Client needs Pt 3
A 4-year-old child had a subungual hemorrhage of the toe after a jar fell on the foot. Which statement regarding the rationale for using electrocautery to treat the injury is most accurate? It's used to prevent loss of the nail. It's used to prevent permanent discoloration of the nail bed. It's used to relieve pain and reduce the risk of infection. It's used to prevent loss of nail growth.
It's used to relieve pain and reduce the risk of infection. Explanation: The hematoma is treated with electrocautery to relieve pain and reduce the risk of infection. Electrocautery doesn't prevent the loss of the nail. The discoloration seen with subungual hemorrhage is from the collection of blood under the nail bed. It isn't permanent and doesn't affect nail growth.
A nurse is collecting data on a client who believes she is pregnant. The nurse would suspect a hydatidiform mole based on which finding? lack of symptoms of pregnancy abnormally high hCG levels rapid fetal heart tones slow uterine growth
abnormally high hCG levels Explanation: In a client with a hydatidiform mole, the trophoblast villi proliferate and then degenerate. Proliferating trophoblast cells produce abnormally high hCG levels. No fetal heart tones are heard because there is no viable fetus. The trophoblast cells rapidly proliferate, causing the uterus to grow fast and larger than expected for a given gestational date. The greatly elevated hCG levels cause a client with a hydatidiform mole to experience marked nausea and vomiting.
When collecting data from a 6-year-old child who has a 20% deep partial-thickness (second-degree) burn of the arms and trunk, the nurse determines that the child has damage to what layer(s) of skin? epidermis epidermis and part of the dermis epidermis and all of the dermis dermis and subcutaneous tissue
epidermis and part of the dermis Explanation: A deep partial-thickness burn affects the epidermis and part of the dermis. A superficial partial-thickness (first-degree) burn affects the epidermis only. A full-thickness (third-degree) burn involves epidermis and all of the dermis, as well as nerves and blood vessels in the skin.
A health care provider tells a client to return 1 week after treatment to have a repeat culture done to verify the cure. This order would be appropriate for a woman with which condition? syphilis genital warts genital herpes gonorrhea
gonorrhea Explanation: Gonococcal infections can be completely eliminated by drug therapy. This cure is documented by a negative culture 4 to 7 days after therapy is finished. Genital warts are not curable and are identified by appearance, not culture. Genital herpes is not curable and is identified by the appearance of the lesions or by cytologic studies. The diagnosis of syphilis is done using dark-field microscopy or serologic tests
The nurse is reinforcing education with parents of a child with growth hormone deficiency. What sport should the nurse encourage? gymnastics field hockey football basketball
gymnastics Explanation: Children with growth hormone deficiency can be just as active as other children if directed to size-appropriate sports, such as gymnastics, swimming, wrestling, or soccer.
A client is admitted with hypoparathyroidism. When collecting data on the client, the nurse should expect to see which sign or symptom? exophthalmos shortness of breath chest pain hand twitching
hand twitching Explanation: Tetany, which is manifested by muscle twitching or spasms, is the chief symptom of hypoparathyroidism. Chest pain and shortness of breath aren't usually symptoms of hypoparathyroidism. Exophthalmos, or bulging eyes, is a common symptom of hyperthyroidism.
A 2-year-old child with status asthmaticus is admitted to the pediatric unit and begins to receive continuous treatment with albuterol, given by nebulizer. The nurse should observe for which adverse reaction? lethargy tachypnea bradycardia tachycardia
tachycardia Explanation: Albuterol is a rapid-acting bronchodilator. Common adverse effects include tachycardia, nervousness, tremors, insomnia, irritability, and headache.
During a breast examination, which finding most strongly suggests that the client has breast cancer? Multiple firm, round, freely movable masses that change with the menstrual cycle Slight asymmetry of the breasts Bloody discharge from the nipple A fixed nodular mass with dimpling of the overlying skin
A fixed nodular mass with dimpling of the overlying skin Explanation: A fixed nodular mass with dimpling of the overlying skin is common during late stages of breast cancer. Many women have slightly asymmetrical breasts. Bloody nipple discharge is a sign of intraductal papilloma, a benign condition. Multiple firm, round, freely movable masses that change with the menstrual cycle indicate fibrocystic breasts, a benign condition.
