client needs missed Qs

Audiometry confirms a client's chronic progressive hearing loss. Further investigation reveals ankylosis of the stapes in the oval window, a condition that prevents sound transmission. This type of hearing loss is called functional hearing loss. fluctuating hearing loss. sensorineural hearing loss. conductive hearing loss.

conductive hearing loss. Conductive hearing loss results from interference with the conduction of sound waves (sound transmission) from the tympanic membrane to the inner ear. The stapes must move freely for sound to be transmitted. Bone tissue overgrowth causes the stapes to become fixed or immobile (ankylosed) in the oval window, preventing sound transmission. In a functional hearing loss, no organic lesion is found. Fluctuating hearing loss is a form of sensorineural hearing loss that varies over time. Sensorineural hearing loss affects the inner ear and involves the cochlea and eighth cranial nerve.

Which of the following variables should the nurse judge as least likely to indicate high risk when assessing a client's potential for suicide? Age 60 and older. Angry behavior. Living alone. Previous suicide attempts.

Angry behavior. Anger is a low risk factor for suicide. Risk factors for completed suicide are hopelessness; medical illness; severe anhedonia (loss of ability to feel pleasure); male gender; Caucasian, Native American, or Aboriginal ethno-racial background; living alone; age 60 or older; unemployment; financial distress; or previous suicide attempt. Age 60 and older is a risk factor for completed suicide. Living alone is a risk factor for completed suicide. Previous suicide attempt is a risk factor for completed suicide.

The nurse is having dinner at a restaurant when a man sitting at the next table collapses and falls to the floor. The nurse yells for help and quickly assesses the client, noting that the client is not breathing and does not have a pulse. The nurse initiates cardiopulmonary resuscitation (CPR) immediately, and the restaurant manager rushes to the scene with an automatic external defibrillator (AED). What should the nurse do next? Use the AED Stop the resuscitation efforts Perform CPR until emergency medical services arrives Check for a pulse for 30 seconds before continuing CPR

use AED Rationale: Basic components of CPR include immediate recognition of the sudden cardiac arrest (unresponsiveness and absence of normal breathing) and activation of the emergency response system, early CPR, and rapid defibrillation with the use of an AED.

A nurse is teaching parents about accident prevention for a toddler. Which guideline is most appropriate? Always make the toddler wear a seat belt when riding in a car. Make sure all medications are kept in containers with childproof safety caps. Never leave a toddler unattended on a bed. Teach rules of the road for bicycle safety.

Making sure all medications are kept in containers with childproof safety caps is the most appropriate guideline, because poisoning accidents are common with toddlers owing to the child's curiosity, increasing mobility, and ability to climb. When riding in a car, a toddler should be strapped into a car seat, not restrained by a seat belt. A seat belt is an appropriate guideline for a school-age child. Never leaving a child alone on a bed is an appropriate guideline for parents of infants. Toddlers already have the ability to climb on and off of beds and other furniture by themselves. Note, however, that toddlers should never be left unattended on high surfaces, such as an examining table in a health care provider's office. Teaching the rules of the road for bicycle safety is an appropriate safety measure for a school-age child. Toddlers should not be allowed in the road unsupervised.

The nurse is administering oxygen by face mask to a client. Which action will the nurse include? Secure the elastic band tightly around the client's head. Assist the client to the semi-Fowler's position if possible. Place the elastic straps below the client's ears. Loosen the connectors between the oxygen equipment and humidifier.

Assist the client to the semi-Fowler's position if possible. promotes easier chest expansion, breathing, and oxygen intake. The nurse would secure the elastic band so that the face mask fits comfortably and snugly rather than tightly, which could cause irritation. The nurse would apply the elastic straps above the client's ears to prevent skin breakdown. The nurse would ensure that the connectors between the oxygen equipment and humidifier are airtight; loosened connectors can cause loss of oxygen.

A client with multiple sclerosis (MS) is experiencing bowel incontinence and is starting a bowel retraining program. What information should the nurse include in the teaching plan for this client? eating a diet low in fiber setting a regular time for elimination using a stool softener daily limiting fluid intake to about 4 cups (1 L) a day

setting a regular time for elimination The nurse can teach the client with MS who is in a bowel retraining program to set a regular time each day for elimination. A diet with adequate amounts of fiber facilitates having a bowel movement. It is not necessary to use a stool softer if bowel training, fluid intake, and the diet are having the intended outcomes. Limiting fluid intake is likely to aggravate rather than relieve symptoms when a bowel retraining program is being implemented. Furthermore, water imbalance, as well as electrolyte imbalance, tends to aggravate the signs and symptoms of MS.

The nurse administers a dose of ramipril 2.5 mg to a client at 9 am. While documenting administration of the medication, the nurse discovers that 1.25 mg, not 2.5 mg, was the prescribed dose. The nurse assesses the client, completes an incident report, and notifies the primary health care provider and nursing supervisor of the error. What statement does the nurse add to the client's record? Ramipril 2.5 mg was administered at 9 am. Twice the amount of the prescribed ramipril was administered at 9 am. Client's blood pressure was 128/82 mm Hg after the administration of the incorrect dose of ramipril. An incident report was completed and filed.

After an incident, the nurse would document a concise and OBJECTIVE description of what occurred and any follow-up actions taken in the client's record. The nurse would not document in the client's record that an incident report was completed. Nor would the nurse document that twice the prescribed dose was given or that an incorrect dose was given.

