Adaptive One
A 24-year-old client who has had type 1 diabetes for 6 years is concerned about how her pregnancy will affect her diet and insulin needs. How should the nurse respond?
"Insulin dosage and dietary needs will be adjusted in accordance with the results of blood glucose monitoring."
A client is admitted with a diagnosis of torsion of the testes. How should the nurse respond when the client asks, "Why do I have to have surgery right now?"?
"Irreversible damage occurs after a few hours."
A male client with dementia due to Parkinson's disease has been placed in a nursing home. His wife appears tired and angry on her first visit with her husband. As she is leaving she says to the unit nurse in a sarcastic tone, "Let's see what you can do with him." What is the most therapeutic response by the nurse?
"It sounds like it's been difficult for you."
The mother of an 18-month-old boy with a cleft palate asks the nurse why the pediatrician has recommended that closure of the palate be performed before the child is 2 years old. How should the nurse respond?
"You need to have the surgery performed before he starts to use faulty speech patterns."
A 67-year-old man with type 2 diabetes sadly confides in the nurse that he has been unable to have an erection for several years. What is the best response by the nurse?
"You sound upset about not being able to have an erection."
A client is scheduled for a laparoscopic bilateral tubal ligation. What should the nurse include in preoperative teaching?
"You will be admitted as an outpatient for same-day surgery.
A nurse teaches a client about wearing thigh-high anti-embolism elastic stockings. What would be appropriate to include in the instructions?
"You will need to apply them in the morning before you lower your legs from the bed to the floor."
A client at 35 weeks' gestation asks a nurse why her breathing has become more difficult. How should the nurse respond?
"Your diaphragm has been displaced upward."
A primigravida at 12 weeks' gestation complains of nausea and vomiting during a visit to the prenatal clinic. Which pregnancy hormone should the nurse explain is thought to be responsible for nausea and vomiting during the first trimester?
Human chorionic gonadotropin (hCG)
Which is the most serious complication for which the nurse must monitor a client with kidney failure?
Hyperkalemia
A nurse is caring for a client who was admitted to the hospital with a diagnosis of Addison disease. The nurse should assess the client for what signs related to this disorder?
Hypoglycemia and hypotension
A preschool-aged child is admitted to the pediatric unit for urinary diversion surgery. The ureters are transplanted to a section of the colon, with one end attached to the abdominal wall as an ileostomy. The parents ask the nurse for the name of the procedure. What is the nurse's response?
Ileal conduit
A widow who is hospitalized for a medical problem has dementia of the Alzheimer type and is no longer able to live alone. The client is to be transferred from the hospital to a long-term care facility. When should the staff begin preparation for the transfer?
Immediately after the client's admission to the hospital
A 12-month-old infant is to receive ferrous sulfate for iron-deficiency anemia. How should the nurse administer the medication?
In a syringe directed toward the back of the mouth
A 13-year-old-child with type 1 diabetes is receiving 15 units of Novolin R insulin and 20 units of Novolin N insulin at 7 am each day. At what time should the nurse anticipate a hypoglycemic reaction from the Novolin N to occur?
In the afternoon (takes 6-8 h to kick in)
A 7-year-old child is admitted for a diagnostic workup and is transferred from the emergency department to the pediatric unit. The nurse reviews the admission note and physical assessment. The nurse obtains the child's vital signs and talks with the parents. The parents ask the nurse why their child has severe headaches. What explanation should the nurse give for the cause of the headaches?7-year-old Reporting general malaise Experiencing severe headaches HematuriaTentative diagnosis: acute post streptococcal glomerulonephritis (APSGN)Temperature: 98.2 °F Pulse: 96 bpm Respirations: 26 breaths/min Blood pressure: 150/90 mmHg
Increased blood pressure
A client has been hospitalized for 3 weeks while receiving a tricyclic medication for severe depression. One day the client says to the nurse, "I'm really feeling better; my energy level is up." After the encounter an aide tells the nurse that the client has given away his favorite jacket. What should the nurse conclude that the client's statement indicates?
Increased risk for suicide
Two days after delivery, a client has a temperature of 101° F (38.3), general malaise, anorexia, and chills. What does the nurse expect to identify on the client's laboratory report?
Increased white blood cell (WBC) count
A nurse is caring for a client with a diagnosis of acute pancreatitis and alcoholism. The client asks, "What does my drinking have to do with my diagnosis?" What effect of alcohol should the nurse include when responding?
Increases enzyme secretion and pancreatic duct pressure that causes backflow of enzymes into the pancreas
A nurse teaches self-care to a client who had a cast applied for a fracture of the right ulna and radius. The nurse instructs the client to notify the primary health care provider immediately if the client experiences:
Increasing pain at the injury site
A client at 10 weeks' gestation phones the prenatal clinic to report that she is experiencing some vaginal bleeding and abdominal cramping. The nurse arranges for her to go to the local hospital. The vaginal examination reveals that her cervix is dilated 2 cm. What diagnosis should the nurse expect?
Inevitable abortion
A client with asthma is being taught how to use a peak flow meter to monitor how well the asthma is being controlled. What should the nurse instruct the client to do?
Inhale completely and then blow out as hard and as fast as possible through the mouthpiece
A woman with five children comes to the emergency department with multiple facial injuries. The client says, "My husband is an alcoholic, and he just beat me up." The nurse concludes that the client appears to be a victim of abuse. What should the nurse do next?
Inquire about her and the children's safety
A 26-year-old primigravida experiencing severe abdominal pain is brought to the emergency department by ambulance with a suspected ruptured tubal pregnancy. What should the nurse do first?
Insert an intravenous cathether
A nurse is preparing a 5-year-old girl who has undergone a myringotomy for discharge. What should the parents be taught about their child's care at home?
Insert ear plugs whenever a bath is given.
An infant is admitted to the pediatric unit with bronchiolitis caused by respiratory syncytial virus (RSV). What interventions are appropriate nursing care for the infant?
Instilling saline nose drops Maintaining contact precautions Suctioning mucus with a bulb syringe
A primigravida at term is admitted to the birthing room in active labor. Later, when the client is dilated 8 cm, she tells the nurse that she has the urge to push. The nurse instructs her to pant-blow at this time because pushing can cause which of the following?
Cervical edema
During a nap, a 3-year-old hospitalized child wets the bed. What is the best response by the nurse?
Change the child's clothes without discussing the incident
An infant is admitted to the pediatric unit with gastroenteritis and dehydration. The nurse determines that the parents understand the teaching about contact precautions when they note that after washing their hands they need to:
Change their gloves each time they change the baby's diaper
A client with a urinary retention catheter reports discomfort in the bladder and urethra. What should the nurse do first?
Check the patency of the catheter.
What behavior does the nurse anticipate while feeding a newborn with choanal atresia?
Chokes on the feeding
A parent brings a 2-month-old infant with Down syndrome to the pediatric clinic for a physical and administration of immunizations. Which clinical finding should prompt the nurse to have further assessment by the care provider?
Circumoral cyanosis
A nurse is preparing to administer an ophthalmic medication to a client. What techniques should the nurse use for this procedure?
Clean the eyelid and eyelashes Apply clean gloves before beginning of procedure Press on the nasolacrimal duct after instilling the solution
A client has chosen not to have her son circumcised. What instruction should be included in discharge teaching for the care of an uncircumcised neonate?
Clean the penis with warm water at each diaper change.
What is the most appropriate toy for the nurse to give a 6-year-old child on complete bedrest?