A 2-year-old child is admitted through the emergency department with a suspected diagnosis of Hirschsprung's disease (aganglionic megacolon). The parent asks about treatment of the disease. What would be an appropriate response from the nurse? "The child will require chemotherapy and radiation therapy in addition to surgery to treat the disease." "The child will require many reconstructive colostomy surgeries over the child's lifetime." "The child will have a permanent colostomy and can learn the required care with maturity." "Initially the child will have a temporary colostomy; later a second operation removes the abnormal part of bowel and reattaches the normal bowel down to the rectum."
"Initially the child will have a temporary colostomy; later a second operation removes the abnormal part of bowel and reattaches the normal bowel down to the rectum." Explanation: Repair of aganglionic megacolon in a child with a suspected diagnosis of Hirschsprung's disease requires dissection of the aganglionic segment and anastomosis with the unaffected intestine. It is usually done in a two-stage operation. The first surgery creates a colostomy to evacuate the bowel of stool and rest the distended portion of the bowel. The second surgery, done several months later, involves colostomy closure and a rectal "pull-through." The colostomy is not permanent. Only a two-stage operation is required. Chemotherapy and radiation therapy are not required for this condition; it is not cancer.
The nurse is caring for a client who is receiving warfarin. The nurse reinforces to the client that anticoagulant effects may not be seen for how many days? 6-8 9-11 3-5 1-2
3-5 Explanation: Anticoagulant effects do not occur for approximately 3 to 5 days after warfarin is started because clotting factors already in the blood follow their normal pathway of elimination.
The nursing instructor asks a nursing student approximately how much time is required for the blastocyst to reach the uterus for implantation. What timeframe does the student provide to the instructor? 7 days 2 days 10 days 14 weeks
7 days Explanation: A blastocyst takes approximately 7 days to travel to the uterus for implantation.
A client has an abnormal result on a Papanicolaou test. After admitting that she read her chart while the nurse was out of the room, the client asks what dysplasia means. Which definition should the nurse provide? Replacement of one type of fully differentiated cell by another in tissues where the second type normally isn't found Increase in the number of normal cells in a normal arrangement in a tissue or an organ Alteration in the size, shape, and organization of differentiated cells Presence of completely undifferentiated tumor cells that don't resemble cells of the tissues of their origin
Alteration in the size, shape, and organization of differentiated cells Explanation: Dysplasia refers to an alteration in the size, shape, and organization of differentiated cells. The presence of completely undifferentiated tumor cells that don't resemble cells of the tissues of their origin is called anaplasia. An increase in the number of normal cells in a normal arrangement in a tissue or an organ is called hyperplasia. Replacement of one type of fully differentiated cell by another in tissues where the second type normally isn't found is called metaplasia.
The nurse is caring for a client undergoing radiation therapy who is noted to have several ulcers of the mucous membranes. Which action will the nurse take as the priority? Assess for dysphagia. Collaborate with dietician for soft foods. Administer pain medication as prescribed. Document the number and characteristics of ulcers.
Assess for dysphagia. Explanation: Stomatitis is a common complication of radiation treatment that arises from destruction of the epithelial layer of tissue. The nurse must assess for dysphagia as the priority, as dysphagia can lead to aspiration, dehydration, and malnutrition. After performing this assessment, the nurse can then collaborate with the dietician to assure that soft, nonirritating foods are provided, that pain medication is given as prescribed, and that documentation takes place so that continued comparison assessments can be evaluated for progress or worsening of the condition.
A client who had a nephrectomy 2 days ago is reporting abdominal pressure and nausea. Which action should the nurse take first? Auscultate bowel sounds. Palpate the abdomen. Measure abdominal girth. Review the 24-hour urine output.
Auscultate bowel sounds. Explanation: If abdominal distention is accompanied by nausea in a client who had a nephrectomy 2 days prior, the nurse must first auscultate bowel sounds. If bowel sounds are absent, the nurse should suspect gastric or small intestine dilation, and these findings must be reported to the primary care provider. Palpation should be avoided postoperatively in cases of abdominal distention. If peristalsis is absent, measuring abdominal girth and inserting a rectal tube will not relieve the client's discomfort.
