diet to avoid complications 4. Will not need to be monitored closely during his early childhood years

1 There is evidence of an increased risk of acquiring metabolic syndrome (i.e., obesity, hypertension, dyslipidemia, and glucose intolerance) in childhood or early adulthood. Nursing care should focus on healthy lifestyle and prevention later in life. The hypoglycemia is transient. Hypoglycemia is a rebound response because the maternal hyperglycemia stimulates insulin production in the fetus, and the newborn is left with excessive insulin after the maternal glucose supply is ended at birth. The infant does have an increased chance of becoming diabetic during childhood, especially of symptoms of metabolic syndrome appear. (Hockenberry & Wilson, 10 ed., p. 396)

The labor monitor tracing shows variable decelerations. What complication would the nurse anticipate is occurring? 1. Cord compression 2. Fetal hypoxia 3. Placental insufficiency 4. Head compression

1 Variable decelerations most commonly occur during the transition phase of the first or second stage of labor as a result of umbilical cord compression or stretching during fetal descent and are correctable. Fetal hypoxia and uteroplacental insufficiency are associated with late decelerations. Head compression is associated with early decelerations. (Lowdermilk et al., 11 ed., p. 420)

In taking the health history of a client with severe painful osteoarthritis, which question should the nurse ask about their condition? Select all that apply. 1. Do you utilize and complementary or alternative therapies for your arthritis? 2. Do you have any joint deformities from your arthritis? 3. Did your symptoms begin during childhood? 4. Have you ever taken corticosteroids or immunosuppressive medication for your arthritis? 5. Have you ever developed kidney stones from your condition?

1, 2 Osteoarthritis has a gradual onset and affects weight-bearing joints with pain that is more pronounced after exercise. The onset of osteoarthritis is gradual, not sudden, and commonly occurs until after age 50. The client will usually complain of increased stiffness in the morning and after periods of inactivity, with improvement after activity. Joint pain generally worsens with joint use, and in the early stages of osteoarthritis, joint pain is relieved by rest. Alternative therapies are often used and need to be evaluated as to any joint deformities from the condition. The development of kidney stones would be secondary to gout, and the use of steroids and immunosuppressive medication are for rheumatoid arthritis. (Lewis et al., 10 ed., p. 1517)

The nurse is evaluating a client's response to hemodialysis. Which laboratory values will indicate the dialysis was effective? Select all that apply. 1. Serum potassium level decreases from 5.4 to 4.6 mEq/L. (5.4 to 4.6 mmol/L) 2. Serum creatinine level decreases from 1.6 to 0.8 mg/dL. (111.44-70.72 umol/L) 3. Hemoglobin increases from 10 to 12 g/dL. (100-120 g/L) 4. White blood cells increase from 5000 to 8000/mm3. (5.00-8.00 3 109/L) 5. BUN decreases from 110 to 90 mg/dL. (39.27-32.13 mmol/L)

1, 2, 5 Primary action of hemodialysis is to clear nitrogenous waste products. The creatinine and BUN provide a measure of how effective the dialysate was in removing the waste products. Electrolytes are altered with a decrease in potassium. Hemoglobin, white blood cells, and sedimentation rate are not affected, these cells are too large to diffuse through the pores of the dialysate membrane. (Lewis et al., 10 ed., p. 1084)

The nurse is instructing a client on dietary restrictions for the management of gout. The instructions include elimination of which of the following foods? Select all that apply. 1. Asparagus 2. Almonds 3. Chicken 4. Grapefruit 5. Red wine 6. Salmon

1, 3, 5 Purine-rich foods (e.g., shellfish such as crab and shrimp; vegetables such as lentils, asparagus, and spinach; meats such as beef, chicken, and pork) will not cause gout but can trigger an acute attack if a person is susceptible to gout. Other foods listed are not considered high in purine. (Lewis et al., 10 ed., p. 1532)

The nurse understands that the following clinical findings are indications for dialysis. Select all that apply. 1. Volume overload 2. Blood urea nitrogen level of 18 mg/dL (6.43 mmol/L) 3. Potassium level of 6.8 mEq/L (mmol/L) 4. Glomerular filtration rate of 25 mL/min 5. Metabolic acidosis 6. Creatinine level of 5.0 mg/dL (442.0 umol/L)

1, 3, 5, 6 Indications for dialysis include volume overload, weight gain, hyperkalemia, metabolic acidosis, and rising BUN (10-20 mg/dL [3.57-7.14 mmol/L]) and serum creatinine (0.5-1.5 mg/dL [44.2- 132.6 umol/L]) levels, along with decreased GFR rate (less that 15 mL/min). A potassium level of 6.8 is hyperkalemia, and a BUN of 18 mg/dL (6.43 mmol/L) is within normal range. (Lewis et al., 10 ed., p. 1084)

The nurse would anticipate that Rho(D) immune globulin would be administered in which of the following situations? Select all that apply. 1. After chorionic villus sampling 2. History of Rh exchange transfusion in a previous pregnancy 3. Following a spontaneous abortion 4. Current pregnancy of an Rh-negative infant 5. Positive indirect Coombs' test at 28 weeks 6. Following delivery of an Rh-positive infant

1, 3, 6 Rho(D) immune globulin is administered to Rh-negative women whose indirect Coombs tests are negative. Women who are sensitized are not given Rho(D) immune globulin; this would be a woman with a history of Rh exchange transfusion in a previous pregnancy and a positive indirect Coombs' test at 28 weeks' gestation (a negative indirect Coombs test means sensitization has not occurred). Also, it is not necessary to give Rho(D) immune globulin if the infant is Rh negative. It is given within 72 hours of an Rhnegative mother's delivery of an Rh-positive infant, after amniocentesis, chorionic villus sampling, ectopic pregnancy, miscarriage, elective abortion, abruptio placentae, placenta previa, or trauma at 28 weeks' gestation (with a negative indirect Coombs' test result). (Hockenberry & Wilson, 10 ed., p. 325)

The nurse received handoff for a client returning from a right leg amputation. What should be included in the plan of care? 1. Applying ice packs to the residual limb for 72 hours 2. Having the client lie on his or her abdomen for 30 minutes three or four times a day 3. Wrapping the residual limb with elastic bandages from proximal to distal ends 4. Managing client's pain with antiinflammatory medications

2 Client should lie on the abdomen for 30 minutes three or four times a day and position the hip in extension while prone. Also, to prevent flexion contractures, clients should avoid sitting in a chair for more than an hour. The residual limb is wrapped from distal to proximal. Ice packs are not used on the residual limb after surgery because the cold restricts blood flow. Antiinflammatory medications may be used for pain relief but not to prevent edema. (Lewis et al., 10 ed., p. 1488)

A client has had a kidney stone removed, and the nurse instructs him in measures to decrease kidney stone formation in the future. Which statement by the client indicates to the nurse that he understood the teaching? 1. "I can continue to drink soda if it is sugar free." 2. "I should consume at least 3000 mL of fluid daily." 3. "I should report nocturia that occurs once a night." 4. "I will ingest megadoses of vitamins C and D daily."