A nurse is caring for an infant with meningitis. Which assessment finding would provide the most accurate confirmation of increased intracranial pressure (ICP)? Bulging fontanels when crying Inconsolable crying while being held Lying in an opisthotonic position Brisk accommodation of pupils

Lying in an opisthotonic position is decerebrate posturing where the neck and back are arched posteriorly. An infant lying in an opisthotonic position is exhibiting a sign of increased ICP. This position alleviates discomfort associated with meningitis. Fontanels may be bulging with increased ICP but fontanels may also bulge when the infant cries under normal circumstances so this not a definitive sign. Inconsolable crying while being held may indicate an increase in ICP but it is not definitive as this could also be indicative of gastric distress or other discomfort. Pupillary reaction is expected to be brisk and is a normal finding.

A nurse is caring for a client who had gastric bypass surgery two days ago. Which assessment finding requires immediate intervention? The client complains of significant pain at the surgical site when rising out of bed. The client is concerned about feeling bloated and being unable to have a bowel movement, even when pushing. The client's right lower leg is red, swollen, and warm to touch. The client's surgical site is reddened and swollen.

The client's right lower leg is red, swollen, and warm to touch. A red, swollen extremity is a possible sign of a thromboembolism, a common complication after gastric surgery. The nurse should inform the physician of the finding. Pain at the surgical site upon rising is normal, but splinting should be reinforced. A reddened surgical site is concerning, but the red, swollen leg is a higher priority. Abdominal bloating occurs due to the carbon dioxide used during the laparoscopy and will lessen when it gets absorbed. Additional teaching is needed to be sure the client does not strain at the toilet.

A nurse is caring for a breastfeeding client diagnosed with mastitis in one breast and prescribed antibiotics. What actions will the nurse recommend the client take related to breastfeeding? Schedule breastfeeding so antibiotics are taken after feeding, not before. Apply a cold compress to the affected breast prior to feeding. Feed from the unaffected breast before feeding from affected side. Apply a warm compress to affected breast prior to feeding.

Apply a warm compress to affected breast prior to feeding. To help relieve mastitis, the nurse should advise the client to use warm compresses and massage the affected area gently before and during breastfeeding. Cold compresses can be used after or between feedings for comfort; this will hinder milk release, though, so the client should not apply them before feeding. It will not be possible to schedule breastfeeding in relation to antibiotic administration; the client is encourage to feed on demand, at least every 2 to 3 hours. To help empty the affected breast, feedings should start with the affected side.

A nurse is having dinner with a friend at a restaurant when a woman at a nearby table suddenly clutches her neck with both hands. Suspecting that the woman is choking, the nurse quickly approaches her. What action should the nurse take first? Asking the woman whether she can speak Helping the woman into a supine position Striking the woman's back forcefully with a fist Opening the woman's airway and attempting to perform ventilation

Asking the woman whether she can speak One sign of airway obstruction is the universal signal for choking (the victim clutches the neck with one or both hands). When someone appears to be choking, the first action is to ask the victim, "Are you choking?" or "Can you speak?" If the victim can cough forcefully or speak, the rescuer need not intervene and should monitor the victim. The victim will not be able to speak or cough if he or she is choking. If an obstruction is present, the rescuer administers the abdominal thrust maneuver and notifies the emergency response system. Opening the woman's airway and attempting to perform ventilation and placing the woman in a supine position are both steps of the abdominal thrust maneuver for an unconscious victim. Striking the woman on the back forcefully with a fist is an incorrect action, can be harmful, and is not a component of the abdominal thrust maneuver.

The spouse of a client with angina pectoris calls the physician's office and reports to the nurse that the client is experiencing chest pain and has taken one sublingual nitroglycerin tablet with no relief. What does the nurse tell the client's spouse to do? Have the client rest and, if no relief is obtained, call the office back Wait until the situation can be discussed with the physician, who will call them soon Call Emergency Medical Services (EMS) immediately to take the client to the emergency department (ED) Correct Give two more nitroglycerin tablets 5 minutes apart and if still no relief, get the client into a car and take the client to the ED

Call Emergency Medical Services (EMS) immediately to take the client to the emergency department (ED) Correct Rationale: Chest pain that is unrelieved by rest and nitroglycerin may be not typical anginal pain but instead a sign of myocardial infarction (MI). Because the risk of sudden cardiac death is greatest in the first 24 hours after MI, it is imperative that the client receive emergency cardiac care. If the client needs to go to the ED, the nurse must instruct the client's spouse to call an ambulance to transport the client. The client's spouse should not drive the client, because the client should not exert energy and place an increased workload on the heart, and the client's spouse would not be able to provide care if an emergency arose during transport to the hospital. Telling the spouse to wait until the physician calls back delays necessary interventions. Having the client rest delays necessary interventions; also, the usual procedure for a client who is at home and develops chest pain is to have the client take one nitroglycerin tablet; if pain is unrelieved EMS is called immediately. While waiting for EMS to arrive, the client would take a second nitroglycerin; if still no relief after 5 minutes, the client can take a third nitroglycerin.

The home care nurse visits a pregnant client with a diagnosis of mild preeclampsia. During the assessment, the client tells the nurse that she has had an upset stomach and pain in the epigastric area. What should the nurse most appropriately do? Contact the primary client's health care provider Tell the client to avoid lying flat Instruct the client to eat a small portion of food every 2 to 3 hours Administers an antacid to the client and tell her to take a dose every 6 hours

Contact the primary client's health care provider Rationale: Preeclampsia is dangerous to the woman and fetus because it can progress rapidly, and the earliest manifestations may go unnoticed by the woman. Some signs/symptoms, such as epigastric pain and upset stomach, are particularly ominous because they indicate distention of the hepatic capsule and often mean that a seizure is imminent. Therefore telling the client to avoid lying flat position, instructing the client to eat a small portion of food every 2 to 3 hours, and administering an antacid and telling the client to take a dose every 6 hours are all incorrect. Additionally, the nurse would not administer an antacid to the pregnant client without a prescription to do so.