Coloring book and crayons
As a nurse enters a room and approaches a client who has schizophrenia, the client shouts, "Get out of here before I hit you! Go away!" The nurse concludes that this aggressive behavior is probably related to the fact that the client felt:
Confined when the nurse walked into the room
The nurse provides discharge teaching to a client with tuberculosis and reinforces that the treatment measure with the highest priority is:
Consistently taking prescribed medication
A nurse is teaching a group of clients with peripheral vascular disease about a smoking cessation program. Which physiological effect of nicotine should the nurse explain to the group?
Constriction of the peripheral vessels increases the force of flow.
A client has been prescribed chlorpromazine (Thorazine) for the management of positive symptoms of schizophrenia. When the client reports difficulty sustaining an erection, the nurse:
Consults with his provider regarding alternative medication therapies
A client is diagnosed with pulmonary tuberculosis, and the health care provider prescribes a combination medication, Rifamate, composed of rifampin (Rifadin) and isoniazid (INH). The nurse evaluates that the teaching regarding the drug is effective when the client says, "The most important thing I must do is:
Continue taking the medicine even after I feel better.
A nurse who is monitoring the blood glucose level of the term infant of a diabetic mother (IDM) identifies a blood glucose level of 48 mg/dL. What should the nurse do?
Continue to monitor the blood glucose level per policy.
While walking in a hallway, a client with a chest tube becomes confused and pulls the chest tube out. What is the nurse's immediate action?
Cover the opening with the cleanest material available
A 9-year-old child who has successfully completed the emergency (resuscitative) phase of treatment for a severe burn injury is started on a high protein, high calorie diet. Which snacks should the nurse encourage between meals?
Crackers and cheese Banana pudding and whipped cream Frozen yogurt and chocolate sprinkles
What should the nurse consider as the goal of therapy when administering allopurinol (Zyloprim) to a client with gout?
Decrease uric acid production
A client on the psychiatric unit tells the nurse, "I'm a movie star, and the other clients are my audience." What is an appropriate conclusion for the nurse to document about what the client is experiencing?
Delusion of grandeur
A male client in a mental health facility turns his head to the side during a unit meeting as if he hears something. When the nurse comments about it, the client replies, "You know, it's that microcomputer those foreign agents implanted in my ear." In light of this statement, the nurse determines that the client is experiencing:
Delusional thoughts
A nurse is planning to teach the importance of handwashing to children in first grade. What is the most effective approach for this age group?
Demonstrating handwashing and asking for return demonstrations
What should be included in the plan of care for a client with vascular dementia?
Details of supportive care interventions
Neuroleptic malignant syndrome is a potentially fatal reaction to antipsychotic therapy. What signs and symptoms of this syndrome should the nurse identify?
Diaphoresis Hyperrigidity Hyperthermia
What clinical finding does a nurse anticipate when admitting a client with an extracellular fluid volume excess?
Distended jugular veins
A client with the diagnosis of bipolar disorder, manic episode, is extremely active, talks constantly, and tends to badger the other clients, some of whom are becoming agitated. What is the best strategy for a nurse to use with this client?
Distraction
The nurse is preparing discharge instructions for a client who was prescribed enalapril maleate (Vasotec) for treatment of hypertension. Which is appropriate for the nurse to include in the client's teaching?
Do not change positions suddenly to prevent orthostatic hypotension
A nurse has been assigned to care for a client with the diagnosis of obsessive-compulsive disorder (OCD). Before providing care for this client, the nurse should consider that clients with OCD:
Do not want to repeat the ritual but feel compelled to do so
A couple, married for 5 years, want to start a family. When talking with the nurse the husband says, "Well, I guess we're going to have to jump into bed three or four times a day, every day, until it works." What is the nurse's best response?
Instructing them in the frequency and timing of intercourse to promote conception
A 2-month-old infant is admitted to the pediatric unit for observation after an automobile collision. Family members are unable to stay. How can the nurse best provide psychological comfort for the infant?
Following a routine to which the infant is accustomed
In addition to Pneumocystis jiroveci, a client with acquired immunodeficiency syndrome (AIDS) also has an ulcer 4 cm in diameter on the leg. Considering the client's total health status, the most critical concern is:
Gas exchange
A parent of a newborn asks, "Why do I have to scrub my baby's formula bottles?" What information about a newborn should the nurse consider before replying in language that the parent will understand?
Gastric acidity is low and does not provide bacteriostatic protection.
A health care provider prescribes an upper gastrointestinal (GI) series and a barium enema. The client asks, "Why do I have to have barium for these tests?" The nurse's best response is "Barium:
Gives more contrast to the soft tissue of the alimentary tract, allowing absorption of x-rays."
A client is diagnosed as having malabsorption syndrome secondary to celiac sprue. The client asks the nurse if there is anything that can help improve symptoms of the syndrome. The nurse encourages the client to incorporate which addition for symptom improvement?
Gluten-free diet
The nurse is caring for a client with the diagnosis of bipolar disorder, manic episode. Which clinical findings support the diagnosis?
Grandiosity Talkativeness Distractibility
A nurse is caring for a female client during the manic phase of a bipolar disorder. What should the nurse do to help the client with personal hygiene?
Guide her to dress appropriately in her own clothing (helps keep in touch with reality)
The nurse manager of the unit comes to work obviously intoxicated. The staff nurse's ethical obligation is to:
Have the supervisor validate the observation
During a client's labor the fetal monitor reveals a fetal heart pattern that signifies uteroplacental insufficiency. What is the nurse's first intervention?
Helping the client turn to the side-lying position
A client who had a transurethral resection of the prostate is transferred to the post-anesthesia care unit with an IV and a urinary retention catheter. For which major complication is it most important for the nurse to assess during the immediate postoperative period?
Hemorrhage
A parent of a 7-year-old child asks a nurse how to tell the difference between measles (rubeola) and German measles (rubella). What should the nurse tell the parent differentiates rubeola from rubella?
High fever and Koplik spots
A nurse is caring for a client who is being treated with continuous ambulatory peritoneal dialysis (CAPD) for chronic glomerulonephritis. What dietary need should the nurse discuss with the client?
High-quality protein
A nonviolent client on the psychiatric unit suddenly refuses to take the prescribed antipsychotic medication. What should the nurse do?
Honor the client's decision and document the behavior and all interventions
What is the most important information the nurse and the rapid response team must keep in mind when caring for a client who had a cardiac arrest?
How long the client was anoxic
A nurse is caring for a client with type 1 diabetes, and the health care provider prescribes one tube of glucose gel. What is the primary reason for the administration of glucose gel to this client?
Insulin-induced hypoglycemia (delivers a measured amount of simple sugars to provide glucose to the blood for rapid action.)
A nurse is evaluating a young adult for evidence of achievement of the age-related developmental stage set forth in Erikson's developmental theory. What developmental crisis is associated with this age group?
Intimacy versus isolation
A client at 36 weeks' gestation exhibits oligohydramnios. What newborn complication should the nurse anticipate?
Intrauterine growth restriction (IUGR)
An adult is found to have schizotypal personality disorder. How should a nurse describe the client's behavior?
Introverted and emotionally withdrawn
What age-related fear should the nurse expect when preparing a 4-year-old child for surgery?
Intrusive procedures
A depressed client resists becoming involved in an activity, complains that he can't do anything well, and claims to be worthless. What is the best approach by the nurse?
Involving the client in an activity in which success can be ensured
A nurse provides dietary teaching for a client with an acute exacerbation of colitis, and afterward the client makes a list of foods that can be included on the diet. Which food choices indicate that the teaching was effective?