2 A high fluid intake will help keep solutes diluted, thus preventing kidney stone formation. Drinking soda (diet or otherwise) is not the best method of increasing urine output. Nocturia and vitamins C and D are not relevant to kidney stones. (Lewis et al., 10 ed. pp. 1045-1046)

The nurse is caring for a newborn with an unrepaired meningocele. What is the highest priority goal for care? 1. Maintaining a patent airway 2. Preventing trauma to the sac 3. Providing nourishment to prepare for surgery 4. Encouraging long-term rehabilitation planning

2 A meningocele is a saclike cyst of meninges filled with spinal fluid that protrudes through a defect in the bony part of the spine. Trauma and/or infection could lead to permanent central nervous system damage. The other responses are important, but preventing trauma to the sac is the highest priority. (Hockenberry & Wilson, 10 ed., p. 1638)

The nurse is discussing the importance of breast self-examination with a client who is being discharged after a vaginal hysterectomy. What is important information for the nurse to give this client? 1. Perform breast self-examination 1 week after her normal period. 2. Examine her breasts on a regular basis about the same time every month. 3. Breasts should be palpated while in the sitting position. 4. Use the tips of the fingers to palpate deeply into the breast tissue.

2 Because she no longer has regular periods, the client should pick a date and perform breast self-examination at the same time each month. Self-examination of the breast a week after the normal period is the best time for a woman who still has menstrual periods because the breast tissue is less glandular a week after the normal period. Breasts are examined lying down and standing, not sitting. The pads of the fingers are used to examine the breast using small circular motions in a spiral pattern or in an up-and-down motion. (Lewis et al., 10ed., p. 1205)

The nursing discharge care plan for a 2-month-old infant in a Pavlik harness includes what nursing instructions? 1. Instruct the parents how to perform the Ortolani test daily. 2. Check at least two or three times a day for red areas under the straps. 3. Check with the physician about using a spica cast because the harness is not effective. 4. Adjust the harness straps if the parents think it is necessary.

2 Check for red areas under the straps at least two or three times a day. The Ortolani test is for diagnostic purposes and should only be performed by trained health care practitioners. The success rate of the Pavlik harness is about 95% when a Pavlik harness is used on a full-time basis for 6 weeks, and spica casting is unnecessary. Adjustment of the harness is done by a health care practitioner. (Hockenberry, 10 ed., pp. 423-424)

Which are signs and symptoms of cystitis. Select all that apply. 1. Increased bladder capacity 2. Frequency 3. Dysuria 4. Nocturia 5. Urgency 6. Polydipsia

2, 3, 4, 5 Classic signs of cystitis include frequency, urgency, decreased bladder capacity, nocturia, and dysuria caused by the inflammatory process. Polydipsia (excessive thirst) is associated with diabetes mellitus. (Lewis et al., 10 ed., p. 1034)

Which of the following statements by the client who has recently had a total hip replacement indicates that the client does not understand the mobility limitations? 1. "I should not bend down to put on shoes or socks." 2. "It is okay to cross my legs if I am sitting in a chair." 3. "I should put a pillow between my legs when lying on my side." 4. "I should not sit in low chairs or on toilet seats that are low."

2 Clients with total hip replacement should not bring their operative leg across midline, which may result in a prosthesis dislocation. Clients should maintain abduction (pillow between legs) and use elevated toilet seats. Crossing the legs is adduction, which is contraindicated for this client. (Lewis et al., 10 ed., p. 1468)

A client is scheduled for an abdominal hysterectomy. Preoperative teaching includes which of the following? 1. A nasogastric tube will be left in to control vomiting after surgery. 2. A douche and an enema may be done the evening before surgery. 3. There will be a moderate amount of bloody vaginal drainage after surgery. 4. Ambulation will be delayed for 48 hours because of the extensive nature of the procedure.

2 Douching and some method of bowel preparation are part of the preoperative measure to cleanse the field of bacteria and pathogens. Vomiting is not a usual postoperative problem. If this occurs, it would most likely be controlled by an antiemetic. Vaginal drainage occurs with a vaginal, not an abdominal, hysterectomy. Ambulation is encouraged to prevent venous stasis. (Lewis et al., 10 ed., p. 1257)

The newborn's mother is concerned about the shape of the baby's head after delivery. She states that the baby looks like a "cone head." What is the most appropriate response by the nurse? 1. "You don't need to worry about it. It is perfectly normal after birth." 2. "It is molding caused by the pressure during birth and will disappear in a few days." 3. "I will report it to the physician and recommend a diagnostic scan." 4. "It is a collection of blood related to the trauma of delivery and will absorb in a few weeks."

2 Explaining that the "cone-head" appearance is molding caused by pressure during birth and that it will disappear in a few days provides the most appropriate response. The nurse reassures the mother that molding is normal and caused by the pressure during delivery and will disappear in 1 to 2 days. The nurse should not tell a concerned mother not to worry, which is a type of false reassurance. The condition does not require a diagnostic scan. The collection of blood related to trauma that will take several weeks to absorb describes cephalhematoma. (Hockenberry & Wilson, 10 ed., p. 253)

A 7-year-old boy is in the emergency department with a greenstick fracture of the ulna. How will the nurse explain the fracture to the parents? 1. The bone is broken across the growth plate. 2. There is a splintering of the bone on one side. 3. There is a separation of the bone at the fracture site. 4. The bone is broken into several fragments.

2 Greenstick fracture refers to splintering of the bone, not a complete fracture. The name comes from the splintering effect in attempts to break a "green stick." It is a common fracture in children. A comminuted fracture (bone is broken into several fragments) has multiple bone fragments and is more common in adults. In a nondisplaced fracture, such as the greenstick fracture, the periosteum is intact across the fracture, and the bone is still in alignment. (Lewis et al., 10 ed., p. 1468)

A client's Pap test reveals epithelial cells characteristic of adenocarcinoma of the cervix. The nurse understands that which of the following is a major risk factor for cervical cancer? 1. Long-term use of oral contraceptives 2. Recurrent outbreaks of human papilloma virus (HPV) 3. Grand multiparity with history of preterm labor 4. Alternative therapy for treatment of menopausal symptoms

2 Increased risk for cervical cancer is associated with a history of HPV (genital warts) infection, STDs, HSV-2, multiple sex partners, first intercourse at early age, and abnormal Pap tests. The use of alternative therapy and estrogen therapy for menopause, oral contraceptive use, and multiple pregnancies do not increase the risk. (Lewis et al., 10 ed., p. 1234)

A client begins receiving methotrexate for severe symptoms of rheumatoid arthritis. What is the most important information for the nurse to give this client regarding the medication? 1. Take extra fiber and fluids to counteract the constipating effect. 2. It is important to have periodic laboratory work done. 3. Take the drug on an empty stomach. 4. Hirsutism and menstrual changes sometimes develop as side effects.