A prescription for IV infusion of 1000 mL of 0.9% NS solution with 10 mEq of K+ rate of 100 mL/hr. Nurse obtains an infusion control device with which to administer the prescription and hangs the IV solution at 7 a.m. At 10 a.m. the nurse notes that 500 mL of solution has infused. Nurse assesses the pt checks the infusion rate, obtains a new infusion control device, and contacts the primary HCP. The primary health care provider prescribes a decrease in the rate of infusion to 50 mL/hr and orders a serum potassium level. The potassium level is 3.5 mEq/L. Which info should be included on the incident report in regard to this event? SATA primary HCP was contacted. K+ level at 10:30 a.m. was 3.5 mEq/L A total of 200 mL of IV fluid was accidentally infused 500 mL of solution remaining in the IV bag at 10 a.m. The infusion control device malfunctioned >excess amount of IV fluid to infuse into the client.

The primary health care provider was contacted. The serum potassium level at 10:30 a.m. was 3.5 mEq/L (3.5 mmol/L). There was 500 mL of solution remaining in the IV bag at 10 a.m. The incident report should contain the client's name, age, and diagnosis. The report should also contain a factual description of the incident, any injuries sustained by those involved, and the outcome of the situation. The nurse avoids the use of subjective data and documents objective data. The nurse also avoids any implication that an accident occurred or that an error was made. The statement that 200 mL of IV fluid was accidentally infused into the client implies that an accident resulted from an error. Likewise, the statement that the infusion control device malfunctioned, causing an excess amount of IV fluid to be infused into the client, poses an implication. The remaining statements identify factual and observable data free of unwanted implications.

A nurse at a community event is called to an unresponsive 3-year-old. The parent states the child was eating a hot dog. The nurse determines the child has an obstructed airway. After instructing an observer to call 911, what intervention should happen first? performing the Heimlich maneuver until the child starts choking or coughing opening the child's mouth and attempting to give 2 breaths delivering five back blows followed by five chest thrusts performing chest compressions with the heel of one hand 30 times

performing chest compressions with the heel of one hand 30 times According to the American Heart Association (Heart and Stroke Foundation of Canada), when a child between 1-and 8-years-old is unconscious and believed to have an obstructed airway, the child should first be laid upon a hard surface, and 30 chest compressions should be given. Delivering five back blows followed by five chest thrusts is appropriate for an infant less than 1-year-old. Performing the Heimlich maneuver is appropriate when the child is still conscious. Attempting to give breaths should happen after the chest compressions. The chest compressions are believed to help expel the obstruction.

A ventilator's low exhaled volume (low-pressure) alarm sounds, and the nurse rushes to the client's room and quickly assesses the client. The client appears to be having respiratory difficulty. What should the nurse do first? Call a code Suction the client Call the anesthesiologist Manually ventilate the client, using a resuscitation bag

Manually ventilate the client, using a resuscitation bag Rationale: Because the client is experiencing respiratory distress, the client should be manually ventilated with the use of a resuscitation bag until the problem can be determined. Mechanical ventilators have alarm systems that warn the nurse of a problem with either the client or the ventilator. Such alarms must be activated and functional at all times. The low exhaled volume alarm sounds when there is a disconnection or leak in the ventilator circuit or a leak in the client's artificial airway cuff. A code is called when the client requires resuscitation. An anesthesiologist may be needed to insert an endotracheal tube or to assist with a code. Accumulation of secretions in the respiratory system and the need for suctioning would trigger the high-pressure alarm.

The health care team determines that the family of an infant with failure to thrive who is to be discharged will need follow-up care. Which approach would be the most effective method of follow-up? daily phone calls from the hospital nurse enrollment in community parenting classes twice-weekly clinic appointments weekly visits by a community health nurse

weekly visits by a community health nurse The most effective follow-up care would occur in the home environment. The community health nurse can be supportive of the parents and will be able to observe parent-infant interactions in a natural environment. The community health nurse can evaluate the infant's progress in gaining weight, offer suggestions to the parents, and help the family solve problems as they arise.

A client has an elective hemorrhoidectomy. What is the priority goal immediately after surgery? prevent venous stasis promote ambulation control pain prevent infection

control pain Rectal surgery is accompanied by severe pain resulting from spasms of sphincters and muscles. Therefore, controlling pain is a priority goal of nursing care.Preventing venous stasis, promoting ambulation, and preventing infection are appropriate goals, but controlling the severe pain that can accompany a hemorrhoidectomy is a priority in the immediate postoperative period.

The risk for injury during an attack of Ménière disease is high. The nurse should instruct the client to take which immediate action when experiencing vertigo? "Place your head between your knees." "Concentrate on rhythmic deep breathing." "Close your eyes tightly." "Assume a reclining or flat position."

"Assume a reclining or flat position." The client needs to assume a safe and comfortable position during an attack, which may last several hours. The client's location when the attack occurs may dictate the most reasonable position. Ideally, the client should lie down immediately in a reclining or flat position to control the vertigo. The danger of a serious fall is real. Placing the head between the knees will not help prevent a fall and is not practical because the attack may last several hours. Concentrating on breathing may be a useful distraction, but it will not help prevent a fall. Closing the eyes does not help prevent a fall.

A client has asked the nurse about the expected course of Ménière disease. The nurse should give the client which information? "The disease process will gradually extend to the eyes." "Control of the episodes is usually possible, but a cure is not yet available." "Continued medication therapy will cure the disease." "Bilateral deafness is an inevitable outcome of the disease

"Control of the episodes is usually possible, but a cure is not yet available."