A pregnant client is suspected of experiencing worsening mitral valve prolapse. Which diagnostic test should the nurse prepare the client for? Echocardiography Chest x-ray Cardiac catheterization Stress test
Echocardiography Explanation: Echocardiography is less invasive than x-rays and other methods; it provides the information needed to determine cardiovascular disease, especially valvular disorders. Cardiac catheterization and stress tests may be postponed until after birth.
A nurse is caring for a client with L1-L2 paraplegia who is undergoing rehabilitation. Which care intervention is appropriate? Manage spasticity with range-of-motion exercises and medications. Establish an intermittent catheterization routine every 4 hours. Establish an ambulation program using short leg braces. Prevent autonomic dysreflexia by preventing bowel impactions.
Establish an intermittent catheterization routine every 4 hours. Explanation: A client with a L1-L2 paraplegia will demonstrate flaccid paralysis. Developing an intermittent catheterization routine offers a way of manually draining the bladder, eliminating the need for an indwelling urinary catheter. Spasticity and autonomic dysreflexia are seen in clients with upper motor injuries above T6. With an injury at L1-L2, ambulation may be possible with long leg braces but not with short leg braces.
The nurse is teaching a client with osteomalacia how to take prescribed vitamin D supplements. The nurse stresses the importance of taking only the prescribed amount because high doses of vitamin D can be toxic. Early signs and symptoms of vitamin D toxicity include: dry skin, hair loss, and inflamed mucous membranes. flushing and orthostatic hypotension. sensory neuropathy and difficulty maintaining balance. GI upset and metallic taste.
GI upset and metallic taste. Explanation: GI upset and metallic taste are early signs and symptoms of vitamin D toxicity. Such toxicity also may cause headache, weakness, renal insufficiency, renal calculi, hypertension, arrhythmias, muscle pain, and conjunctivitis. Dry skin, hair loss, and inflamed mucous membranes suggest vitamin A toxicity. Flushing and orthostatic hypotension (effects of vasodilation) may result from nicotinic acid and nicotinamide supplements, used to correct niacin deficiency. Sensory neuropathy and difficulty maintaining balance suggest pyridoxine toxicity.
The nurse is caring for a client recently diagnosed with gastric cancer. Which bacteria does the nurse anticipate may be present? Clostridium difficile Helicobacter pylori Lactobacillus acidophilus Bacillus anthracis
Helicobacter pylori Explanation: Viruses and bacteria are implicated in many cancers. The cell changes that a virus incorporates into the genetic information may cause cancerous cells to form. Helicobacter pylori is associated with gastric cancers, so the nurse will anticipate this bacteria may be present. Bacillus anthracis, Lactobacillus acidophilus, and Clostridium difficile are not associated with gastric cancers.
A 69-year-old client asks the nurse what the difference is between osteoarthritis (OA) and rheumatoid arthritis (RA). Which response is correct? OA and RA are very similar. OA affects the smaller joints and RA affects the larger, weight-bearing joints. OA is more common in women. RA is more common in men. OA is a noninflammatory joint disease. RA is characterized by inflamed, swollen joints. OA affects joints on both sides of the body. RA is usually unilateral.
OA is a noninflammatory joint disease. RA is characterized by inflamed, swollen joints. Explanation: OA is a degenerative arthritis, characterized by the loss of cartilage on the articular surfaces of weight-bearing joints with spur development. RA is characterized by inflammation of synovial membranes and surrounding structures. OA may occur in one hip or knee and not the other, whereas RA commonly affects the same joints bilaterally. RA is more common in women; OA affects both sexes equally.
A nurse is monitoring a client who has just returned from a cardiac catheterization. Which is an appropriate nursing intervention? Assist the client to ambulate. Assess for bowel sounds. Palpate the peripheral pulses. Remove the dressing over the puncture site.
Palpate the peripheral pulses. Explanation: Cardiac catheterizations are invasive procedures in which a catheter is threaded through an artery. Postprocedure care requires bed rest and monitoring vital signs, puncture sites, and peripheral pulses. The dressing over the puncture site should not be removed. Assessing bowel sounds is not the priority. Assist the client to ambulate is not appropriate.