2 Laboratory work will need to be done periodically during administration to monitor for the development of anemia, leukopenia, thrombocytopenia, and/or hepatic toxicity. Hirsutism and menstrual changes occur with long-term corticosteroid use. Methotrexate should be given 1 hour before or 2 hours after meals to prevent vomiting when given by mouth (PO). Antiemetics are given concurrently with the medication. (Lewis et al., 10 ed., p. 1525)

A client is receiving magnesium sulfate to help suppress preterm labor. The nurse should watch for which sign of magnesium toxicity? 1. Headache 2. Loss of deep tendon reflexes 3. Palpitations 4. Dyspepsia

2 Magnesium toxicity causes central nervous system depression; this would be observed as loss of deep tendon reflexes, paralysis, respiratory depression, drowsiness, lethargy, blurred vision, slurred speech, and confusion. Headache may be an adverse effect of calcium channel blockers, which are sometimes used to treat preterm labor. Palpitations are an adverse effect of terbutaline, which is also used to treat preterm labor. Dyspepsia may occur as an adverse effect of indomethacin, a prostaglandin synthetase inhibitor used to suppress preterm labor. (Lowdermilk et al., 11 ed., p. 664)

The nurse is assessing a primigravida client who is at 26 weeks' gestation; the client's blood type is AB negative, her serology is negative, and she has a history of one miscarriage at 20 weeks. On the basis of this information, what will the nurse anticipate being ordered for this client? 1. An amniocentesis at 30 weeks' gestation 2. Administration of Rho(D) immune globulin at 28 weeks' gestation 3. A blood test on the father to determine his blood type 4. Fetal blood sampling to determine fetal blood type

2 Rho(D) immune globin is given to all Rh-negative women in the 28th week of gestation. The blood type of the father may be determined, but paternity is not an important issue in this situation. An amniocentesis is not necessary at this time, and obtaining fetal blood to determine blood type is more risky than administering the medication to the mother. (Lowdermilk et al., 11 ed., p. 494)

A multigravida client comes into the emergency department complaining of abdominal pain. She is at 30 weeks' gestation. On assessment, the nurse observes complete dilation and effacement of the cervix with the perineal area bulging and the infant's head crowning. The mother states she is feeling a strong urge to push. What is the best nursing action? 1. Prepare the client for an emergency cesarean delivery. 2. Place even gentle pressure on infant's head and support it through the birth canal. 3. Have the client hold her legs together and take her to the labor and delivery unit. 4. Have the client take two deep breaths and push hard with the next contraction.

2 The birth of this infant is imminent. The infant is probably small because of prematurity, the mother is multigravida, and the mother has not received any analgesics. The nurse should place hands at the perineum to apply light pressure to the fetal head to prevent rapid expulsion. Do not attempt to take the mother to labor and delivery; notify labor and delivery and newborn nursery units of the impending birth of premature infant. If the mother pushes hard with the next contraction, the infant may progress too rapidly. There is no need for a cesarean delivery; no attempt should be made to slow or prevent the delivery because this would put the infant in further jeopardy. (Lowdermilk et al., 11 ed., p. 462)

The nurse is discussing testicular self-examination with a male client. What information is important for the nurse to include in the discussion? 1. The best time to perform the examination is 24 hours after sexual intercourse. 2. The examination should be conducted at the same time each month. 3. The client should perform this self-examination every 3 to 4 months. 4. When the scrotum is pulled up tight against the body, the testes are easier to palpate.

2 The examination should be done at the same time each month to develop a regular routine. After a shower, when the scrotum is warm and the testicles are descended away from the body, is a good time to perform the examination. (Lewis et al., 10 ed., p. 1205)

At 9:00 a.m. a 24-hour (composite) urine collection is started. What instructions will the nurse provide to the client? 1. Place the first voided specimen in the container and continue to collect the urine until 9:00 a.m. the following day. 2. Discard the first morning specimen, collect urine for the next 24 hours, and make sure to void before the collection is completed at 9:00 a.m. the following day. 3. Discard the first morning specimen because it may contain concentrated abnormal components. 4. Collect all urine from 9:00 a.m. onward in separate containers that are labeled for time and amount of voiding.

2 The first specimen is discarded before the collection is started. Collection will continue until the completed time frame; the client should void before the collection is completed. (Lewis et al., 10 ed., p. 1024)

The nurse is responsible for documenting the first meconium stool the newborn passes. If the newborn does not have a stool in the first 24 hours of life, the nurse should first: 1. Insert a rectal thermometer to facilitate the process. 2. Inspect the anal area for an opening. 3. Monitor the vital signs for a rise in temperature. 4. Increase oral feeding to stimulate passage of stool.

2 The lack of passage of a meconium stool requires further assessment; it may be a sign of imperforate anus. The first assessment the nurse should perform is to visually inspect the anal area for an opening. Inserting a rectal thermometer could tear the anal mucosa, and if an imperforate anus is present, all oral feedings will be stopped. (Hockenberry & Wilson, 10 ed., p. 253)

Which statement best describes the problem of regulation of body temperature in a 3-lb (1361-g) premature infant? 1. The surface area of the premature infant is relatively smaller than that of a healthy term infant. 2. There is a lack of subcutaneous fat, which furnishes insulation. 3. There are frequent episodes of diaphoresis, causing loss of body heat. 4. There is a limited ability to produce body proteins.

2 The premature infant's temperature-regulating mechanism is poorly developed at birth. Heat production is low, and heat loss is high because of the greater body surface area relative to weight and the infant's lack of subcutaneous fat. No diaphoresis should be occurring, and the question has nothing to do with protein metabolism. The statement "The surface area of the premature infant is relatively smaller than that of a healthy term infant" describes the body surface area of the infant, and although true, it does not have any implication for maintaining emperature. (Hockenberry & Wilson, 10 ed., p. 341)

The nursing assessment of an infant reveals expiratory grunting, substernal retractions, and a temperature of 99°F (37.2°C). What is the first nursing action? 1. Place the infant in Trendelenburg position. 2. Begin administration of 40% humidified oxygen via hood. 3. Increase the temperature of the environment. 4. Perform a complete assessment for congenital anomalies.

2 The priority here is the respiratory distress. The first nursing action is to increase the inspired oxygen; it would be appropriate to determine whether the infant has any mucus in the airway. Do a quick but thorough assessment of the infant and advise the supervisor or doctor regarding the infant's status. Trendelenburg position would be contraindicated because it would make breathing more difficult. Although performing an assessment is important, respiratory distress is a priority. Increasing the temperature of the neonate's environment could lead to an increased pulse rate and may lead to more oxygen consumption as an attempt of the body to cool itself. (Hockenberry & Wilson, 10 ed., p. 373)

The nurse encourages a client in labor to assume a side-lying position. What is the purpose of this position? 1. Prevents prolapse of the cord 2. Enhances venous return 3. Relaxes the pelvic musculature 4. Promotes crowning

2 The weight and pressure of the uterus on the vena cava decreases the venous return to the mother's heart. This will precipitate a drop in blood pressure and decreased blood supply to the fetus. In a side-lying position, pressure is reduced and adequate cardiac output is promoted. (Lowdermilk et al., 11 ed., p. 440)

A client in kidney failure is to have a serum blood urea nitrogen level determined. What will this diagnostic test measure? 1. Concentration of the urine osmolarity and electrolytes 2. Serum level of the end products of protein metabolism 3. Ability of the kidneys to concentrate urine 4. Levels of C-reactive protein to determine inflammation

2 Urea is an end product of protein metabolism. In kidney failure, the kidneys cannot clear all of the urea from the blood, and the creatinine and BUN level will be elevated. The C-reactive protein is a diagnostic test used in assessing clients with inflammatory bowel disease, rheumatoid arthritis, autoimmune diseases, and pelvic inflammatory disease (PID). A specific gravity test of the urine would assess the ability of the kidneys to concentrate urine. The urine osmolarity (concentration of particles in urine) and electrolytes assess fluid balance. The kidneys play an important role in the balance of electrolytes and fluids. (Lewis et al., 10 ed., p. 1024)

The nurse is assessing a client who had a fractured femur repairedwith an external fixator device. Which assessment findings should the nurse report to the health care provider? Select all that apply. 1. Increase in pulse rate in affected leg 2. Paresthesia distal to area of injury 3. Toes on affected leg cool to touch and edematous 4. Reports that pins are hurting 5. Reports of leg pain unrelieved by analgesics or repositioning 6. Client angry and calling loudly to the nurse every 10 minutes