Jelly sandwich Lean roast beef Scrambled eggs
The nurse teaches a premenopausal obese client about strategies to prevent osteoporosis. Which strategy identified by the client indicates that the teaching is effective?
Joins a tennis league and practices every day.
The nurse is caring for a client who is experiencing signs and symptoms of a cardiac dysrhythmia who is scheduled to wear a Holter monitor for 24 hours. During the test, the client should be instructed to:
Keep a diary of activities
A nurse is caring for an infant immediately after surgical repair of a cleft lip. What is the priority nursing action for this infant?
Keeping crying to a minimum
A nurse concludes that a positive contraction stress test (CST) result may be indicative of potential fetal compromise. A CST result is considered positive when during contractions the fetal heart rate show
Late decelerations
A nurse finds a victim under the wreckage of a collapsed building. The individual is conscious, supine, breathing satisfactorily, and reports back pain and an inability to move the legs. Which action should the nurse take first?
Leave the individual lying on the back with instructions not to move, and leave to seek additional help.
At night an older client with dementia sleeps very little and becomes more disoriented. How can the nurse best limit this confusion resulting from sleep deprivation?
Leaving a dim light on in the client's room at night
A client is admitted in active labor. The nurse, performing Leopold maneuvers, determines that the fetus is in the left occiput anterior (LOA) position. Where should the nurse place the transducer of the electronic fetal monitor?
Left lower quadrant
A preadolescent brings home a note from the school nurse informing the parents that the child should be evaluated for scoliosis. The mother calls the clinic nurse to ask for a description of scoliosis. Before responding, the nurse recalls that in scoliosis:
There is a rotary deformity of the lateral curvature of the spine
A nurse is caring for a client who sustained trauma to the head. What criteria should a nurse evaluate to determine the client's score on the Glasgow Coma Scale (GCS)?
Quality of verbal response Ability to follow commands Stimulus needed to open the eyes
Examination of a client in active labor reveals fetal heart sounds in the right lower quadrant. The head is in the anterior position, is well flexed, and is at the level of the ischial spines. What fetal position should the nurse document?
ROA, 0 station
A nurse is providing postoperative care for a client who just had a thyroidectomy. For what response should the nurse assess the client when concerned about the potential risk of thyrotoxic crisis?
Rapid heartbeat and tremors
A 7-year-old child who has sustained frostbite of the toes after skiing in below-freezing weather is brought to the emergency department. What is the nurse's initial intervention?
Rapidly rewarming the toes by placing the feet in warm water
A housekeeping staff member in a mental health unit reports to the nurse that food was found hidden in a client's room. Knowing that the client was admitted with a fluid and electrolyte imbalance because of anorexia nervosa, the nurse should ask housekeeping personnel to:
Report it to the nursing staff if this happens again
The parents of an infant with pyloric stenosis ask a nurse many questions about the problem. What information should the nurse communicate when answering these questions?
This is a condition with an excellent prognosis.
A toddler has just had a cast applied for a fractured wrist. The wrist and elbow are immobilized. What information should the nurse include in the home care instructions before discharge?
Report swelling of fingers. Elevate casted arm when the child is standing.
A client has surgery to repair a bladder laceration. The nursing intervention that takes priority in the postoperative care of this client is:
Repositioning frequently (to prevent obstruction and efficient drainage)
A client who has acromegaly and insulin-dependent diabetes undergoes a hypophysectomy. The nurse identifies that further teaching about the hypophysectomy is necessary when the client states, "I know I will:
Require larger doses of insulin than I did preoperatively."
A nurse begins a therapeutic relationship with a client with the diagnosis of schizotypal personality disorder. What is the best initial nursing action?
Respecting the client's need for social isolation
In her 36th week of gestation, a client with type 1 diabetes has a 9-lb 10-oz infant in a cesarean birth. For which condition should the nurse monitor this infant of a diabetic mother?
Respiratory distress syndrome
An infant is admitted to the pediatric unit with bronchiolitis caused by the respiratory syncytial virus (RSV). What medication does the nurse anticipate that the practitioner will prescribe?
Ribavirin
A nurse is caring for an infant after a cleft lip repair. Which item should the nurse use to feed the infant for several days after the surgery?
Rubber-tipped syringe
A nurse is teaching a client how to use the call bell/call light system. Which level of Maslow's Hierarchy of Needs does this nursing action address?
Safety
A nurse is preparing a client with a ruptured tubal pregnancy for immediate surgery. What type of surgery should the informed consent include?
Salpingectomy
When discussing dietary needs during pregnancy, a client tells the nurse that milk causes her to be constipated at times. What should the nurse teach the client?
Treat constipation when it occurs and continue drinking milk.
A home health nurse teaches a family member to cleanse a client's wound and apply a sterile dressing. Which action by the family member during a return demonstration indicates the need for additional teaching?
Using a back-and-forth motion while cleaning the wound
What is the best approach for the nurse to use when preparing a preschooler for surgery?
Using a doll to demonstrate perioperative care
A nurse instructs the parents of an adolescent with asthma how to reduce the allergens in the child's bedroom. The mother tells the nurse what she plans to do to make the room hypoallergenic. Which idea indicates that further teaching is needed?
Using flat outdoor carpeting to cover hardwood floors
A nurse is caring for a client with antisocial personality disorder. What client characteristic should the nurse consider when formulating a plan of care?
Usually is unable to postpone gratification
A nurse plans to administer vitamin K to a newborn. What site should the nurse use for the injection?
Vastus lateralis
The nurse assures a breastfeeding mother that one way she will know that her infant is getting an adequate supply of breast milk is if the infant gains weight. What behavior does the infant exhibit if an adequate amount of milk is being ingested?
Voids six or more times a day
A nurse must administer a medication by means of injection to a 2-year-old whose parent is not present. What is the most therapeutic approach for the nurse to use?
Warning the child about the injection just before administering it, saying that it is OK to cry, and then comforting the child
A nurse is teaching a breastfeeding mother about cleansing her nipples. What technique should the nurse emphasize?
Wash the breasts and nipples with water when bathing
The parents of an adolescent who engages in self-injurious cutting behavior ask the nurse why their child self-mutilates. What should the nurse give as the reason for the cutting?
Way to manage overwhelming feelings
The nurse is giving unlicensed assistive personnel (UAP) strategies to care for a 2-year-old child admitted to the hospital with severe diarrhea. Which strategies should the nurse provide?
Weighing the child at the same time every day
When assessing a client with Graves disease, the nurse expects to identify:
Weight loss, exophthalmos, and restlessness
A nurse is preparing a 10-year-old child for a tonsillectomy and adenoidectomy to be performed later in the day. What information should the nurse share with the child?
What the child will experience before and after the procedure
A client with small-cell lung cancer is receiving chemotherapy. A complete blood count is prescribed before each round of chemotherapy. The component of the complete blood count that the nurse is concerned about most is:
White blood cells (WBCs)
When seeing her preterm infant son in the neonatal intensive care unit for the first time, a mother exclaims, "He's so little! How will I ever be able to take care of him?" The nurse explains to the mother that she:
Will be encouraged to participate in his care as much as possible
A nurse is caring for a client with cholelithiasis. Which clinical manifestation does the nurse expect if the client develops obstructive jaundice?
Yellow sclera
A client in thyroid storm tells the nurse, "I know I'm going to die. I'm very sick." What is the nurse's best response?
"You must feel very sick and frightened."