A client is receiving supplemental oxygen. When determining the effectiveness of oxygen therapy, which arterial blood gas value is most important? pH Bicarbonate (HCO3-) Partial pressure of arterial oxygen (PaO2) Partial pressure of arterial carbon dioxide (PaCO2)
Partial pressure of arterial oxygen (PaO2) Explanation: The most significant and direct indicator of the effectiveness of oxygen therapy is the PaO2 value. Based on the PaO2 value, the nurse may adjust the type of oxygen delivery (cannula, Venturi mask, or mechanical ventilator), flow rate, and oxygen percentage. The other options reflect the client's ventilation status, not oxygenation.
A client who had a nephrectomy 2 days ago is reporting abdominal pressure and nausea. Which action should the nurse take first? Auscultate bowel sounds. Review the 24-hour urine output. Palpate the abdomen. Measure abdominal girth.
Prevent the infant from crying. Explanation: The stomach and intestine in the chest cavity become distended with swallowed air from crying. Negative pressure from crying pulls the intestines into the chest cavity, increasing the amount of distention. The infant usually is not fed until after surgery. Tactile stimulation is limited because it may disturb the infant's fragile condition. The infant is always placed on the affected side.
A female client who had pelvic surgery 2 weeks ago is readmitted to the facility with a warm, tender, reddened area on her right calf. Which of the following contributing factors would the nurse recognize as most important? A history of diabetes Recent pelvic surgery An active daily walking program History of increased aspirin use
Recent pelvic surgery Explanation: The client shows signs of deep vein thrombosis (DVT). The pelvic area is rich in blood supply, and thrombophlebitis of the deep veins is associated with pelvic surgery. Aspirin, an antiplatelet agent, and an active walking program help decrease the client's risk of DVT. In general, diabetes is a contributing factor associated with peripheral vascular disease.
A client has a history of schizophrenia. Because she has a history of noncompliance with antipsychotic therapy, she'll receive fluphenazine decanoate injections every 4 weeks. Before discharge, what should the nurse include in her teaching plan? Sitting up for a few minutes before standing to minimize orthostatic hypotension Notifying the physician if her thoughts don't normalize within 1 week Expecting symptoms of tardive dyskinesia to occur and to be transient Asking the physician for droperidol to control any extrapyramidal symptoms that occur
Sitting up for a few minutes before standing to minimize orthostatic hypotension Explanation: The nurse should teach the client how to manage common adverse reactions, such as orthostatic hypotension and anticholinergic effects. The antipsychotic effects of the drug may take several weeks to appear. Droperidol increases the risk of extrapyramidal effects when given in conjunction with phenothiazines such as fluphenazine. Tardive dyskinesia is a possible adverse reaction and should be reported immediately.
The nurse is providing care to a postpartum client with mastitis. As part of the client's teaching plan, the nurse is reinforcing information about the condition. Which information should the nurse emphasize? A breast abscess is a common complication of mastitis. Mastitis usually develops in both breasts of a breast-feeding client. Symptoms include fever, chills, malaise, and localized breast tenderness. The most common pathogen is group A beta-hemolytic streptococci.
Symptoms include fever, chills, malaise, and localized breast tenderness. Explanation: Mastitis is an infection of the breast characterized by flulike symptoms, along with redness and tenderness in the breast. The most common causative agent is Staphylococcus aureus. Breast abscess is rarely a complication of mastitis if the client continues to empty the affected breast. Mastitis usually occurs in one breast, not bilaterally.
The nurse is evaluating a client who had a myocardial infarction (MI) 7 days ago. Which outcome indicates that the client is responding favorably to therapy? The client states that sublingual nitroglycerin usually relieves chest pain. The client demonstrates the ability to tolerate increasing activity without chest pain. The client exhibits a heart rate above 100 beats/minute. The client verbalizes the intention of making all necessary lifestyle changes except for stopping smoking.
The client demonstrates the ability to tolerate increasing activity without chest pain. Explanation: The ability to tolerate increasing activity without chest pain indicates a favorable response to therapy in a client who is recovering from an MI or who has a history of coronary artery disease. The client should have a normal electrocardiogram with no arrhythmias and a regular heart rate of 60 to 100 beats/minute. Smoking is a cardiovascular risk factor that the client must be willing to eliminate. A client who responds favorably to therapy shouldn't have chest pain.