A client fell and broke an arm and had a cast applied. Which of these statements by the client indicates an immediate risk for compartment syndrome? "My arm hurts." "I can't wiggle my fingers." "I need to go home." "Don't touch me."

"I can't wiggle my fingers." Signs and symptoms of compartment syndrome, such as motor weakness, reflect a deficit or deterioration of neuromuscular status in the involved area. Inability to wiggle fingers indicates an immediate risk for compartment syndrome because it could suggest neurovascular pressure or damage caused by edema following the injury. The other statements don't indicate risk for compartment syndrome.

A nurse is teaching the parent of a 5-month-old infant diagnosed with bronchiolitis. Which statement by the mother indicates that teaching has been effective? "I hope my baby will come home from the hospital." "I know that this disease is serious and can lead to asthma." "My baby needs to be cured this time so it won't happen again." "My baby has been sick. A machine will help him breathe."

"I know that this disease is serious and can lead to asthma." By saying that bronchiolitis places the child at risk for developing asthma, the parent demonstrates understanding of the infant's condition. If diagnosed and treated promptly, most infants recover from the illness and return home. Infants typically don't have recurrences of bronchiolitis. Infants diagnosed with bronchiolitis rarely require mechanical ventilation.

After 1 month of therapy, a client in spinal shock begins to experience muscle spasms in the legs and calls the nurse in excitement to report the leg movement. Which response by the nurse would be the most accurate? "These movements indicate that the damaged nerves are healing." "This is a good sign. Keep trying to move all the affected muscles." "The return of movement means that eventually you should be able to walk again." "The movements occur from muscle reflexes that cannot be initiated or controlled by the brain."

"The movements occur from muscle reflexes that cannot be initiated or controlled by the brain." The movements occur from muscle reflexes and cannot be initiated or controlled by the brain. After the period of spinal shock, the muscles gradually become spastic owing to an increased sensitivity of the lower motor neurons. It is an expected occurrence and does not indicate that healing is taking place or that the client will walk again. The movement is not voluntary and cannot be brought under voluntary control.

The nurse teaches the parent of an infant with pyloric stenosis about the condition. Which cause, if stated by the parent, indicates effective teaching? "an enlarged muscle below the stomach" "a telescoping of the large bowel into the smaller bowel" "a result of giving the baby more formula than is necessary" "a genetically smaller stomach than normal"

"an enlarged muscle below the stomach" Pyloric stenosis involves hypertrophy of the pylorus muscle distal to the stomach and obstruction of the gastric outlet resulting in vomiting, metabolic acidosis, and dehydration. Telescoping of the bowel is called intussusception. Overfeeding, feeding too quickly, or underfeeding is not associated with pyloric stenosis. The stomach is obstructed, but it is not smaller than normal.

A neonate with a 3 × 5-cm sac in the lumbar region of the back is diagnosed with myelomeningocele. What should the nurse expect to find when inspecting this sac? spinal fluid, nerve tissue, and spinal bony defect

A myelomeningocele has three components (bony defect, spinal fluid, and nerve tissue such as meninges, spinal cord, or nerve roots) and protrudes over the vertebrae, usually in the lower back. A simple cyst contains serosanguineous fluid and fatty tissue and is located on any area of the spinal column. A pilonidal cyst is a skin-covered sac containing bits of hair located on the low lumbar or sacral area of the spine. A meningocele is a soft sac containing only spinal fluid and meninges located anywhere on the spine.

A client has been admitted to the hospital with draining foot lesions. What should the nurse do? Select all that apply. Place the client in a room with negative air pressure. Admit the client to a semi-private room. Admit the client to a private room. Post a "contact isolation" sign on the door. Wear a protective gown when in the client's room. Wear gloves when providing direct care.

Admit the client to a private room. Post a "contact isolation" sign on the door. Wear a protective gown when in the client's room. Wear gloves when providing direct care.

A toddler is receiving an infusion of total parenteral nutrition via a Broviac catheter. As the child plays, the I.V. tubing becomes disconnected from the catheter. What should the nurse do first? Turn off the infusion pump. Position the child on the side. Clamp the catheter. Flush the catheter with heparin.

Clamp the catheter. First, the nurse must clamp the catheter to prevent air entry, which could lead to air embolism. If an air embolism occurs, the nurse should position the child on the side after clamping the catheter. The nurse may turn off the infusion pump after ensuring the child's safety. If blood has backed up in the catheter, the nurse may need to flush the catheter with heparin; however, this isn't the initial priority.

The parent of a toddler with nephrotic syndrome asks the nurse what can be done about the child's swollen eyes. Which is the best measure that the nurse should suggest? Apply cool compresses to the child's eyes. Elevate the head of the child's bed. Apply eye drops every 8 hours. Limit the child's television watching.

Elevate the head of the child's bed. The child's swollen eyes are caused by fluid accumulation. Elevating the head of the bed allows gravity to increase the downward flow of fluids in the body, away from the face. Applying cool compresses or eye drops or limiting television may be comforting but will not relieve the swelling.

A client is diagnosed with herpes simplex. Which statement about herpes simplex infection is true? During early pregnancy, herpes simplex infection may cause spontaneous abortion or premature birth.

Herpes simplex may be passed to the fetus transplacentally and, during early pregnancy, may cause spontaneous abortion or premature birth. Genital herpes simplex lesions typically are painful, fluid-filled vesicles that ulcerate and heal within 1 to 2 weeks. Herpetic keratoconjunctivitis usually is unilateral and causes localized symptoms, such as conjunctivitis. A client with genital herpes lesions should avoid all sexual contact to prevent spreading the disease.