A nonstress test is scheduled for a client with preeclampsia. During the nonstress test the nurse concludes that if nonperiodic accelerations of the fetal heart rate occur with fetal movement, this probably indicates:
Fetal well-being
An infant born with hydrocephalus is to be discharged after insertion of a ventriculoperitoneal shunt. Which common complication should the nurse instruct the parents to report if it occurs at home?
Fever accompanied by decreased responsiveness
Sildenafil (Viagra) is prescribed for a man with erectile dysfunction. A nurse teaches the client about common side effects of this drug.
Flushing Headache Dyspepsia
What is the best nursing intervention to encourage a socially withdrawn client to talk?
Focusing on nonthreatening subjects
A nurse understands that when a client is a member of a different ethnic community it is important to:
Offer a therapeutic regimen compatible with the lifestyle of the family
After a cervical neck injury, a client is placed in a halo fixation device with a body cast. A statement that indicates that the client's concern about body image has been resolved successfully is:
"I've gotten used to the brace. I may even miss it when it's gone."
A nurse is giving discharge instructions to a client who has undergone anterior colporrhaphy. The nurse knows the teaching has been understood if the client says:
" For discomfort I can try using warm compresses on my abdomen."
An insulin pump is instituted for a client with type 1 diabetes. The nurse plans discharge instructions. Which short-term goal is the priority for this client?
"Demonstrate correct use of the insulin pump."
A client with type 2 diabetes is taking one glyburide (Micronase) tablet daily. The client asks whether an extra pill should be taken before exercise. What is the nurse's best reply?
"Do not take an extra pill because you may become hypoglycemic when exercising."
A nurse is teaching a childbirth class to a group of pregnant women. One of the women asks the nurse at what point during the pregnancy the embryo becomes a fetus. How should the nurse respond?
"During the eighth week of the pregnancy."
A nurse moves into the working phase of a therapeutic relationship with a depressed client who has a history of suicide attempts. What question should the nurse ask the client when exploring alternative coping strategies?
"How will you manage the next time your problems start piling up?"
A nurse is teaching an older adult client about managing chronic pain with acetaminophen (Tylenol). Which client statement indicates that the teaching is effective?
"I have to be careful about which over-the-counter cold preparations I take when I have a cold."
A client who was diagnosed recently with type 1 diabetes states, "I feel bad. I don't think I even want to go home. My spouse doesn't care about my diabetes." What is the most appropriate nursing response?
"You are unhappy. Have you tried to talk with your spouse?"
The nurse is reinforcing best parenting practices to the parents of a 13-year-old child. Which statements made by the parent need correction?
"I should motivate my child to perform well in exams by comparing her to her siblings." "I should teach my child to make decisions and understand consequences as an adult would."
When a nurse sits next to a depressed client and begins to talk, the client responds, "I'm stupid and useless. Talk with the other people who are more important." Which response is most therapeutic?
"I want to talk with you because you are important to me."
Which statement regarding treatment with interferon indicates that the client understands the nurse's teaching?
"I will drink two to three quarts of fluid a day." (to help flush the kidneys and prevent nephroxicity)
A nurse teaches the mother of a child with a pinworm infestation how pinworms are transmitted. Which statement indicates that the teaching has been effective?
"I'll have to reinforce her handwashing habits, especially before she handles food."
A multipara who is admitted to the hospital for repair of a rectocele and cystocele asks a nurse why these problems happened to her. How should the nurse respond?
"You have relaxation of the muscles in your lower pelvis."
A primigravida is admitted to the birthing suite at term with contractions occurring every 5 to 8 minutes and a bloody show. She and her partner attended childbirth preparation classes. Vaginal examination reveals that the cervix is dilated 3 cm and 75% effaced. The fetus is at +1 station in occiput anterior position, and the membranes are intact. The client is cheerful and relaxed and asks the nurse whether it is all right for her to walk around. In light of the nurse's observations regarding the contractions and the client's knowledge of the physiology and mechanism of labor, how should the nurse respond?
"It's all right for you to walk as long as you feel comfortable and your membranes are intact."
A client with schizophrenia plans an activity schedule with the help of the treatment team. A written copy is posted in the client's room. What should the nurse say when it is time for the client to go for a walk?
"It's time for you to go for a walk now."
After an uneventful 8-hour labor a client gives birth. Once the airway has been ensured and the neonate has been dried and wrapped in a blanket, the nurse places the newborn in the mother's arms. The mother asks, "Is my baby normal?" What is the best response by the nurse?
"Let's unwrap your baby so you can see for yourself
A client receives spinal anesthesia during labor and birth. Twenty-four hours later, she tells a nurse that she has a headache. Which statements indicate to the nurse that the headache is a reaction to the anesthesia?
"My ears are ringing." "It gets better when I lie down." "Bright lights really bother my eyes." "My head hurts more when I'm sitting watching TV."
A client with alcohol dependence problem asks whether the nurse can see the bugs that are crawling on the bed. What is the nurse's initial reply?
"No, I don't see any bugs."
Which statement made by a 28-year-old client recently diagnosed with type 1 diabetes indicates that further education is necessary regarding the teaching plan?
"Once I reach my target weight there is a good chance that I will be able to switch from insulin to an oral medication to control my blood sugar."
A 2-year-old child with developmental dysplasia of the hip has a spica cast applied. The mother asks the nurse how to keep the cast clean. How should the nurse respond?
"Place plastic wrap or duct tape around the perineal edges of the cast."
What instruction should a nurse include when teaching about the correct use of a female condom?
"Remove the condom before standing up."
A client with a seizure disorder is receiving phenytoin (Dilantin) and phenobarbital (Barbital). What client statement indicates that the instructions regarding the medications are understood?
"Stopping the drugs can cause continuous seizures and I may die."
The parents of a school-aged child with recently diagnosed leukemia ask the nurse why they were told that their child has too many white blood cells. How should the nurse respond?
"The bone marrow is not controlling your child's white blood cell production as it should."
A client with a history of ulcerative colitis is admitted to the hospital because of severe rectal bleeding. The client appears to be an angry, demanding person. One day the unlicensed assistive personnel (UAP) tells the nurse, "I've had it with that client's demands. I'm not going in that room again." The nurse's best response to this statement is:
"The client is frightened. Let's think about the best approach we can take."
The condition of an infant child dying of leukemia deteriorates and the child becomes comatose. The parents state that a relative told them that they should not allow the child to be resuscitated, but they are unsure. Which response by the nurse best demonstrates recognition of the ethical issues involved?
"The final decision must be made by you and your doctor, but it's important to talk about it."
Which client statement indicates an understanding of the nurse's instructions concerning a Holter monitor?
"The monitor will record any abnormal heart rhythms while I go about my usual activities."
A mother asks why her 2-year-old toddler's cleft palate was not repaired at the same time that the cleft lip was repaired. What is the best response by the nurse?
"The palate usually is repaired before a child starts to speak. Some surgeons prefer to wait up to 2 years."
A client just has been diagnosed with multiple sclerosis. The client is upset and asks the nurse, "Am I going to die?" What is the nurse's best response?
"There is a variable prognosis, with most individuals experiencing remissions and exacerbations."
A complete blood count (CBC), urinalysis, and x-ray examination of the chest are prescribed for a client before surgery. The client asks why these tests are done. Which is the best reply by the nurse?
"They are done to identify other health risks."
A client arrives in the birthing room with the fetal caput emerging. What should the nurse say to the client during a contraction?
"Use the panting-breathing pattern."
A client has a tonic-clonic seizure at work and is admitted to the emergency department. Which question is most useful when planning nursing care related to the client's seizure?
"Were you aware of anything different or unusual just before your seizure began?"