After a motor vehicle crash, a client has a chest tube inserted that begins to drain a large amount of dark red fluid. Which explanation best describes what caused this type of drainage from the chest tube insertion? An artery was nicked when the chest tube was inserted. The client has experienced a hemothorax instead of a pneumothorax. It is normal for the drainage to be dark red. The chest tube was inserted improperly.
The client has experienced a hemothorax instead of a pneumothorax. Explanation: Because of the traumatic cause of injury, the client has a hemothorax, in which blood collection causes the collapse of the lung. The placement of the chest tube will drain the blood from the space and re-expand the lung. There's a slight chance of nicking an intercostal artery during insertion, but it's fairly unlikely if the person placing the chest tube has been trained. The initial chest x-ray would help confirm whether there was blood in the pleural space or just air.
A client is admitted to the facility for investigation of balance and coordination problems, including possible Meniere disease. When reviewing this client's chart, the nurse expects to find which signs and symptoms? Vertigo, blurred vision, and fever Vertigo, pain, and hearing impairment Vertigo, vomiting, and nystagmus Vertigo, tinnitus, and hearing loss
Vertigo, tinnitus, and hearing loss Explanation: Meniere disease, an inner ear disease, is characterized by the symptom triad of vertigo, tinnitus, and hearing loss. The combination of vertigo, vomiting, and nystagmus suggests labyrinthitis. Meniere disease rarely causes pain, blurred vision, or fever.
A home health nurse is evaluating a client's risk of contracting herpes zoster. Which client is most at risk for developing herpes zoster? a 5-year-old client recently diagnosed with strep throat a 76-year-old client taking immunosuppressant medication a 42-year-old client with a previous myocardial infarction a 21-year-old client with a heat rash and psoriasis
a 76-year-old client taking immunosuppressant medication Explanation: Herpes zoster (shingles) is an acute inflammation caused by infection with the herpes virus varicella-zoster (chickenpox virus). It is most common in adults age 65 years and older. Others at risk include clients with decreased immunity (transplants, HIV/AIDS, immunosuppressant medications, etc.), chronic lung or kidney disease, or clients who had chickenpox at a younger age.
A client has been diagnosed with primary pulmonary tuberculosis (TB). Which condition should the nurse monitor the patient for? active TB within 2 weeks a fever requiring hospitalization active TB within 1 month a positive skin test
a positive skin test Explanation: A primary TB infection occurs when the bacillus has successfully invaded the entire body after entering through the lungs. At this point, the bacilli are walled off, and skin tests read positive. However, all but infants and immunosuppressed people will remain asymptomatic. The general population has a 10% risk of developing active TB over their lifetime, often because of a break in the body's immune defenses. The active stage shows the classic symptoms of TB: fever, hemoptysis, and night sweats.
A 5-year-old child sustained third-degree burns to the right upper extremity after tipping over a frying pan. Which skin structures would the nurse include when explaining a third-degree burn to the child's parent? epidermis only epidermis and dermis all skin layers and nerve endings skin layers, nerve endings, muscles, tendons, and bone
all skin layers and nerve endings Explanation: A third-degree burn involves all of the skin layers and the nerve endings. First-degree burns involve only the epidermis. Second-degree burns affect the epidermis and dermis. Fourth-degree burns involve all skin layers, nerve endings, muscles, tendons, and bone.
A client with pulmonary edema is receiving furosemide. To determine the effectiveness of this diuretic, what data should the nurse obtain? breath sounds neurovascular status bowel sounds heart sounds
breath sounds Explanation: Because a diuretic is prescribed to reduce pulmonary congestion, the nurse can evaluate its effectiveness by auscultating the lungs of a client with pulmonary edema, which should show clearing of adventitious breath sounds. Heart sounds are important but are not the indicator. Bowel sound auscultation is important in a client with paralytic ileus or another diuretic effectiveness for the treatment of pulmonary edema. Neurological status is not affected by pulmonary edema or furosemide therapy, so it does not need to be evaluated. Neurovascular checks evaluate cerebrovascular function, rather than respiratory function, which is the client's immediate problem.