2, 3, 5 Paresthesia, edema, and leg pain unrelieved by analgesics are classic indicators of the development of compartmental syndrome. With a femur fracture, there is some degree of edema postoperatively that may leave the toes on the affected leg cool to touch. An increase in pulse rate is not an indication of a problem; a decrease in pulse strength is. The pins usually do not cause undue pain, and frequently the client is angry regarding the immobility and does not use effective coping measures; neither would need to be reported. (Lewis et al., 10 ed., p. 1483)

In the immediate postoperative phase for a client with a mandibular fracture repair, what are the priority nursing concerns? Select all that apply. 1. Postoperative bleeding 2. Postoperative pain 3. Client positioning 4. Client's inability to speak 5. Respiratory distress 6. Location of scissors and wire cutters

2, 3, 5 Two potential life-threatening problems in the immediate postoperative period are airway obstruction and aspiration of vomitus. Because the patient cannot open the jaws, it is essential that an airway is maintained. Place the patient on the side with the head slightly elevated immediately after surgery. The wire cutter or scissors may be used to cut the wires or elastic bands in case of an emergency. Although pain is an important consideration for any postoperative patient, it is not a life- threatening priority, nor are the patient's inability to speak or bleeding. (Lewis et al., 10 ed., p. 1468)

The nurse understands that a client may experience pain during peritoneal dialysis because of which of the following? Select all that apply. 1. Warming the dialysate solution before administration 2. Too-rapid instillation of the dialysate 3. Infiltration of solution into the bloodstream 4. Increased intraabdominal pressure 5. Too-rapid outflow rate of the dialysate solution

2, 4 Rapid instillation of dialysate fluid and accumulation of the fluid within the abdomen can lead to pain and discomfort. Warming the dialysate solution helps in the clearance and may diminish any cold sensation of fluid entering the body. It will also assist to diminish any cold sensation of fluid entering the body. The dialysate fluid does not infiltrate and enter the circulatory system. Rapid outflow of dialysate does not cause pain. (Lewis et al., 10 ed., pp. 1084-1086)

The nurse is caring for a client scheduled for a bone scan. What should be included in the preprocedure teaching? Select all that apply. 1. Maintain NPO (nothing by mouth) status for 8 hours before the procedure. 2. The procedure will involve intravenous injection of radioisotopes. 3. The procedure will involve a small incision where bone tissue is removed for biopsy. 4. The client will have to lie supine for about an hour during the scan. 5. Avoid stimulants such as caffeine for 24 hours before the procedure. 6. Increase intake of fluids after the procedure is completed.

2, 4, 6 The procedure will include an IV injection of radioisotopes that are given 2 hours before procedure; ensure client empties bladder before the procedure; the procedure takes about 1 hour; the client will lie supine during the procedure; fluid intake should be increased after the procedure to promote excretion of radioisotopes. Food or fluids are not limited before the scan, and no biopsy of the bone will be taken. (Lewis et al., 10 ed., p. 1458)

A client had a left modified radical mastectomy 48 hours ago. What would be important for the nurse to include in a discharge teaching plan for this client? Select all that apply. 1. Massage wound site with essential oils once incision has healed. 2. Avoid needle-sticks in the left arm. 3. Begin active exercises, such as pendulum arm swings, immediately. 4. Avoid abduction and external rotation of the upper arm. 5. Elevate arm on pillows to prevent edema. 6. Take blood pressure readings from the right arm.

2, 5, 6 Important teaching to include in the discharge plan of care for a client who has undergone a mastectomy includes the avoidance of needle-sticks in the arm on the side of the mastectomy and having blood pressure readings taken from the opposite arm. These measures are done to avoid any type of trauma that could lead to the development of lymphedema. Begin finger, wrist, and hand exercises to facilitate muscle contraction and to help prevent edema. Active exercises, such as pendulum swings and finger wall-climbing, are started after the incision has healed. As the area heals, abduction and external rotation will help improve the range of motion. (Lewis et al., 10 ed., p. 1214)

The nurse is caring for a child who had a long-leg plaster cast applied for a femur fracture. What action is a priority as the cast is drying? 1. Use only the fingertips when moving the cast. 2. Keep the client and cast covered with blankets. 3. Perform frequent neurovascular checks distal to fracture. 4. Place a heat lamp directly over the cast.

3 After cast application, observe for signs of compartment syndrome by performing neurovascular checks distal to the end of the cast. Palms of the hand should be used in turning the client. Heat should not be applied to a damp cast. (Lewis et al., 10 ed., p. 1472)

Which statement about the results of a contraction stress test (oxytocin challenge test) is considered accurate? 1. Negative if no fetal heart rate accelerations occur with accompanying fetal movements 2. Nonreactive if no late decelerations occur in more than half of the contractions 3. Positive if late decelerations occur in more than half of the contractions 4. Reactive if the fetal heart rate accelerates with accompanying fetal movement

3 An oxytocin challenge test, or contraction stress test, is conducted by giving an infusion of oxytocin to the mother and evaluating the fetal response to subsequent uterine contractions as plotted on a fetal monitor. The test result is negative if there are no late decelerations; it is positive if there are late decelerations in more than one-half of the contractions. If the CST result is positive and there is no acceleration of FHR with fetal movement (nonreactive NST result), the positive CST (nonreassuring; abnormal) result is an ominous sign, often indicating late fetal hypoxia. A negative CST (reassuring) result with a reactive NST result is desirable. (Lowdermilk et al., 11 ed., p. 649)

A client with chronic kidney disease has been prescribed calcium carbonate. What is the rationale for this particular medication? 1. Diminishes incidence of gastric ulcer formation 2. Alleviates constipation 3. Binds with phosphorus to lower concentrations 4. Increases tubular reabsorption of sodium

3 Clients with chronic kidney disease have hypocalcemia and hyperphosphatemia. Clients are prescribed calcium-based phosphate binders, such as calcium acetate or calcium carbonate to improve excretion of phosphorus. (Lewis et al., 10 ed., p. 1079)

A primigravida client is experiencing Braxton Hicks contractions. Which statement is true concerning these contractions? 1. They are intensified by walking about. 2. They are confined to the low back. 3. They do not increase in intensity or frequency. 4. They result in cervical effacement and dilation.

3 False labor contractions decrease when the client is walking, are not concentrated in one part of the uterus, and do not increase in intensity and frequency. True labor is characterized by cervical effacement or dilation. (Lowdermilk et al., 11 ed., p. 287)

A neonate is being discharged home with a fiber-optic blanket for treatment of physiologic jaundice. What is important for the nurse to include in the discharge instructions? 1. Cover the infant's eyes during the treatment. 2. Reduce the daily number of formula feedings. 3. Encourage frequent feeding to increase intake. 4. Expect a constipated stool until jaundice clears.

3 Feedings and fluids should be encouraged to promote excretion of the bilirubin. It is not necessary to cover the neonate's eyes with use of the fiber-optic blanket, but there should be a covering pad between the infant's skin and the fiber-optic blanket. The stool would be loose, rather than constipated, while the jaundice is resolving. (Hockenberry & Wilson, 10 ed., p. 322)

What is an important nursing action when assisting the doctor with a pelvic examination? 1. Instruct the client to bear down and hold her breath during the procedure. 2. Explain to the client that she will not feel any pain. 3. Have the client empty her bladder before the examination begins. 4. Lubricate the speculum well before handing it to the doctor.