A 7-year-old child is expressing fear concerning an uncomfortable sterile dressing change. What should the nurse say to be most therapeutic?
"Will you help hold the package of bandages for me?"
A practitioner prescribes an initial loading dose of 75 mcg of oral digoxin (Lanoxin) for a school-aged child. The medication is supplied as an elixir, 50 mcg/mL. How many milliliters of solution should the nurse administer?
1.5 mL
A client in a detoxification unit has an alcohol withdrawal seizure. Diazepam (Valium) 7.5 mg intramuscularly stat is prescribed. Valium is available 5 mg/mL. How many milliliters should the nurse administer? Record your answer using one decimal place.
1.5 ml Solve for x with the "desire over have" formula of ratio and proportion
To evaluate kidney function, the nurse must accurately measure the hourly urine output of a 1½-year-old toddler weighing 22 lb who has been admitted with extensive burns. What is the minimum safe output per hour for a child this age?
10 to 20 mL
An adolescent is hospitalized with multiple internal injuries after an automobile collision. The adolescent is being kept NPO and is receiving an IV infusion at 125 mL/hr and an antibiotic reconstituted in 10 mL of normal saline every 6 hours (6 am, 12 pm, 6 pm, 12 am). What is the intake from 7 am to 3 pm? Record your answer using a whole number and no punctuation.
1010 mL (125 mL × 8 hours = 1000 mL; one dose of the reconstituted antibiotic is administered at 12 pm = 10 mL; 1000 mL + 10 mL = 1010 mL.)
A client who menstruates regularly every 30 days asks a nurse on what day she is most likely to ovulate. Because the client's last menses started on January 1, the nurse should tell her that ovulation should occur on which day in January?
16
Cyanocobalamin (vitamin B12) 0.2 mg intramuscularly (IM) is prescribed for a client with pernicious anemia. A vial of the drug labeled "1 mL = 100 mcg" is available. How many milliliters should the nurse administer?
2 mL
A 6-month-old infant weighing 15 lb is admitted with a diagnosis of dehydration. A prescription for oral rehydration therapy 4 mL/kg Pedialyte over 4 hours is made. What is the approximate amount of fluid that the infant should ingest during the 4 hours?
4 mL × 7 kg = 28 mL
A 4-year-old child is admitted with burns over the entire right arm and the anterior and posterior aspects of both legs. Using the percentage of total body surface area (TBSA) that was burned, the nurse estimates that the TBSA affected is approximately:
41% (total arm is 8.5% and each total leg is 16.25%)
A nurse on the psychiatric unit of the hospital has been assigned four clients for the shift. The assignment includes an 84-year-old client who is severely depressed, a 73-year-old client who is being discharged, a 53-year-old client who was admitted for lithium toxicity, and a 48-year-old client who has panic attacks. Which client should the nurse evaluate first after receiving report?
53-year-old client
A client with chronic kidney disease has been on hemodialysis for two years. The client relates to a nurse in the dialysis unit in an angry, critical manner and frequently does not follow the prescribed diet or take prescribed medications. What does the nurse identify as the most likely underlying cause of this behavior?
A defense against underlying depression and fear
A client has been diagnosed with type 1 Diabetes Mellitus. When providing instructions on sharps disposal, the nurse should instruct the client to place the syringes in:
A plastic liquid detergent bottle with a screw-top lid
A client with a diagnosis of major depression refuses to participate in unit activities, saying that she is "just too tired." What is the best nursing approach?
Accepting the client's feelings about activities calmly while setting firm limits
A nurse is in the process of developing a therapeutic relationship with a client who has an addiction problem. What client communication permits the nurse to conclude that they are making progress in the working stage of the relationship?
Acknowledges the effects of the addiction on the family Addresses how the addiction has contributed to family distress Verbalizes difficulty identifying personal strengths
A client who is addicted to opioids undergoes emergency surgery. During the postoperative period the health care provider decreases the previously prescribed methadone dosage. For what clinical manifestations should the nurse monitor the client?
Agitation and attempts to escape from the hospital
A client is brought to the emergency department with chest pain. The client asks why an electrocardiogram (ECG) has been prescribed. The nurse explains that the ECG will:
Aid in detecting heart damage
A 6-month-old infant is to be on nothing-by-mouth (NPO) status for 4 hours before surgery for cleft palate repair. What is the most important concern for the infant before surgery?
Altered fluid intake before surgery
A client with rheumatoid arthritis has been given a prescription for acetylsalicylic acid. The client asks the nurse, "What kind of drug is acetylsalicylic acid?" The nurse recalls that the classification to which this drug belongs is:
Analgesics
A husband sits in the waiting room while his wife is getting her infertility prescription refilled by the clinic pharmacist. As the nurse sits down beside him, he blurts, "It's like there are three of us in bed—my wife, me, and the doctor." What feeling is reflected by this statement?
Anger
A client comes to the ambulatory surgery unit on the morning of an elective surgical procedure. The client reports shortness of breath, dizziness, and palpitations. The nurse observes profuse diaphoresis and is concerned that the client may be having either a panic attack or a myocardial infarction. Which assessments support the conclusion that the client may be experiencing a myocardial infarction?
Anxiety Chest pain Irregular pulse
A client is scheduled for surgery. Legally, the client may not sign the operative consent if:
Any sedative type of medication has been given recently
Which assessment should the nurse obtain before administering digoxin (Lanoxin) to a client?
Apical heart rate
A 7-year-old child with juvenile idiopathic arthritis (JIA) complains of knee pain. What does the nurse expect to be prescribed to help relieve this discomfort?
Application of moist heat
One afternoon a nurse sees a client rushing down the hall of the mental health unit, rapidly tapping his fingers against the wall. What is the most appropriate nursing action at this time?
Approaching the client in a nonthreatening manner to determine the cause of the agitation
A parent tearfully tells a nurse, "They think our toddler is developmentally delayed. We're investigating a preschool program for cognitively impaired children." What is the most appropriate response by the nurse?
Asking for more specific information related to the developmental delays
On her second visit to the fertility clinic, a client whose temperature charts demonstrate an ovulatory pattern and a regular menstrual cycle requests fertility drugs. What is the nurse's best intervention?
Asking the client to have her partner's semen examined
The nurse evaluates that the preoperative teaching regarding a bronchoscopy was understood when the client states, "I recognize I cannot eat or drink for several hours after the procedure to prevent:
Aspiration of food."
A client who just returned from a cardiac catheterization reports to the nurse that the pressure bandage on the right groin is tight. What action should the nurse take?
Assess the pulses distal to the dressing.
A client enters the emergency department reporting shortness of breath and epigastric distress. What should be the triage nurse's first intervention?
Assess vital signs
How does a nurse identify possible developmental dysplasia of the hip (DDH) during a newborn assessment?
Asymmetry of the gluteal folds
A client with a recent colostomy expresses concern about the inability to control the passage of gas. The nurse should teach the client to:
Avoid foods that in the past caused flatus
For which clinical indicator should a nurse monitor a client with end-stage renal disease?
Azotemia
The parents of a 3-month old infant who is breastfed ask the nurse how to prevent nutritional anemia. What is the best response by the nurse?
Baby cereal or an iron supplement should be given around 4 months of age.
What characteristic of the environment is most therapeutic for clients with the diagnosis of bulimia nervosa?
Based on realistic limits
A child with celiac disease is prescribed a gluten-restricted diet. Which lunch selection for the child indicates that the parent understands the dietary instruction provided by the nurse?