A nurse performs cardiopulmonary resuscitation (CPR) for 1 minute on an infant without calling for assistance. In reassessing the infant after 1 minute of CPR, the nurse finds the infant still isn't breathing and has no pulse. The nurse should then: resume CPR beginning with chest compressions. declare her efforts futile. call for assistance. resume CPR beginning with breaths.
call for assistance. Explanation: After 1 minute of CPR, the nurse should call for assistance and then resume efforts. CPR shouldn't be stopped after it has been started unless the nurse is too exhausted to continue. A cycle usually ends with breaths, so the next beginning cycle after pulse check and summoning help would begin with chest compressions.
A male with heart failure is experiencing tachycardia, decreased blood pressure, and decreased peripheral pulses. The nurse interprets these symptoms as indicating which condition? distributive shock myocardial infarction (MI) cardiogenic shock anaphylactic shock
cardiogenic shock Explanation: Cardiogenic shock is related to ineffective pumping of the heart and is an acute and serious complication of heart failure. Anaphylactic shock results from an acute allergic reaction. Distributive shock results from changes in the intravascular volume distribution and is usually associated with increased cardiac output. An MI isn't a shock state but can lead to cardiogenic shock; however, an MI is usually associated with chest pain.
The ingestion of substances containing lead is mostly influenced by which risk factor? a parent with the same habit child's nationality child's gender child's age
child's age Explanation: The highest risk of lead poisoning occurs in young children who tend to put things in their mouths. In older homes that contain lead-based paint, paint chips may be eaten directly by the child, or they may cling to toys or hands that are then put into the child's mouth. Poisoning isn't gender-related. Blacks have a higher incidence of lead poisoning, but it can happen in any race. Children of low socioeconomic status are more likely to eat lead-based paint chips. Most parents don't eat lead-based paint on purpose.
When collecting data on an infant diagnosed with pyloric stenosis, which finding should the nurse anticipate? irregular heart murmur increased bowel sounds decreased bowel sounds normal respiratory effort
decreased bowel sounds Explanation: Bowel sounds decrease in an infant with pyloric stenosis because food cannot pass into the intestines. Normal respiratory effort is adversely affected due to the abdominal distention that pushes the diaphragm up into the pleural cavity. Heart murmurs may be present, but are not directly associated with pyloric stenosis.
A nurse is caring for a client who is undergoing treatment for acute alcohol dependence. The client tells the nurse, "I don't have a problem. My wife made me come here." Which defense mechanism does the nurse determine the client is using? suppression and denial denial and rationalization projection and suppression rationalization and repression
denial and rationalization Explanation: The client is using denial and rationalization. Denial is the unconscious disclaimer of unacceptable thoughts, feelings, needs, or certain external factors. Rationalization is the unconscious effort to justify intolerable feelings, behaviors, and motives. The client isn't using projection, suppression, or repression. Emotions, behavior, and motives, which are consciously intolerable, are denied and then attributed to others in projection. Suppression is a conscious effort to control and conceal unacceptable ideas and impulses into the unconscious. Repression is the unconscious placement of unacceptable feelings into the unconscious mind.
A client is suspected of having developed an acute pulmonary embolism. Which symptom would a nurse most likely observe first? distended jugular veins nonproductive cough bradycardia dyspnea
dyspnea Explanation: Dyspnea is usually the first symptom of pulmonary embolus because the thrombus prevents gas exchange in the pulmonary arterial bed. If the embolus is large enough, the client may then develop right ventricular failure with symptoms such as distended jugular veins, tachycardia, and circulatory collapse. He may also have hemoptysis.
A client exhibits signs of dementia. Which condition, that can cause a dementia similar to Alzheimer's disease (AD), is reversible? electrolyte imbalance multiple small brain infarctions human immunodeficiency virus infection (HIV) multiple sclerosis
electrolyte imbalance Explanation: Electrolyte imbalance is a correctable metabolic abnormality that may present with dementia type symptomology. Multiple sclerosis presents with neuromuscular changes, not dementia. Small brain infarctions do not present with dementia-like symptoms. HIV does not present with dementia.
A 14-year-old diagnosed with acne vulgaris asks what causes it. Which factors should the nurse identify for this client? Select all that apply: heredity chocolates and sweets growth of anaerobic bacteria fatty foods caffeine increased hormone levels
increased hormone levels growth of anaerobic bacteria heredity Explanation: Acne vulgaris is characterized by the appearance of comedones (blackheads and whiteheads). Comedones develop for various reasons, including increased hormone levels, heredity, irritation or application of irritating substances (such as cosmetics), and growth of anaerobic bacteria. A direct relationship between acne vulgaris and consumption of chocolates, caffeine, or fatty foods hasn't been established.