3 Having the client void before the examination will make the procedure less painful and more accurate. There is no need for the patient to bear down or hold her breath. The patient should relax as much as possible during the procedure. The level of pain, if any, is highly dependent on the patient and her pain tolerance. Lubricant on the speculum may interfere with the Pap smear. The client should not douche or have intercourse before a pelvic examination, especially if any specimens are to be obtained, because changes in the normal flora and pH could occur from douching and the presence of semen. (Ignatavicius & Workman, 8 ed., p. 1454)

A client with acute kidney injury develops severe hyperkalemia. What prescription would the nurse anticipate? 1. Furosemide 2. Calcium carbonate 3. 50% glucose and regular insulin 4. Epoetin alfa

3 Hyperkalemia can develop into an emergency situation (cardiac arrest). It is important to quickly move the potassium back into the cells by administering 50% glucose and regular insulin, usually in conjunction with some type of base to correct the acidosis, such as sodium bicarbonate or calcium gluconate given intravenously. Insulin assists in the movement of potassium into the cells and helps to reduce the serum potassium level. Calcium carbonate is used for the treatment of hyperphosphatemia that occurs with chronic kidney disease. Procrit is used for the treatment of anemia caused by a decrease in erythropoietin production by the kidneys. A diuretic, such as Lasix, may lead to a loss of potassium, but the rate is too slow. (Lewis et al., 10 ed., p. 1)

The nurse is instructing a student nurse concerning the differences in the joints affected in osteoarthritis and rheumatoid arthritis. Which of the following is an important fact to include? 1. In rheumatoid arthritis, weight-bearing joints are affected first. 2. In osteoarthritis, only the small joints of the fingers are affected. 3. In rheumatoid arthritis, there is usually bilateral joint involvement. 4. In osteoarthritis, joint destruction is due to changes in the synovial fluid.

3 In rheumatoid arthritis, small joints typically first (proximal interphalangeal [PIPs], metacarpophalangeals [MCPs], metatarsophalangeals [MTPs]), wrists, elbows, shoulders, knees. Usually bilateral, symmetric joint involvement. In osteoarthritis, weightbearing joints of knees and hips are most often affected, although small joints of the hands and feet and cervical/lumbar spine, often asymmetric, may also be involved; and joint destruction is caused by long-term use and weight bearing. (Lewis et al., 10 ed., p. 1525)

In the recovery room, the best immediate postoperative position for an infant who has had a cleft lip repair is: 1. Prone with the head turned to one side 2. Left Sims' position 3. Supine with the head turned to the side 4. Trendelenburg position to facilitate drainage

3 It is important that the child be positioned in such a manner that he does not traumatize the incisional area and that the airway is maintained, which would be supine with the head turned to the side. Trendelenburg position would compromise respiration. The prone position would cause trauma to the incisional area and is to be avoided in infants. Sims' position is not appropriate for an infant because the infant should rest in a supine position. (Hockenberry & Wilson, 10 ed., pp. 307)

Which client is at the highest risk for developing chronic kidney disease? 1. Client with severe acute glomerulonephritis 2. Client with placenta previa and hemorrhage at delivery 3. Client with poorly controlled long-term hypertension 4. Client who received IV aminoglycosides for an infection

3 Long-term hypertension and diabetes are the leading causes of chronic kidney disease. The client with placenta previa and hemorrhage is at risk for developing acute kidney injury. Acute glomerulonephritis may decrease renal function but seldom to the point of chronic kidney disease, as most clients recover. Aminoglycosides can be nephrotoxic and cause damage (acute kidney injury), but chronic kidney disease is not common. (Lewis et al., 10 ed., p. 1083)

The nurse is infusing dialysate during peritoneal dialysis. What is a nursing action to make the client more comfortable at this time? 1. Increase the rate of flow. 2. Raise the head of the bed. 3. Turn the client from side to side. 4. Refrigerate the fluid before infusion.

3 Movement of the client will help disseminate the fluid throughout the abdomen. The fluid should be instilled within the prescribed period of time; therefore, the dialysate flow should not be decreased. Raising the head of the bed will make the client more uncomfortable and increase intraabdominal pressure. The solutions should be infused at body temperature. (Lewis et al., 10 ed., p. 1085)

While discussing her diagnosis of hypertension, a client asks the nurse how long she is going to have to take all of the medications that have been prescribed. On what principle is the nurse's response based? 1. The client will be scheduled for an appointment in 2 months; the doctor will decrease her medications at that time. 2. As soon as her blood pressure (BP) returns to normal levels, the client will be able to stop taking her medications. 3. To maintain stable control of her BP, the client will have to take the medications indefinitely. 4. The nurse cannot discuss the medications with the client; the client will need to talk with the doctor.

3 Noncompliance with blood pressure medications is a common problem in the treatment of hypertension. The client must understand that the only way to keep her blood pressure under control is to continue to take her medications, potentially for the rest of her life. She will not be able to discontinue the medications unless there is a significant change in her condition as a result of weight loss, an exercise program, and/or decreased stress. Patients usually require follow-up and adjustments at monthly intervals until the goal BP is reached. Antihypertensives control BP but do not cure hypertension, therefore the medication cannot be stopped once the target reading is reached. (Ignatavicius & Workman, 8th ed., pp. 712-713, 717-718)

A client with chronic kidney disease has an internal venous access site for hemodialysis on their left forearm. What action will the nurse take to protect this access site? 1. Irrigate with heparin and normal saline solution every 8 hours. 2. Apply warm moist packs to the area after hemodialysis. 3. Do not use the left arm to take blood pressure readings. 4. Keep the arm elevated above the level of the heart.

3 Protect the arm with the functioning shunt. No blood pressure readings should be taken from that arm, and there should be no needlesticks. The access is not irrigated with heparin. (Lewis et al., 10 ed., p. 1087)

Each newborn should be screened before discharge for phenylketonuria (PKU), which can lead to mental retardation if not treated. The nurse knows that the blood screening test will have the most reliable results if the baby: 1. Is kept NPO for 6 hours before the blood is drawn 2. Has the heel wrapped in a warm towel for 30 minutes 3. Has been fed breast milk or formula at least 24 hours before the test 4. Is held by the mother and remains perfectly still

3 The Guthrie blood-screening test measures the amount of phenylalanine in the blood. It is most reliable if blood is drawn at least 24 hours after the newborn has ingested a source of protein. Breast milk and formula are both sources of protein. The heel stick is usually how the screening test is collected, so warming the extremity may increase blood flow. The infant would be held by a health care person, not the mother, for the blood collection. (Hockenberry & Wilson, 10 ed., p. 269)

A newborn is suspected of having esophageal atresia with a tracheal esophageal fistula. What nursing assessment information would assist in validating the presence of a fistula? 1. Clammy skin and a croupy cough 2. Crying and chest retractions 3. Choking and coughing 4. Chin tug and circumoral pallor

3 The classic three Cs—choking, coughing, and cyanosis—plus frothy saliva and constant drooling are the characteristic signs of esophageal atresia with a tracheoesophageal fistula. The other options are an incomplete description of the signs and symptoms. (Hockenberry & Wilson, 10 ed., p. 1108)

A young woman comes into the emergency department with menorrhagia. What is the priority concern for the nurse caring for this client? 1. The chronic bleeding will cause anemia. 2. The client is at a high risk for development of an infection. 3. The woman may be pregnant and is aborting the fetus. 4. The increased bleeding will promote later problems with infertility.

3 The nurse must rule out pregnancy/aborting first because of the potential for shock or damage to a fetus. Once aborting is ruled out or treated, the nurse addresses the issues of anemia and infection. Infertility would be the last concern, although it should be assessed. (Lewis et al., 10 ed., p. 1246.)