Beef taco, corn, canned peaches, chocolate milk
A nurse assisting in a research study calculates the risk-benefit ratio and concludes that there were no harmful effects associated with a survey of diabetic clients. This researcher was applying which principle?
Beneficence
What client response indicates to the nurse that a vasodilator medication is effective?
Blood pressure changes from 154/90 to 126/72
Which nutrient-related problem is common to a newborn infant, a client after a cholecystectomy, and a client receiving anticoagulant therapy after a myocardial infarction?
Blood-clotting function of vitamin K
A nurse is providing discharge instructions about digoxin (Lanoxin). Which response should a nurse include as a reason for a client to withhold the digoxin?
Blurred vision
An adolescent with a major depressive disorder is prescribed venlafaxine (Effexor). What signs or symptoms related to the medication should the nurse communicate immediately to the prescribing provider?
Blurred vision Suicidal ideation Difficult urination
A 16-year-old adolescent at 24 weeks' gestation visits the prenatal clinic for the first time. After the physical examination she tells the nurse, "I can't believe how big I am. Will I get much bigger?" What information about adolescent growth and development does the nurse need to know before responding?
Body image is very important to adolescents, so pregnant teenagers are concerned about body size.
A nurse assesses a client with the diagnosis of an intestinal obstruction in the descending colon. When auscultating the midabdomen, the nurse expects to hear:
Borborygmi
A client who is visiting the family planning clinic is prescribed an oral contraceptive. As part of teaching, the nurse plans to inform the client of the possibility of:
Breakthrough bleeding (bleeding btw periods)
A 1-year-old infant is receiving zidovudine (AZT) for management of HIV infection. The nurse determines that the infant is exhibiting signs of life-threatening zidovudine toxicity. What clinical finding supports this conclusion?
Bruises over the body
Loratadine (Claritin), 10 mg by mouth once a day in the morning, is prescribed for a 15-year-old girl with hay fever. The girl tells the school nurse that she is concerned that she will be sleepy for a quiz the next day. How should the nurse respond?
By explaining that this medication rarely causes drowsiness
A resident in a nursing home recently immigrated to the United States from Italy. How does the nurse plan to provide emotional support?
By offering choices consistent with the client's heritage
An older client with the diagnosis of dementia, Alzheimer type, is admitted to a nursing home. The client is confused and forgetful, wanders, and has intermittent episodes of urinary incontinence. How should the nurse plan to meet this client's elimination needs?
By taking the client to the bathroom at regular intervals
A client had a laparoscopic cholecystectomy. Postoperatively the client experiences nausea and vomiting and is admitted overnight for observation and hydration. What should the nurse include in the teaching plan when preparing this client for discharge?
Call the health care provider if you have a fever of 100 o F or more for two days. Check the puncture sites daily for redness, tenderness, swelling, heat, or drainage.
A nurse is administering oxygen to a client with chest pain who is restless. What method of oxygen administration will most likely prevent a further increase in the client's anxiety level?
Cannula
A nurse is providing education about excellent food sources of vitamin A for a client who is deficient in this vitamin. Which foods should the nurse include in the teaching
Carrots and leafy greens
The nurse should instruct a client with an ileal conduit to empty the collection device frequently because a full urine collection bag may:
Cause the device to pull away from the skin.
A nurse determines that a 1-day-old newborn has a heart rate of 138 beats/min. What is the best nursing action at this time?
Documenting the heart rate (130 to 140 is normal)
A health care provider has prescribed isoniazid (Laniazid) for a client. Which instruction should the nurse give the client about this medication?
Drinking alcohol daily can cause drug-induced hepatitis.
A nurse understands that autism is a form of a pervasive developmental disorder (PDD). Which factor unique to autism differentiates it from other forms of PDD?
Early onset, before 36 months of age
One principle to be followed for children with type 1 diabetes is to provide for the variability of the child's activity. What should the nurse teach the child about how to compensate for increased physical activity?
Eat more food when planning to exercise more than usual.
A disturbed client starts to repeat phrases that others have just said. How should the nurse document this speech?
Echolalia
A client comes to the medical clinic complaining of headaches. The nurse measures the blood pressure at 172/114. What should the nurse do first?
Elevate the head of the bed, provide reassurance, and reassess the blood pressure
What action should be included in the nursing care of an infant with increased intracranial pressure?
Elevating the head higher than the hips
A 28-year-old woman is recovering from her third consecutive spontaneous abortion in 2 years. What is the most therapeutic nursing intervention for this client at her follow-up appointment?
Encouraging the client to verbalize her feelings about the loss
What clinical signs should lead a nurse to suspect that a 1-year-old child has rubella (German measles)?
Enlarged posterior cervical and postauricular nodes
A nurse in the fertility clinic is instructing a client who will be using progesterone gel vaginally in the treatment of luteal phase infertility. When discussing the side effects of progesterone, what should the nurse tell the client to expect?
Enlarged, tender breasts
A client is scheduled for a barium swallow. How should the nurse prepare the client for this test?
Ensure that a laxative is prescribed after the test. Instruct to withhold prescribed opioids for one day before the test.
After abdominal surgery, a 5-year-old child is experiencing pain, and an opioid analgesic is prescribed. What should the nurse consider about children in pain and their response to opioid analgesics when an opioid analgesic is prescribed?
Even though children do not like taking medicines, analgesics will make them more comfortable.
After prostate surgery a client's indwelling catheter and continuous bladder irrigation (CBI) are to be removed. The nurse discusses the procedure with the client. The nurse evaluates that the teaching is understood when the client states, "After the catheter is removed I probably will:
Experience some burning on urination."
To confirm a tentative diagnosis of leukemia a bone marrow aspiration and biopsy are to be performed on a 4-year-old boy. The nurse gives an age-appropriate explanation of the procedure to the child. What else is involved in caring for this child?
Explaining to the child that he will sleep during the procedure
A nurse is collecting data from a client with varicose veins who is to have sclerotherapy. What should the nurse expect the client to report?
Feeling of heaviness in both legs.
A nurse receives a shift report on four adult clients that are between the ages of 25-55. Which client should the nurse assess first?
Female client on warfarin (Coumadin) with an International Normalized Ratio (INR) of 7.5
A client at 32 weeks' gestation is admitted in active labor. Her cervix is effaced and dilated 4 cm. Intramuscular betamethasone (Celestone) 12 mg is prescribed. What should the nurse tell the client about why the medication is being given?
Fetal lung maturity is accelerated.
A client is admitted to the hospital for surgery for a total abdominoperineal resection. What position should the nurse encourage the client to maintain when in bed to promote perineal wound healing after surgery?
Left or right side-lying
A client with respiratory difficulties asks why the percussion procedure is being performed. The nurse explains that the primary purpose of percussion is to:
Loosen pulmonary secretions.
A nurse is caring for a client with a diagnosis of renal calculi secondary to hyperparathyroidism. Which type of diet should the nurse explore with the client when providing discharge information?
Low calcium (along with phosphorus make stones)
A nurse explains to the parents of a toddler with a diagnosis of tetralogy of Fallot that the aim of palliative surgery is to directly increase the blood flow to the
Lungs
The mother of a 3-year-old child with rubeola states that she once heard that it was called by another name. The nurse tells the mother that rubeola commonly is known as:
Measles
A client is admitted to the hospital after a motor vehicle accident with multiple abrasions and lacerations to the chest and all four extremities. The nurse helps the client select food items for the upcoming meals and recommends:
Meatloaf and strawberries
When reviewing a drug to be administered, the nurse identifies that the package insert indicates that the Z-track injection technique should be used. Under what circumstance does the nurse expect that this technique will be necessary?