When completing the preoperative checklist on the nursing unit, the nurse discovers an allergy that the client has not reported. What should the nurse do first? Withhold the prescribed preanesthetic medication. Note this new allergy prominently on the medical record. Contact the scrub nurse in the operating room. Inform the anesthesiologist.

Inform the anesthesiologist. The anesthesiologist who administers the anesthetic agent and monitors the client's physical status throughout the surgery must have knowledge of all known allergies for client safety. The completed record (with the preoperative checklist) must be available to all members of the surgical team, and any unusual last-minute observations that may have a bearing on anesthesia or surgery are noted prominently at the front of the medical record. The nurse should first notify the anesthesiologist of the allergy; it is not the nurse's responsibility to withhold the preoperative medications unless the anesthesiologist rewrites the preoperative orders. The nurse in the scrub role provides sterile instruments and supplies to the surgeon during the procedure and does not determine if the client's allergy will cause the surgery to be canceled.

A client with suspected severe acute respiratory syndrome (SARS) comes to the emergency department. Which physician order should the nurse implement first? Institute isolation precautions. Begin an I.V. infusion of dextrose 5% in half-normal saline solution at 100 ml/hour. Obtain a nasopharyngeal specimen for reverse-transcription polymerase chain reaction testing. Obtain a sputum specimen for enzyme immunoassay testing.

Institute isolation precautions. SARS, a highly contagious viral respiratory illness, is spread by close person-to-person contact. Contained in airborne respiratory droplets, the virus is easily transmitted by touching surfaces and objects contaminated with infectious droplets. The nurse should give top priority to instituting infection-control measures to prevent the spread of infection to emergency department staff and clients. After isolation measures are carried out, the nurse can begin an I.V. infusion of dextrose 5% in half-normal saline and obtain nasopharyngeal and sputum specimens.

A client who has abruptio placentae exhibits cyanosis in the earlobes, capillary filling time >3 seconds, and reports "heartburn." Which is the best nursing intervention? Notify the healthcare provider immediately. Assess for vaginal bleeding. Increase the temperature of the room and provide warmed blankets. Elevate the head of the bed.

Notify the healthcare provider immediately. The manifestations of earlobe cyanosis, capillary filling time >3 seconds, and gastric distress in this client may indicate disseminated intravascular coagulation. The healthcare provider should be notified immediately. Increasing the ambient temperature may increase client comfort, and an assessment of vaginal bleeding is indicated. Sitting the client up in bed is not indicated.

While the nurse is delivering abdominal thrusts to a 6-year-old who is choking on a foreign body, the child begins to cry. What should the nurse do next? Tap or gently shake the shoulders. Deliver back slaps. Perform a blind finger sweep of the mouth. Observe the child closely.

Observe the child closely. Crying indicates that the airway obstruction has been relieved. No additional thrusts are needed. However, the child needs to be observed closely for complications, including respiratory distress. Tapping or shaking the shoulders is used initially to determine unresponsiveness in someone who appears unconscious. Delivering chest or back slaps could jeopardize the child's now-patent airway. Because the obstruction has been relieved, there is no need to sweep the child's mouth. Additionally, blind finger sweeps are contraindicated because the object may be pushed further back, possibly causing a complete airway obstruction.

The nurse is caring for a child in Bryant traction (see figure). What action should the nurse take? Adjust the weights on the legs until the buttocks rest on the bed. Provide frequent skin care. Place a pillow under the buttocks. Remove the elastic leg wraps every 8 hours for 10 minutes.

Provide frequent skin care. The traction is positioned correctly; the nurse should provide frequent skin care to the back and shoulder areas. The hips and buttocks should be lifted off the bed to provide countertraction; the nurse should not adjust the weights. The nurse should not place a pillow under the buttocks as this would prevent countertraction. The elastic wraps should remain on the legs unless removal is prescribed by the health care provider.

A client is seeking infertility treatment after attempting pregnancy for 2 years. Of the data from the client's history, which has the greatest impact on infertility? The client has used no birth control for 2 years. The client is a gymnast weighing 105 lb (47.6 kg). The client travels by air frequently. The client is an ovo-vegetarian.

The client is a gymnast weighing 105 lb (47.6 kg). Estrogen is stored in body fat, and weighing 105 lb (47.6 kg) at any height indicates a small amount of body fat. With minimal fat, little estrogen can be stored, and these women are often anovulatory and without menstrual cycles. This greatly influences the ability to become pregnant. Using no birth control for 2 years, traveling by air, and being an ovo-vegetarian do not influence the ability to conceive.

The nurse is assessing an older adult's ability to perform activities of daily living. Which approach will be most effective? Observe the client performing varied activities of daily living.

To assess the client's ability to perform activities of daily living, it is important for the nurse to observe clients actually performing them. This way, nurses can assess any problems occurring with a specific activity. Asking the client what he or she is able to do will not always provide reliable information, and documentation on the chart may not reflect if the client has had help in performing specific tasks .Family members can provide some information but are not trained in how to evaluate the client.

The nurse is reading the medical record of a pregnant client in the second trimester with a diagnosis of abruptio placentae. Which clinical manifestation of the disorder does the nurse expect to see documented? Uterine tenderness Lack of uterine activity Painless vaginal bleeding Constipation

Uterine tenderness Rationale: In abruptio placentae, abdominal pain and uterine tenderness are present. Uterine tenderness accompanies placental abruption, especially with a central abruption in which blood becomes trapped behind the placenta. The abdomen will feel hard and boardlike on palpation because the blood penetrates the myometrium, resulting in uterine irritability. Excessive uterine activity with poor relaxation between contractions is present. Fetal monitoring often reveals increased uterine resting tone, caused by failure of the uterus to relax in an attempt to constrict blood vessels and control bleeding. Painless bright-red vaginal bleeding in the second or third trimester of pregnancy is a sign of placenta previa. Constipation is not associated with this disorder.