After delivery, a neonate is transferred to the nursery. The nurse is planning interventions to prevent hypothermia. What is the common source of radiant heat loss? 1. Low room humidity 2. Cold weight scale 3. Cool bassinette walls 4. Variable room temperature

3 The nurse understands that the common sources of radiant heat loss include cool bassinettes and bassinettes placed close to windows or areas of drafts. Low room humidity promotes evaporative heat loss. When the infant's skin has direct contact with a cooler object, such as a cold weight scale, conductive heat loss may occur. Convective heat loss occurs with a cool room temperature. (Hockenberry & Wilson, 10 ed., p. 343)

The nurse is discussing the prevention of urinary tract infections with a female client. What would be important to include in the discussion? 1. Decrease fluid intake to decrease burning on urination. 2. Take warm sitz baths with a mild bubble bath. 3. Avoid spermicides with nonoxynol-9. 4. Drink only acidic fluids such as orange juice.

3 The use of nonoxynol-9 spermicides can be irritating to the urinary tract and lead to infections. UTIs in women can be prevented by urination before and after sexual intercourse. Fluid intake should be increased, and no soap should be added to the sitz bath. (Lewis et al., 10 ed., p. 1036)

A client is diagnosed with epididymitis related to bladder outlet obstruction. The nurse teaches which intervention to assist the client in recovery? 1. Walk briskly at least 30 minutes every day. 2. Limit oral intake to minimize nausea and vomiting. 3. Apply scrotal support to relieve edema and discomfort. 4. Use warm baths and compresses during acute inflammation.

3 To facilitate lymphatic drainage from the inflamed epididymis, the client should be taught to use a towel roll to act as a "scrotal bridge." Cool compresses should be used in the acute phase. There is no reason to limit oral intake. Walking is extremely painful, and bed rest is usually indicated to prevent spread of infection. (Lewis et al., 10 ed., p. 1284)

A sexually active female 17-year-old is diagnosed with trichomoniasis through vaginal discharge analysis. The nurse explains which pharmacologic intervention to minimize symptoms and the risk for reoccurrence? 1. Return to clinic each week for intramuscular injection of penicillin. 2. Perform a daily vaginal douche with a weak iodine solution. 3. Oral administration of metronidazole three times a day to client and her partner. 4. Application of trichloroacetic acid to lesions daily for 6 to 8 weeks.

3 Trichomoniasis is a protozoal infection transmitted through sexual intercourse. All sexual partners need to be treated with the oral administration of metronidazole, a systemic antiprotozoal. Males may be asymptomatic. Intramuscular injection of penicillin is prescribed for syphilis. Douching should be avoided because it destroys the normal vaginal flora and increases the risk for developing the problem. Trichloroacetic acid (TCA) or podophyllin is topically applied to genital warts. (Lewis et al., 10 ed., p. 1231)

The night-shift nurse notes at the end of her shift that a client who had a mastectomy has a total of 90 mL of serosanguineous drainage from the incision over a 24-hour period. What is the best nursing action? 1. Report amount of drainage to the physician. 2. Start frequent blood pressure checks and observe for hemorrhage. 3. Continue to monitor the drainage. 4. Reinforce packing at the wound site.

3 Up to 100 mL of serosanguineous fluid would be an acceptable amount of drainage over a 24-hour period in a client who has had a mastectomy. Drains are usually removed when there is less than 25 mL in a 24-hour period. There is no indication of hemorrhage or the need to perform frequent blood pressure checks. If the nurse observes a greater amount of fluid in the drains, then it would be important to notify the physician. (Ignatavicius & Workman, 8 ed., pp. 1472-1474)

Which of the following circumstances is most likely to cause uterine atony leading to postpartum hemorrhage? 1. Hypertension 2. Cervical and vaginal tears 3. Urine retention 4. Endometritis

3 Urine retention is a common cause of uterine atony and can lead to postpartum hemorrhage. Urine retention causes a distended bladder to displace the uterus above the umbilicus and to the side, which prevents the uterus from contracting. The uterus needs to continue contracting if bleeding is to stay within normal limits. Cervical and vaginal tears can cause postpartum hemorrhage, but in the postpartum period, a full bladder is the most common cause of uterine bleeding. Neither endometritis, an infection of the inner lining of the endometrium, nor maternal hypertension causes postpartum hemorrhage. (Lowdermilk et al., 11 ed., p. 486)

A week after a right knee arthroplasty, a client continues to report moderate knee pain with activity. What recommendations should the nurse make? Select all that apply. 1. Rotate warm and ice packs to the incisional site around the clock. 2. Increase the amount of narcotic pain medication. 3. Perform isometric and active range of motion to the extremity every hour. 4. Take pain medicine before physical therapy sessions. 5. Progress physical activity as directed by the therapist.

3, 4, 5 The emphasis after a knee arthroscopic surgery should be on pain management and physical therapy. Postoperative pain is reduced with movement, so it should be encouraged. Isometric and active range of motion will increase muscle strength and flexion of the joint. Pain medicine should be reduced over time to encourage activity. Increased used of narcotics will decrease the mental alertness and the activity level. (Lewis et al., 10 ed., p. 1491)

A client reports that her last menstrual period was November 10. She asks the nurse, "When will my baby be due?" What is the best answer? 1. July 3 2. August 30 3. Around the middle of September 4. Around the third week of August

4 According to Näegele's rule, count back 3 months from the date of the last menstrual period and add 7 days to determine the estimated date of conception. About 35% of all women deliver within 5 days of (either before or after) this date. (Lowdermilk et al., 11 ed., p. 302)

The nurse is caring for a client is being treated with Buck's traction. What is a priority action for the nurse? 1. Remove the traction boot every 6 hours to provide skin care. 2. Check and clean the pin sites at least three times daily. 3. Check the area around the hip where the traction is applied. 4. Verify that weights are in the amounts ordered and are hanging freely.

4 Always check the weight amounts and make sure they are not lodged against the bed or another area. There are no pin sites because Buck's traction is skin traction, not skeletal traction. The traction boot does not need to be removed as often as every 6 hours to provide skin care. (Lewis, et al., 10 ed., p. 1470)

A pregnant client had an abruptio placentae after a hemorrhagic episode; an emergency delivery was completed. The client is stable, and the cesarean delivery was performed 2 days ago. During the postoperative period, the nurse is observing for potential complications. What would be important for the nurse to assess regarding the development of complications? 1. Check the blood sugar level every 2 hours. 2. Assess vital signs hourly. 3. Place client in side-lying position. 4. Monitor fibrinogen and coagulation studies.

4 Clients with abruptio placentae are prone to the development of disseminated intravascular coagulation after delivery, which is characterized by abnormal fibrinogen and coagulation studies. Although checking vital signs is important to continue to monitor, the delivery and hemorrhagic episode has occurred. Checking blood sugar would be appropriate for a client with gestational diabetes. Side-lying position would improve placental perfusion. (Lowdermilk et al., 11 ed., p. 683)

A woman has experienced an incomplete abortion. She is scheduled for a dilation and curettage (D&C). What is the purpose of this procedure? 1. To protect the uterus and the ovaries for future pregnancies 2. To provide a healthier uterine environment for future pregnancies 3. To provide reinforcement for an incompetent cervix 4. To scrape the uterine walls and remove the uterine contents

4 D&C is the dilation (opening) of the cervix and curettage (scraping) of the inner walls of the uterus to remove the uterine contents to control bleeding and, in this instance, remove any products of conception that were not expelled. It does not protect the uterus or the ovaries. It is not recommended for incompetent cervical os, nor does it promote health of future pregnancies. (Lewis et al., 10 ed., p. 1246)

The nurse is caring for a client who has had a mastectomy. What is important nursing care regarding the positioning of the affected arm? 1. Hold the arm close against the side of her body. 2. Secure the arm below the level of the heart. 3. Wrap the arm in an elastic bandage and keep it below the heart. 4. Elevate the arm above heart level.