Medication is irritating to subcutaneous tissue and skin
An arterial blood gas report indicates the client's pH is 7.25, PCO 2 is 35 mm Hg, and HCO 3 is 20 mEq/L. Which disturbance should the nurse identify based on these results?
Metabolic acidosis
The postoperative prescriptions for a client who had repair of an inguinal hernia include docusate sodium (Colace) daily. Before discharge, the nurse teaches the client that an intermittent side effect of this medication may be:
Mild abdominal cramping
A 3-year-old child is scheduled for cardiac catheterization. What is the priority nursing care after this procedure?
Monitoring the site for bleeding
A newborn's birth was prolonged because the shoulders were very wide. With which reflex does the nurse anticipate a problem?
Moro
The mother of a 13-year-old child with sickle cell anemia tells the nurse that the family is going camping by a lake this summer. She asks what activities are appropriate for her child. Which activity should the nurse suggest?
Motorboat rides around the lake
The nurse is caring for four clients on the postpartum unit. Which client will most likely state that she is having difficulty sleeping because of afterbirth pains?
Multipara who has vaginally delivered three children
What drug should a nurse anticipate that the health care provider will prescribe for a client demonstrating clinical manifestations associated with an opioid overdose?
Naloxone
During an interview the client reports overwhelming, irresistible attacks of sleep. Which sleep disorder does the nurse conclude that the client is experiencing?
Narcolepsy
A nurse is assigned to care for a group of clients who have been found to have depression. Which clinical manifestations does the nurse anticipate?
Neglect of personal hygiene "I don't know" answers to questions Apathetic response to the environment
While caring for a client, a nurse notes that the client has begun to create new words. What term does the nurse use to document this finding?
Neologism
A client with cancer develops pancytopenia during the course of chemotherapy. The client asks the nurse why this has occurred. The nurse explains that:
Noncancerous cells also are susceptible to the effects of chemotherapeutic drugs
A nursing team leader identifies that a nurse is coming to work after drinking alcohol. What is the most appropriate way for the team leader to approach this ethical situation?
Notify the nurse manager about the problem.
A client is admitted to the hospital for a surgical resection of the lower left lobe of the lung. After surgery the client has a chest tube to a closed-chest drainage system. What should the nurse do to determine if the chest tube is patent?
Observe for fluctuations of the fluid in the water-seal chamber
The health care provider prescribes propylthiouracil (PTU) for a client with the diagnosis of Graves' disease. What should the nurse teach the client when discussing the self-administration of this medication?
Observe for signs of infection
A client at 40 weeks' gestation is admitted to the birthing unit in early active labor. She tells the nurse that her membranes ruptured 26 hours ago. Assessments of the fetal heart rate range between 168 and 174 beats/min. What is the priority nursing action?
Obtaining maternal vital signs (accompany with fetus tachycardia, mother is at risk of infection)
A chronically ill, older client tells the home care nurse that the daughter with whom the client lives seems run-down and disinterested in her own health, as well as the health of her children, who are 5, 7, and 12 years old. The client tells the nurse that the daughter coughs a good deal and sleeps a lot. Why is it important that the nurse pursue the daughter's condition for potential case finding?
Older adults with chronic illness are more susceptible to tuberculosis.
An adolescent is undergoing radiation for Hodgkin's lymphoma. The nurse talks with the family about the importance of:
Overwhelming fatigue and the need for rest
A nurse in the pediatric clinic is caring for an 11-month-old infant with iron-deficiency anemia. The infant's hemoglobin is 8 g/dL. What does the nurse expect to observe when evaluating the infant?
Pallor (absence of hemoglobin)
A nurse plans to talk to the parents of a toddler about toilet training. What should the nurse tell the parents is the most important factor in the process of toilet training?
Parents' attitude about it
A client is admitted to the hospital with a diagnosis of chronic kidney disease. Which responses should the nurse expect the client to exhibit?
Paresthesias Hypertension
A client is admitted to the hospital with numbness of the hands and feet, which has progressed upward and now involves the arms, legs, and lower trunk. The client tells the nurse that approximately two weeks ago, the client experienced 48 hours of chills, fever, and upper respiratory congestion. A tentative diagnosis of Guillain-Barré syndrome is made. The nurse assesses for what major clinical manifestations of the syndrome?
Paresthesias and paralysis
While mopping the kitchen floor, a client at 37 weeks' gestation experiences a sudden sharp pain in her abdomen with a period of fetal hyperactivity. When the client arrives at the prenatal clinic, the nurse examines her and detects fundal tenderness and a small amount of dark-red bleeding. What does the nurse conclude is the probable cause of these clinical manifestations?
Partial abruptio placentae
A mother is concerned that her newborn will be exposed to communicable diseases when she goes home. While teaching the mother ways to decrease the risk of Infection; what type of immunity should the nurse explain was transferred to her baby through the placenta?
Passive natural
A psychiatric unit uses a behavioral approach to determine a client's level of privileges. Which factor should a nurse use to determine whether an increase in privileges is warranted?
Performing hygiene activities independently
A client has a compound fracture of the femur. The nurse should assess the client for the typical signs and symptoms of a fat embolus. In comparison to thromboembolism, which clinical indicator is unique to a fat embolus?
Pinpoint red spots on the chest
A client with a diagnosis of bipolar disorder, manic episode, is admitted to the mental health unit. Because the environment is important, what should the nurse do?
Place the client in a private room to provide a quiet atmosphere
A client is admitted to the hospital with deep partial-thickness burns to both hands and forearms after an accident. How should the nurse apply the prescribed antimicrobial medication?
Place the medication directly on the burn wound in a thin layer using sterile gloves.
A client has an order for a sublingual nitroglycerin tablet. The nurse should teach the client to use what technique when self-administering this medication?
Place the pill under the tongue and let it dissolve
A left modified radical mastectomy is performed on a client with breast cancer. What is the most important measure to be included in the care plan for the first postoperative day?
Placing the client in the semi-Fowler position with the left arm and hand elevated
A client who is employed as a carpenter has trouble holding tools because of carpal tunnel syndrome but continues to work to meet family financial obligations. Which is the priority concern when health care instructions are discussed with the client?
Potential for injury
For what client response must the nurse monitor to determine the effectiveness of amiodarone (Cordarone)?
Presence of cardiac dysrhythmias
While caring for a client who had an open reduction and internal fixation of the hip, the nurse encourages active leg and foot exercises of the unaffected leg every two hours. The nurse explains that these exercises will help:
Prevent clot formation
A client with severe preeclampsia in the high-risk unit is receiving an infusion of magnesium sulfate. If eclampsia were to occur, what action would the nurse take first?
Prevent injury
Which relationship does the nurse consider reflective of the relationship of naloxone (Narcan) to morphine sulfate?
Protamine sulfate to parenteral heparin
After an uneventful pregnancy a client gives birth to an infant with a meningocele (spina bifida). The neonate has 1-minute and 5-minute Apgar scores of 9 and 10, respectively. What is the priority nursing care for this newborn?
Protecting the sac with moist sterile gauze
What nursing intervention best meets the developmental needs of hospitalized preschool-age children?
Providing materials for simulating activities (imaginary play)
A nurse is caring for an infant with talipes equinovarus (clubfoot) who has had a corrective boot cast applied. Which peripheral vascular observation cannot be performed while the cast is in place?