A 13-year-old has received third--degree burns over 20% of the body. When observing this client 72 hours after the burn, which finding should the nurse expect? respiratory distress absent bowel sounds severe peripheral edema increased urine output
increased urine output Explanation: During the resuscitative-emergent phase of a burn, fluids shift back into the interstitial space, resulting in the onset of diuresis. Edema resolves during the emergent phase, when fluid shifts back to the intravascular space. Respiratory rate increases during the first few hours as a result of edema. When edema resolves, respirations return to normal. Absent bowel sounds occur in the initial stage.
The nurse is caring for a toddler with right lower lobe pneumonia. In order to improve gas exchange, which position should the child be placed in? supine left side-lying prone right side-lying
left side-lying Explanation: The child with right lower lobe pneumonia should be placed on the left side. This places the unaffected left lung in a position that allows gravity to promote blood flow though the healthy lung tissue and improve gas exchange. Placing the child on the right side, back, or stomach does not promote circulation to the unaffected lung.
The nurse is caring for a client with severe diarrhea. The nurse recognizes that the client is at risk for developing which of the following acid-base imbalances? respiratory alkalosis metabolic alkalosis metabolic acidosis respiratory acidosis
metabolic acidosis Explanation: The client is at risk for developing metabolic acidosis. Metabolic acidosis is caused by diarrhea, lower intestinal fistulas, ureterostomies, and use of diuretics; early renal insufficiency; excessive administration of chloride; and the administration of parenteral nutrition without bicarbonate or bicarbonate-producing solutes (e.g., lactate).
A client at the eye clinic is newly diagnosed with glaucoma. What should the nurse inform the client might occur if administration of the medication is not closely adhered to? permanent vision loss diplopia loss of central vision pupillary constriction
permanent vision loss Explanation: Without proper treatment, glaucoma may progress to irreversible blindness. Treatment won't restore visual damage but will halt disease progression. Miotics, which constrict the pupil, are used in the treatment of glaucoma to permit outflow of the aqueous humor. Loss of peripheral vision and blurred or foggy vision (not diplopia) are typical in glaucoma. Loss of central vision is common in clients with macular degeneration.
A nurse is caring for a client who received 1 unit of fresh frozen platelets (FFP) for a platelet count of 20,000 mm3. Which repeat laboratory values will be of greatest concern to the nurse? white blood cell count 4.8 µL blood urea nitrogen 20 mg/dL red blood cell count 5.2 µL platelet count 22,000 mm3
platelet count 22,000 mm3 Explanation: Platelet transfusions are given when the platelet count falls below 20,000 mm3. One unit is expected to raise the count by 5000 to 10,000 mm3. The count was only raised by 2000 mm3. All other laboratory values are within normal range.
A client gives birth to a neonate prematurely, at 28 weeks' gestation. To obtain the neonate's Apgar score, the nurse assesses the neonate's: temperature. blood pressure. weight. respiration.
respiration. Explanation: The Apgar score is determined by the neonate's heart rate, respiration, muscle tone, reflex irritability, and color. Temperature, blood pressure, and weight don't affect the Apgar score.
Considering a client's atrial fibrillation, the nurse must administer digoxin with caution because it: can induce hypertensive crisis by constricting arteries. affects the sympathetic division of the autonomic nervous system, decreasing vagal tone. can trigger proarrhythmia by increasing stroke volume. stimulates the parasympathetic division of the autonomic nervous system, increasing vagal tone.
stimulates the parasympathetic division of the autonomic nervous system, increasing vagal tone. Explanation: The nurse must administer digoxin with caution in a client with atrial fibrillation because digoxin stimulates the parasympathetic division of the autonomic nervous system, increasing vagal tone. The vagal effect slows the heart rate, increases the refractory period, and slows conduction through the atrioventricular node and junctional tissue, thus increasing the potential for new arrhythmias to develop. Digoxin doesn't constrict arteries. Although it can trigger proarrhythmias, it does so by increasing vagal tone (not stroke volume).