4 Elevating the affected arm promotes drainage of lymph from the extremity and decreases fluid from the wound site, which reduces swelling. An elastic wrap may be applied to the affected arm to reduce swelling, but it would not be positioned below the heart level. (Lewis et al., 10 ed., p. 1219)

The client has had a right nephrostomy tube placed after a nephrolithotomy for removal of a kidney stone. When the client returns to the room, what is a priority nursing action? 1. Irrigate the tube with 30 mL of normal saline solution four times a day. 2. Clamp the tube if drainage is excessive. 3. Advance the tube 1 inch every 8 hours. 4. Ensure that the tube is draining freely.

4 Failure of the tube to drain freely can result in pain, trauma, wound dehiscence, and infection. If an irrigation is ordered for a nephrostomy tube, no more than 5 mL of sterile normal saline should be gently instilled. (Lewis et al., 10 ed., p. 1062)

A client is admitted because of benign prostatic hypertrophy and is scheduled to have a transurethral prostate resection. What assessment data would indicate to the nurse that a complication is developing? 1. The client has difficulty emptying his bladder. 2. Client states he feels like he cannot empty his bladder. 3. The client complains of frequency and nocturia. 4. Increasing complaints of flank pain and hematuria.

4 Flank pain may be indicative of an infection or a ureteral obstruction causing increased pressure on the renal pelvis. Other options are symptoms of benign prostatic hypertrophy, for which he will be treated while he is in the hospital. (Lewis et al., 10 ed., p. 1268)

Which is an appropriate nursing action for a child with acute glomerulonephritis?\ 1. Initiating contact isolation precautions 2. Encouraging increased fluid intake 3. Encouraging ambulation, as tolerated 4. Providing a fluid-restricted, low-sodium diet

4 For individuals with acute glomerulonephritis, edema is treated by restricting sodium and fluid intake and by administration of diuretics. Isolation is not required because this is an autoimmune problem. Although ambulation is not incorrect for the child, it is best to encourage rest periods and focus on ways to allow the kidneys to repair and restore themselves. (Lewis et al., 10 ed., p. 1042)

A teenage boy comes to the office complaining of intense burning while urinating and gray-green discharge coming from his penis. The nurse recognizes these as symptoms of what problem? 1. Herpes (HSV-2) with open lesions 2. Secondary stage syphilis 3. Urinary tract infection 4. Gonorrhea

4 Gonorrhea in men is the most symptomatic, with urethritis, dysuria, and purulent drainage, but the disease can be asymptomatic. The purulent secretion should be cultured to identify the microorganism. HSV-2 infections are characterized by painful vesicles surrounded by an erythematous base that progress to shallow ulcers, which eventually crust and epithelialize as they heal. In the secondary stage of syphilis the client is often asymptomatic; however, a maculopapular rash on the palms of the hands and soles of the feet may be noted with lymphadenopathy, sore throat, headache, and condylomata lata (flat lesions appearing in moist areas— not to be confused with condylomata acuminata in genital warts). A lower urinary tract infection would be characterized by dysuria, urgency, frequency, hematuria, and possible low back pain. (Lewis et al., 10 ed., p. 1230)

A primigravida client at 26 weeks' gestation has been administered a glucose tolerance test. What would the nurse anticipate as a normal finding? 1. Glycosylated hemoglobin A1c of 5.0% (0.05 proportion of hemoglobin) 2. Blood glucose of 200 mg/L at 60 minutes (11.1 mmol/L) 3. 24-hour urine glucose level of 5 mg/dL (0.28 mmol/L) 4. Blood glucose level of 110 mg/L (6.11 mmol/L) at 3 hours

4 In the oral glucose tolerance test (OGTT), the blood glucose level is evaluated before the test (a fasting blood glucose), 1 hour after a 100 g glucose load, 2 hours after the glucose load, and 3 hours after the glucose load. The normal value for 1 hour is less than 180 mg/L (10.0 mmol/L), the normal value for 2 hours is less than 155 mg/L (8.6 mmol/L), and the normal value for 3 hours is less than 140 mg/L (7.8 mmol/L). The glycosylated hemoglobin value reflects blood glucose control for the past 120 days, and the urine glucose level is not as reliable an indicator of control as the serum glucose level. (Lowdermilk et al., 11 ed., p. 700)

What is an important nursing action in the safe administration of heparin? 1. Check the prothrombin time (PT) and administer the medication if it is less than 20 seconds. 2. Use a 20-gauge, 1-inch (2.5 cm) needle and inject into the deltoid muscle and gently massage the area. 3. Dilute in 50 mL 5% dextrose in water (D5W) and infuse by intravenous piggyback (IVPB) over 15 minutes. 4. Use a 25-gauge, 1⁄2-inch (1.25 cm) needle and inject the medication into the subcutaneous tissue of the abdomen.

4 Medication should be administered with a small-gauge (25 gauge) needle into the subcutaneous tissue without aspirating or massaging the area. Partial thromboplastin time (PTT) is used to monitor the effects of heparin. Although heparin may be administered IV, it must be diluted in more than 50 mL D5W and would be administered over a longer period of time than 15 minutes. (Lewis et al., 10th ed., p. 820)

During peritoneal dialysis treatment, the nurse continually evaluates the client for poor dialysate flow. How will this complication be identified? 1. Increased urine albumin level 2. Decreased plasma osmolality 3. An increase in sodium transfer to serum 4. Outflow is intermittent

4 Outflow should be a continuous stream after the clamp is opened (end of dwell time). Constipation, kinked or clamped connection tubing, client's position, or catheter displacement can lead to poor dialysate flow. Sodium is often evaluated once daily but not in correlation with the outflow of the dialysate. Typically, the client does not have sufficient urine output for a fractional urine, which is a urine specimen collected that has a separate examination for different solutes (glucose, acetone, etc.). Serum plasma osmolarity does not give an indication of poor outflow. (Lewis et al., 10 ed. p. 1086)

A client with diabetes and a right below-the-knee amputation tells the nurse that he feels pain in the amputated leg, even though the leg is gone. The nurse's response is based on what information? 1. Phantom pain is experienced by most amputees; it will resolve without pain medication. 2. The client thinks he feels pain, but it is actually a response to his denial about the amputation. 3. The nurse cannot adequately assess the pain, therefore medication cannot be given. 4. Phantom pain occurs when the nerve endings have not adjusted to the loss of the extremity, and the client should be offered pain medication.

4 Phantom limb pain is real pain for the client and is common in amputees. Phantom pain can best be controlled by pain medication. It is important to respect a client's interpretation of the experience of pain and offer him or her pain medication. (Lewis et al., 10 ed., p. 1487)

A client is 37 weeks' gestation and is admitted to the hospital with bright red vaginal bleeding, complaining of abdominal discomfort but no contractions. After assessing the client's vital signs and determining the fetal heart rate, which is 105, what is the most important information to obtain? 1. The amount of cervical dilation that is present 2. The exact location of her abdominal discomfort 3. The station of the presenting part 4. Assess urinary output.