Pulse
A client admitted to the hospital with a diagnosis of chronic obstructive pulmonary disease (COPD) has received a prescription for a medication that is delivered via a nebulizer. When teaching about use of the nebulizer, the nurse should teach the client to:
Seal the lips around the mouthpiece and breathe in and out taking slow, deep breaths
A nurse is developing a teaching plan for a client with lower extremity arterial disease (LEAD). The plan should include the importance of:
Securing professional treatment for any minor injuries to the extremities
A nurse educator is presenting information about the nursing process to a class of nursing students. What definition of the nursing process should be included in the presentation?
Sequence of steps used to meet the client's needs.
A client being prepared for surgery because of a ruptured tubal pregnancy complains of feeling lightheaded. Her pulse is rapid, and her color is pale. What condition does the nurse anticipate as a common complication of a ruptured tubal pregnancy?
Shock
When is the best time to prepare a toddler for impending surgery?
Shortly before the procedure
A 44-year-old client has been unable to function since her husband asked for a divorce 2 weeks ago. She is brought to the crisis intervention center by a friend. What type of crisis is this situation?
Situational
A severely depressed client is to have electroconvulsive therapy (ECT). What should a nurse include when discussing this therapy with the client?
Sleep will be induced and the treatment will not cause pain.
A nurse considers that communication links people with their surroundings. What should the nurse identify as the most important communication link?
Social
A pregnant client who has a history of cardiac disease asks how she can relieve her occasional heartburn. The nurse should instruct the client to avoid antacids containing:
Sodium
A client who has been hospitalized with schizophrenia tells the nurse, "My heart has stopped and my veins have turned to glass!" What should the nurse conclude that the client is experiencing?
Somatic delusion
The nurse is providing teaching to a client with atrial flutter who has received a prescription for an oral anticoagulant. The client asks the nurse to provide a list of foods that are high in Vitamin K and that should be avoided. What should the nurse include on the list?
Spinach Broccoli
A health care provider tells a mother that her newborn has multiple visible birth defects. The mother seems composed and asks to see her baby. What nursing action will be most helpful in easing the mother's stress when she sees her child for the first time?
Staying with her after bringing the infant to help her verbalize her feelings.
During a blood transfusion a client develops chills and a headache. What is the priority nursing action?
Stop the transfusion at once.
A nurse in the pediatric clinic is advising the mother of a toddler who has a pinworm infestation. What should the nurse teach the mother about caring for her child during and after treatment?
Strategies to prevent reinfestation The need for medication for the entire family The importance of handwashing before eating
A nurse is teaching a postoperative client about the importance of vitamin C for wound healing. Which food selection demonstrates the client is applying the information correctly?
Strawberries
During the first month in a nursing home, an older client with dementia demonstrates numerous disruptive behaviors related to disorientation and cognitive impairment. What should the nurse take into consideration when planning care?
Stressors that appear to precipitate the client's disruptive behavior
What should a nurse do when caring for a client with continuous bladder irrigation?
Subtract the amount of irrigant instilled from the output.
What chelating agent does the nurse anticipate will be prescribed for a toddler with lead poisoning?
Succimer (Chemet)
A client who is a pipe smoker is diagnosed with cancer of the tongue. A hemiglossectomy and right radical neck dissection are performed. To ensure airway patency during the first hours after surgery, the nurse should:
Suction as needed due to difficulty swallowing
A nurse evaluates that a client with diabetes understands the teaching about the treatment of hypoglycemia when the client says, "If I become hypoglycemic I initially should eat:
Sugar and a slice of bread.
An executive, busy at work, receives a phone call from a friend relating bad news. The woman makes a conscious effort to put this information out of her mind and continues to work at the task at hand. The next day she remembers that her friend telephoned her but is unable to recall the message. Which defense mechanism does this behavior represent?
Suppression
A client at 28 weeks' gestation with previously diagnosed mitral valve stenosis is being evaluated in the clinic. Which sign or symptom indicates that the client is experiencing cardiac difficulties?
Syncope on exertion
A client is scheduled for an intravenous pyelogram (IVP). The nurse explains that on the day before the IVP the client must:
Take a laxative before going to bed
Which statement by the unlicensed assistive personnel (UAP) indicates a correct understanding of the UAP's role? "I will:
Take clients' vital signs after their procedures are over."
A client has been taking prescribed risperidone (Risperdal) 3 mg twice a day for the past 8 days. A friend brings the client to the outpatient clinic. The client reports tremors, shortness of breath, a fever, and sweating. What should the nurse do?
Take the client's vital signs and arrange for immediate transfer to a hospital
A nurse provides instruction when the beta-blocker atenolol (Tenormin) is prescribed for a client with moderate hypertension. What action identified by the client indicates to the nurse that the client needs further teaching?
Take the medication before going to bed.
The gravida 1 now para 1 woman delivered a 7-lb 6 oz female infant at 11 pm yesterday after a labor of 14 hours. After breakfast the nursery staff brings the baby to the new mother. The mother smiles at the baby, then asks that the nurse take the baby back to the nursery because she has not had a shower yet. One hour later the nurse returns with the infant. Again the mother smiles at the baby; then she holds her, kisses her, and feeds her a bottle. Immediately after feeding the baby, the mother calls the nursery and asks that the baby be picked up so she can take a nap. What behavior is the new mother demonstrating?
Taking-in
A couple who recently immigrated from Israel tell a nurse in the prenatal clinic that they are concerned about a genetic disease that is prevalent among Jewish people. Which genetic screening should the nurse expect the health care provider to recommend to determine the possibility of the couple's child's inheriting the disease?
Tay-Sachs disease
A client demonstrating manic behavior is elated and sarcastic. The client is constantly cursing and using foul language and has the other clients on the unit terrified. Initially the nurse should:
Tell the client firmly that the behavior is unacceptable
A school-aged child with cystic fibrosis has recurrent episodes of bronchitis, and the parents ask the nurse why this happens. What reason should the nurse include in the reply?
Tenacious secretions that obstruct the respiratory tract provide a favorable medium for growth of bacteria.
A young sexually active client at the family planning clinic is advised to have a Papanicolaou (Pap) smear. She has never had a Pap smear before. What should the nurse include in the explanation of this procedure?
The Pap smear can detect cancer of the cervix.
The mother of a toddler is anxious about her child's eating habits because the child is very fussy and doesn't eat well. What should the nurse explain to the mother?
The child's eating habits are normal for this age.
A preschool child presents to the clinic for a well-child examination. What feature of the child's dress is most important for the nurse to address with the parents?
The child's name is embroidered on a jacket pocket. (Predators may use that as an advantage)
A client with paranoid schizophrenia tells the nurse, "My neighbors are spying on me because they want to rob me and take money." While hospitalized, the client complains of being poisoned by the food and of being given the wrong medication. The nurse evaluates the client's response to medications and therapy. Which finding leads the nurse to conclude that the client's reality testing has improved?
The client eats the food provided on the hospital tray.
A 16-year-old single mother of a 1-month-old infant and the infant's grandmother bring the baby to the emergency department and report that the infant accidentally fell down the stairs. The nurse knows that a consent form for treatment should be signed. Who has the responsibility for signing the consent?
The mother, despite her age
On which generally accepted concept of personality development should a nurse base care?
The personality is capable of being modified throughout life.
A nurse is providing discharge instructions for a client with angina who has a prescription for sublingual nitroglycerin tablets. The nurse should teach the client that the nitroglycerin sublingual tablets have lost their potency when:
The tablets are more than three months old.
A client who is scheduled to have surgery to remove an aldosterone-secreting adenoma asks the nurse what will happen if surgery is not performed. On what information should the nurse base a response?
The tumor must be removed to prevent heart and kidney damage.