The nurse teaches the parent of a child diagnosed with phenylketonuria (PKU) about its transmission. The nurse should understand which factor as the basis for the discussion? chromosome translocation chromosome deletion autosomal recessive gene X-linked recessive gene

autosomal recessive gene PKU is caused by an inborn error of metabolism. It is an autosomal recessive disorder that inhibits the conversion of phenylalanine to tyrosine. A form of Down syndrome, trisomy 21, is an example of a disorder caused by chromosomal translocation. Cri du chat is an example of a disorder caused by chromosomal deletion. Hemophilia A is an example of a disorder caused by an X-linked recessive gene.

A client reports abdominal pain and vomiting for 24 hours. The client's blood pressure is 98/48 mm Hg. The client is diagnosed with large-bowel obstruction. What is the priority nursing diagnosis for the client? deficient fluid volume deficient knowledge acute pain ineffective tissue perfusion

deficient fluid volume Feces, fluid, and gas accumulate above a bowel obstruction. Then the absorption of fluids decreases and gastric secretions increase. This process leads to a loss of fluids and electrolytes in circulation. In addition the client has been vomiting for 24 hours and has a low blood pressure. Therefore, deficient fluid volume is the priority diagnosis. deficient knowledge and ineffective tissue perfusion are applicable but not the primary nursing diagnoses. Pain is an issue with this client; however, treating the client's hypovolemia is the priority.

A nurse is caring for a client who underwent a subtotal gastrectomy. To manage dumping syndrome, the nurse should advise the client to restrict fluid intake to 1 qt (1,000 ml)/day. drink liquids only with meals. not drink liquids 2 hours before meals. drink liquids only between meals.

drink liquids only between meals. A client who experiences dumping syndrome after a subtotal gastrectomy should be advised to ingest liquids between meals rather than with meals. Taking fluids between meals allows for adequate hydration, reduces the amount of bulk ingested with meals, and aids in the prevention of rapid gastric emptying. There is no need to restrict the amount of fluids, just the time when the client drinks fluids. Drinking liquids with meals increases the risk of dumping syndrome by increasing the amount of bulk and stimulating rapid gastric emptying. Small amounts of water are allowable before meals.

A child is in the emergency department with suspected epiglottitis and has been ordered an X-ray to confirm the diagnosis. The nurse would prepare the child for X-ray by which methods? in radiology, transported by wheelchair, accompanied by a nurse in radiology, transported by stretcher, accompanied by a nurse in surgery, by portable X-ray in the emergency department, by portable X-ray

in the emergency department, by portable X-ray The child is at risk for obstruction related to the swollen epiglottis. The nurse should not move the child, keep a careful watch, and get a portable X-ray in the emergency department.

A client with chronic obstructive pulmonary disease (COPD) is intubated and placed on continuous mechanical ventilation. Which equipment is most important for the nurse to keep at this client's bedside? tracheostomy cleaning kit water-seal chest drainage set-up manual resuscitation bag oxygen analyzer

manual resuscitation bag The client with COPD depends on mechanical ventilation for adequate tissue oxygenation. The nurse must keep a manual resuscitation bag at the bedside to ventilate and oxygenate the client in case the mechanical ventilator malfunctions. Because the client doesn't have chest tubes or a tracheostomy, keeping a water-seal chest drainage set-up or a tracheostomy cleaning kit at the bedside isn't necessary. Although the nurse may keep an oxygen analyzer (pulse oximeter) on hand to evaluate the effectiveness of ventilation, this equipment is less important than the manual resuscitation bag.

Which finding is expected when the nurse is assessing a child who has sustained full-thickness burns? blanching to the touch excessive bleeding minimal pain blistering and a moist appearance

minimal pain Full-thickness burns are serious injuries in which all the skin layers are destroyed. Lack of pain is characteristic of full-thickness burns. With full-thickness burns, blanching and bleeding are absent because the blood supply is destroyed. Blisters and a moist appearance characterize partial-thickness burns.

The nurse is caring for a young child who has been admitted to the hospital with pertussis. To prevent the spread of the infection, which of the following is the most important action of the nurse? wear gloves when providing care for the child place the child in a negative pressure room provide masks for everyone entering the room use eye protection for direct contact with the child

provide masks for everyone entering the room Pertussis is spread via droplet transmission, so droplet precautions are necessary for the first 5 days after the child has begun medical treatment. This requires that everyone entering the room wears a mask. When administering direct care, eye protection can be worn to prevent coughing of droplets into the eyes.

A client with diabetes who just gave birth plans to breastfeed. The nurse determines that the client's understanding of breastfeeding instructions is sufficient when the client makes which statement? help in lowering maternal blood glucose

Breastfeeding consumes maternal calories and requires energy that increases the maternal basal metabolic rate and assists in lowering the maternal blood glucose level. Insulin is not transferred to the infant through breast milk. Breastfeeding is recommended for clients with diabetes because it lowers blood glucose levels. The number of antibodies in breast milk is not altered by maternal diabetes.

A nurse should question an order for a heating pad for a client who has

active bleeding.

What response by the nurse would be most appropriate when responding to a parent who asks how to manage their child's morning hyperglycemia? Tell the parent that this is normal and to continue with the prescribed doses. Ask the parent what the child's blood glucose levels have been for the last few days. Inform the parent that this is unusual and the child needs to be seen in the emergency department at once. Ask the parent if the child has been avoiding sweets.