4 The bright red bleeding may be an indication of placenta previa or abruptio placentae, and the client is more than 36 weeks' gestation, so the nurse should anticipate and plan for an emergency cesarean delivery. Vital signs may be normal even with heavy blood loss. Decreasing urinary output may be better indicator of acute blood loss than vital signs alone. The other options are appropriate to check, but they are not of any assistance in the woman's current situation, which could progress to hemorrhage and the need for emergency surgery. (Lowdermilk et al., 11 ed., p. 681)

During a well-woman physical examination, a young woman is diagnosed with a primary genital herpes lesion. When completing the client's history, the nurse would anticipate the client to report: 1. Purulent urethral discharge 2. Diffuse red rash 3. Generalized abdominal pain 4. Painful urination

4 The client usually seeks treatment for a variety of symptoms, including pain on urination from urine touching painful ulcerations. A purulent urethral discharge would be seen in STDs such as gonorrhea. A diffuse red rash might be caused by syphilis, and generalized abdominal pain might be caused by a variety of reproductive disorders but not genital herpes. (Lewis et al., 10 ed., p. 1232)

The nurse is caring for a client in labor. How are contractions timed? 1. End of one to the beginning of the next 2. Beginning of one to the end of the next 3. End of one to the end of the next 4. Beginning of one to the beginning of the next

4 The correct method of timing contractions is from the beginning of one contraction to the beginning of the next. The point at which the contraction ends is of concern only when the nurse needs to know the duration of the contraction, not the frequency or timing of the contractions. (Lowdermilk et al., 11 ed., p. 440)

After examining a painless sore on the penile shaft, the doctor asks the nurse to order a fluorescent treponemal antibody absorption (FTA-ABS) test. The nurse knows that the purpose of this test is to diagnose what condition? 1. Herpes simplex virus type 2 (HSV-2) 2. Trichomoniasis 3. Cytomegalovirus 4. Syphilis

4 The fluorescent treponemal antibody absorption test is a serum blood test used to identify the spirochete Treponema pallidum, which causes syphilis. HSV-2 is diagnosed by tissue culture from a specimen obtained from an active lesion and by a serologic blood test. Trichomoniasis is diagnosed by a wet mount slide obtained from vaginal or penile secretions. Cytomegalovirus is diagnosed by blood test and by urine and tissue culture. (Lewis et al., 10 ed., p. 1235)

What will the nurse identify as the goal of treatment for a client with chronic renal insufficiency? 1. Increase the urine output by increasing liver and renal perfusion. 2. Prevent the loss of electrolytes across the basement membrane. 3. Increase the concentration of electrolytes in the urine. 4. Maintain present renal function and decrease renal workload.

4 The goal in chronic kidney disease is to prevent acute failure and maintain whatever function is left. This is best done by minimizing stress and the workload on the kidneys. Increasing liver perfusion does not affect renal function. Until the renal function improves, there will be increased permeability in the basement membrane and electrolyte concentration in the urine will be diminished because solutes are being retrained rather than excreted. (Lewis et al., 10 ed., p. 1083)

The nurse understands the key to managing the therapeutic regimen and client compliance for an adolescent girl recently diagnosed with scoliosis includes consideration of which of the following? 1. The ability of the parents to afford the expenses of the braces and surgical procedures 2. The adolescent's understanding the importance of wearing the brace 3. The ability of the parents to control and enforce compliance with the therapeutic regimen 4. The psychological needs and developmental stage to encourage compliance by the adolescent

4 The identification of scoliosis as a "deformity," in combination with unattractive appliances and the potential of a surgical procedure, can have a negative effect on the already fragile adolescent's body image. The adolescent and family require excellent nursing care to meet not only physical needs but also psychological needs associated with a diagnosis of scoliosis. (Hockenberry, 10th ed., p. 1671)

The nurse would identify which situation as an indication for the administration of Rho(D) immune globulin? 1. A woman who has been Rh sensitized in the past two pregnancies 2. An infant with increased hemolysis of red blood cells because of ABO incompatibility 3. An infant with an increase in serum bilirubin levels as a result of the presence of Rh factor antibodies 4. A primigravida who is Rh negative is pregnant with an infant who is Rh positive

4 The medication Rho(D) immune globulin is given to prevent maternal sensitization to the Rh antibodies to women who are Rh negative. Rho(D) immune globulin will not prevent or treat the problem if it has already occurred. Rho(D) immune globulin is not given to the infant. (Hockenberry & Wilson, 10 ed., p. 322)

The best way for the nurse to maintain the safety of the newborn in the hospital is to: 1. Have the mother come to the nursery to pick up the baby for feedings. 2. Take the baby to the mother's room for rooming-in. 3. Ask the mother her name and social security number. 4. Compare the name band information of the mother and baby.

4 The mother and baby have identification bands secured to a wrist or ankle in the delivery room. The nurse should compare these every time the baby is returned to the mother and when the infant is prepared for discharge. The other options are incomplete and will not ensure the safety of the baby. (Hockenberry & Wilson, 10 ed., p. 268)

An infant born at 28 weeks' gestation weighs 4 lb 3 oz (1950 g). What does the initial nursing care of this infant include? 1. Place the infant in protective isolation because of the underdeveloped immune system. 2. Feed him a low-phenylalanine formula to increase digestion and utilization of calories. 3. Provide gavage feedings every 2 hours because of an inadequate sucking and swallow reflex. 4. Place the infant under a radiant heater to maintain regulation of body temperature.

4 The premature infant is at greater risk for chilling. A premature infant has less brown fat than does a term neonate, as well as a lower reserve of glycogen and lower reserve for breathing. A lower body temperature leads to greater oxygen consumption, a decrease in surfactant production, and a tendency to develop acidosis. The infant does not need to be in protective isolation due to an underdeveloped immune system. There is no indication in the stem of the question that the infant has PKU, for which a lowphenylalanine diet would be indicated. Gavage feedings provide nourishment to the neonate who is compromised by respiratory distress or who is too immature to have coordinated suck-swallow reflexes, or who is easily fatigued by sucking. (Hockenberry & Wilson, 10 ed., p. 341)

The nurse is assessing a client 12 hours after a prolonged labor and delivery. What assessment data would cause the nurse the most concern? 1. Oral temperature of 100.6°F (38.1°C) 2. Moderate amount of dark red lochia 3. Episiotomy area bruised with small amount of dark bloody drainage 4. Uterine fundus palpated to the right of the umbilicus

4 Uterus palpated to right of umbilicus may indicate a full bladder. The fundus should be at the level of the midline. The temperature, lochia, and episiotomy assessment findings are within normal limits. (Lowdermilk et al., 11 ed., p. 476)

To meet the goal of promoting infant feeding in a breastfed baby, the nurse should teach the mother to do which of the following? Select all that apply. 1. Feed the baby on a 3- to 4-hour schedule. 2. Alternate breast milk and formula for each feeding. 3. Stop breastfeeding if her nipples get sore. 4. Maintain on-demand breastfeeding for the first 4 weeks. 5. Drink lots of fluids and get adequate rest. 6. Offer a pacifier between feedings to satisfy sucking needs.

4, 5, 6 The mother should be taught to feed the baby on demand for at least the first 4 weeks until lactation is well established. Feeding only breast milk frequently stimulates milk production. Nipple soreness is one of the most common problems, but the use of a cream to soften the nipples is often helpful, as is offering a pacifier to satisfy sucking needs of the infant between feedings after breastfeeding has been established. Adequate rest and good fluid intake help promote milk production. (Hockenberry & Wilson, 10 ed., p. 279)