Ask the parent what the child's blood glucose levels have been for the last few days. Management of children with early morning hyperglycemia depends on whether the hyperglycemia is due to insulin waning, a progressive rise in blood glucose throughout the day, or rebound hyperglycemia (Somogyi effect: an increase in blood sugar glucose at bedtime, a drop at about 0200, and then a rebound rise early in the morning). Information about the child's blood glucose levels would provide clues to determine which event is occurring. Telling the parent that this is normal is inappropriate. Early morning hyperglycemia is not unusual nor is it an emergency situation. Although questioning the parent to gain more information is appropriate, asking them specifically about avoiding sweets may imply the parent is at fault for not monitoring the child's intake closely. Additionally, carbohydrates, not merely sweets, are implicated in diabetes.

An adolescent client who is being seen by the crisis nurse after making several superficial cuts on their wrist states that all their friends are siding with their ex-partner and will not talk to the client anymore. The client says that although they know the relationship is over, "If I can't have my ex, no one else will." Which client problem takes the highest priority? situational low self-esteem risk for other-directed violence risk for suicide risk-prone health behavior

risk for other-directed violence The threat toward the ex-partner is the most immediate concern now, as the client turns their anger toward their ex-partner instead of themself. Although situational low self-esteem, risk for suicide, and risk-prone health behavior are evident, these problems are less of a concern at this time.

The nurse is monitoring a client who is in the active phase of labor and has been experiencing contractions that are coordinated but weak. Which assessment finding indicates to the nurse that the client may be experiencing hypotonic contractions? Fetal hypoxia Discomfort with each contraction Increased frequency and longer duration of contractions Contractions that can be indented easily with fingertip pressure at their peak

Contractions that can be indented easily with fingertip pressure at their peak Rationale: Hypotonic contractions, coordinated but too weak to be effective, usually occur during the active phase of labor, when progress normally quickens. Contractions are infrequent and brief and can easily be indented on the abdomen with fingertip pressure at their peak. These contractions cause minimal discomfort because the contractions are weak. Fetal hypoxia is not usually seen with hypotonic contractions.

The nurse provides instructions to a client about measures to prevent an acute attack of gout. What client statement does the nurse determine indicates that the client needs additional instructions? "I don't need medication unless I'm having a severe attack." Correct

Rationale: Treatment of gout includes both nutrition and medication therapy. The client should be encouraged to limit the use of alcohol and reduce the consumption of foods high in purines. Such foods include sardines, herring, mussels, liver, kidney, goose, venison, and sweetbreads. Medication therapy is a primary component of management for clients with gout, and the primary health care provider normally prescribes a medication that will promote uric acid excretion or reduce its production. Fluid intake is important in preventing the development of uric acid stones. Fad or starvation diets can precipitate an acute attack because of the rapid breakdown of cells they induce. Excessive physical and emotional stress can exacerbate the disease.

The nurse completes an admission assessment of a child admitted to the pediatric unit with osteomyelitis of the left tibia. When assessing the area over the tibia, the nurse understands that which finding is expected? diffuse tenderness decreased pain increased warmth localized edema

increased warmth Findings associated with osteomyelitis commonly include pain over the area, increased warmth, localized tenderness, and diffuse swelling over the involved bone. The area over the affected bone is red.

The nurse is assessing the client who had a gastric resection yesterday. Which finding indicates the development of a leaking anastomosis? pain, fever, and abdominal rigidity diarrhea with fat in the stool palpitations, pallor, and diaphoresis after eating feelings of fullness and nausea after eating

pain, fever, and abdominal rigidity Pain, fever, and abdominal rigidity are signs and symptoms of inflammation or peritonitis caused by the leaking anastomosis. Diarrhea with fat in the stool is steatorrhea and is not present in peritonitis. Palpitations, pallor, and diaphoresis after eating are vasomotor symptoms of gastric retention. Feelings of fullness and nausea after eating are not present in peritonitis.

The parent of a school-age client with diabetes tells the nurse that they do not want the school to know about their child's condition. Which is the nurse's best response? "Our office will not discuss your child's diabetes with the school without your written permission." "What is it that concerns you about having the school know about your child's condition?" "It would be fine not to tell your child's friends, but the teacher must know." "To keep your child safe, it is necessary for all adults in the school to know about the condition."

"What is it that concerns you about having the school know about your child's condition?" The nurse's first response should be to obtain more information about the parent's concerns. The nurse can then facilitate a dialogue that will help the parent weigh their concerns against the potential risks to the child's safety. It is true that the nurse would not discuss a client's medical condition with a school without permission, but this statement does facilitate discussion. It is also true that the child may have a diabetic reaction anywhere at school, and it is advisable that their teacher, classmates, and other adults know about their diabetes to help the client; however, it is ultimately the client and their parents who will make the decision about informing the school. Dictating to the parent does not explain any rationale for the necessity of sharing the information.

A client in the third trimester of pregnancy is experiencing painless vaginal bleeding, and placenta previa is suspected. For which intervention does the nurse prepare the client? An ultrasound examination Internal fetal monitoring Administration of oxytocin A manual (digital) pelvic examination

An ultrasound examination Rationale: A manual pelvic examination or any action that would stimulate uterine activity is contraindicated when vaginal bleeding is apparent in the third trimester until a diagnosis is made and placental previa is ruled out. Digital examination of the cervix can lead to maternal and fetal hemorrhage. A diagnosis of placental previa is made with the use of ultrasound. Electronic fetal monitoring (external) is crucial in evaluating the status of the fetus that is at risk for severe hypoxia, but internal fetal monitoring is contraindicated. Oxytocin would stimulate uterine contractions and is therefore contraindicated.

A client arrives in the emergency department reporting intense pain in the abdomen and tells the nurse that it feels like a heartbeat in the abdomen. Which nursing assessment would indicate potential rupture of an aortic aneurysm? The blood pressure and pulse are within normal limits, but the client's skin color is pale and slightly diaphoretic. The client reports feeling nauseated. The client has been taking an antihypertensive for the past 3 years but forgot to take it today. The client reports increasing severe back pain.

The client reports increasing severe back pain. Increased severe back pain and increased irritation to nerves are indicative of a potential rupture of an aneurysm. The client would be hypertensive and present with tachycardia, so the other choices are not correct. Nausea, although possible, or a missed dose of medication, do not indicate potential rupture.

A client with emphysema is receiving continuous oxygen therapy. Depressed ventilation is likely to occur unless the nurse ensures that the oxygen is administered in which way? cooled humidified at a low flow rate through a nasal cannula

at a low flow rate The client with emphysema has a chronically elevated carbon dioxide level. As a result, the normal stimulus for breathing in the medulla becomes ineffective. Instead, peripheral pressoreceptors in the aortic arch and carotid arteries, which are sensitive to oxygen blood levels, stimulate respirations. This is in response to low oxygen levels that have developed over time. If the client receives high concentrations of oxygen, the blood level of oxygen will rise excessively, the stimulus for respiration will decrease, and respiratory failure may result. Oxygen is not cooled. Humidification or administration of the oxygen through a nasal cannula will not prevent depressed ventilation if the flow rate of the oxygen is too high.

At a previous visit, the parents of an infant with cystic fibrosis received instruction in the administration of pancrelipase. At a follow-up visit, which finding in the infant suggests that the parents require more teaching about administering the pancreatic enzymes? fatty stools liquid stools bloody stools normal stools

fatty stools Pancreatic enzymes normally aid in food digestion in the intestine. In a child with cystic fibrosis, however, these natural enzymes cannot reach the intestine because mucus blocks the pancreatic duct. Without these enzymes, undigested fats and proteins produce fatty stools. If the parents were administering the pancreatic enzymes correctly, the child would have stools of normal consistency. Noncompliance doesn't cause liquid or bloody stools

A nurse is assessing a client and obtains the following findings: abdominal discomfort, mild diarrhea, and a temperature of 100°F (37.8°C). The nurse questions the client about a past diagnosis of what condition? inflammatory bowel disease (IBD) colorectal cancer diverticulitis liver failure

inflammatory bowel disease (IBD) IBD is a collective term for several GI inflammatory diseases with unknown causes. The most prominent sign of IBD is mild diarrhea, which sometimes is accompanied by fever and abdominal discomfort. Colorectal cancer is usually diagnosed after the client complains of bloody stools; the client will rarely have abdominal discomfort with colorectal cancer. A client with diverticulitis commonly reports chronic constipation with occasional diarrhea, nausea, vomiting, and abdominal distention. Jaundice, coagulopathies, edema, and hepatomegaly are common signs of liver failure.

A client diagnosed with paranoid personality disorder is hospitalized for physically threatening their spouse because they suspect the spouse is having an affair with a coworker. What approach should the nurse employ with this client? authoritarian parental matter-of-fact controlling

matter-of-fact For this client, the nurse needs to use a calm, matter-of-fact approach to create a nonthreatening and secure environment because the client is experiencing problems with suspiciousness and trust. The use of "I" statements and responses would be therapeutic to reduce the client's suspiciousness and increase their trust in the staff and the environment. An authoritarian approach is nontherapeutic and inappropriate because the client may perceive this approach as an attack, subsequently responding with anger and threatening behavior. A parental or controlling approach may be perceived as authoritarian, and the client may become defensive and angry.

The nurse creates a monitoring plan for an infant with severe diarrhea. Which assessment would be the most important for the nurse to include in the plan of care? monitoring the total 8-hour formula intake weighing the infant each day checking the anterior fontanelle every shift monitoring abdominal skin turgor every shift

weighing the infant each day high risk for a fluid volume deficiency, needs to evaluate the infant's fluid balance status by weighing the infant at least every day. BODY WEIGHT is the best indicator of HYDRATION STAUS because a higher proportion of an infant's body weight is water, compared with an adult. Initially, the infant with severe diarrhea is not allowed liquids but is given fluids intravenously. Therefore, monitoring the oral intake of formula is inappropriate. Although checking the anterior fontanelle for depression or bulging provides information about hydration status, this method is not considered the best indicator of the infant's fluid balance. Monitoring skin turgor can provide information about fluid volume status. The abdomen is commonly used to assess skin turgor in an infant because it is a large surface area and can be accessed quickly. However, weight is the best indicator of fluid balance. Add a Note

The nurse is conducting an assessment of a client with mild preeclampsia. Which sign/symptom indicates improvement in the client's condition? Complaint of headache Trace protein in the urine Blood pressure 148/94 mm Hg Blood urea nitrogen (BUN) of 40 mg/dL (14.2 mmol/L)

Trace protein in the urine Rationale: Preeclampsia is considered mild when the systolic blood pressure is 140 mm Hg or greater but less than 160 mm Hg and the diastolic blood pressure is 90 mm Hg or greater but less than 110 mm Hg, proteinuria is 1+ on a random dipstick, and signs/symptoms such as headache, visual disturbances, and abdominal pain are absent. In addition, signs of kidney or liver involvement are absent. The normal BUN range is 6-20 mg/dL (2.1-7.1 mmol/L). An increased BUN level indicates kidney damage, a result of the preeclampsia.