Comp 5

A client develops a facial rash and urticaria after receiving penicillin. Which laboratory value does the nurse expect to be elevated? IgA IgB IgE IgG

IgE Explanation: Immunoglobulin E (IgE) is involved with an allergic reaction. IgA combines with antigens and activates the complement system. IgB coats the surface of B lymphocytes. IgG is the principal immunoglobulin formed in response to most infectious agents.

Multiple Sclerosis (MS)

Multiple sclerosis affects the central nervous system, and as a result over time it can affect the patient's vision, speech, minor motor skills, and memory. The condition causes the myelin sheath of the nerves to wear away, thus causing a slowing of the nerve signals and eventual damage to the nerves themselves. The disease is classified as a chronic autoimmune one and affects women more than men. Diagnosis is most common between the ages of 20 and 50. birth defect; symptoms vary and come and go; becomes progressively worse over time

pentoxifylline

Pentoxifylline is a prescription drug used to improve the symptoms of a certain blood flow problem in the legs/arms (intermittent claudication due to occlusive artery disease). Pentoxifylline can decrease the muscle aching/pain/cramps during exercise, including walking, that occur with intermittent claudication.

A client who is 16 weeks pregnant has an elevated alpha-fetoprotein (AFP) level. The nurse understands that the physician is likely to refer this client to: a nutritionist. a perinatologist. a nurse-midwife. an endocrinologist.

a perinatologist. Explanation: An elevated AFP level may indicate a fetal congenital abnormality. The physician will likely refer the client to a perinatologist, who cares for clients with high-risk pregnancies. A nutritionist provides guidance about a healthy diet. A nurse-midwife follows low-risk pregnancy cases. An endocrinologist deals with metabolic disorders. Referrals to these providers aren't necessary at this time.

asphyxia

deprivation of oxygen for tissue use; suffocation

tinea corporis

ringworm

The nurse is administering adenosine to a client with supraventricular tachycardia. What is the expected therapeutic response? A short period of asystole A brief episode of ventricular tachycardia An increase in blood pressure Brief feeling of numbness and tingling of extremities

A short period of asystole Explanation: The expected response to this medication is a short period of asystole, bradycardia, hypotension, dyspnea, and chest pain followed by a return to normal sinus rhythm. It is used to convert dysrhythmias to normal sinus rhythm and should not cause ventricular tachycardia. Numbness and tingling of extremities is not an expected side effect.

Which finding in a client who is receiving albuterol would require a nurse to take immediate action? Stridor Crackles Wheezes Pleural rub

Stridor Explanation: Stridor indicates partial airway obstruction, and requires immediate intervention. A pleural rub, crackles, and wheezes should be further assessed.

Nurses who provide care in a large, long-term care facility use charting by exception (CBE) as the preferred method of documentation. This documentation method may have which of the following drawbacks? Vulnerability to legal liability because the nurse's safe, routine care is not recorded. Increased workload for nurses to complete necessary documentation. Failure to identify and record problems and associated interventions. Significant differences in charting among nurses from lack of standardization.

Vulnerability to legal liability because the nurse's safe, routine care is not recorded. Explanation: A significant drawback to charting by exception is its limited usefulness when trying to prove high-quality and safe care in response to a negligence claim made against nursing. CBE is generally less time-consuming than alternate methods of documentation, and both standardization of charting and identification of client-specific problems are possible within this documentation framework.

catatonic schizophrenia

serious neurological or psychological condition in which two kinds of behaviors are typically displayed: stupor and motor rigidity or excitement. When people experience rigidity or stupor, they are unable to speak, respond or even move.

A physician orders chlorzoxazone, 500 mg P.O. t.i.d for a client. The nurse knows that chlorzoxazone, a centrally acting skeletal muscle relaxant, is commonly used to treat: muscle spasm caused by cerebral palsy. chronic musculoskeletal disorder. lower extremity spasticity. severe muscle spasm.

severe muscle spasm. Explanation: Chlorzoxazone is used to treat acute, painful musculoskeletal conditions or severe muscle spasm. Centrally acting skeletal muscle relaxants such as chlorzoxazone are ineffective in treating spasticity associated with chronic neurologic disease, such as cerebral palsy, and they treat acute musculoskeletal disorders, not chronic ones. Chlorzoxazone and the other relaxants are used to treat spasticity of any extremity, not just lower extremity spasiticity.

During the assessment stage, a client with schizophrenia leaves his arm in the air after the nurse has taken his blood pressure. His action shows evidence of: somatic delusions. waxy flexibility. neologisms. nihilistic delusions.

waxy flexibility. Explanation: Waxy flexibility is defined as retaining any position that the body has been placed in. Somatic delusions involve a false belief about the functioning of the body. Neologisms are invented meaningless words. Nihilistic delusions are false ideas about self, others, or the world.

Pyelenephritis

inflammation of the kidney

pruritis

itching

A client is treated in the emergency department for acute muscle strain in the left leg caused by trying a new exercise. During discharge preparation, the nurse should provide which instruction? "Apply ice packs for the first 12 to 18 hours." "Apply heat packs for the first 24 to 48 hours." "Apply ice packs for the first 24 to 48 hours, then apply heat packs." "Apply heat packs for the first 24 hours, then apply ice packs for the next 48 hours."

"Apply ice packs for the first 24 to 48 hours, then apply heat packs." Explanation: The nurse should instruct the client to apply ice packs to the injured area for the first 24 to 48 hours to reduce swelling and then apply heat to increase comfort, promote reabsorption of blood and fluid, and speed healing. Applying ice for only 12 to 18 hours may not keep swelling from recurring. Applying heat for the first 24 to 48 hours would worsen, not ease, swelling. Applying ice 48 hours after the injury would be less effective because swelling already has occurred by that time.

Which of the following questions is most important for a nurse to ask when taking a history from a client diagnosed with tinea corporis?

"Do you have any pets?"

A client with class II cardiac disease in active labor is planning on epidural anesthesia for labor and birth. After the anesthesiologist has explained the procedure and potential complications, the nurse determines that the client needs further instructions when she says: "Sometimes the labor process is slower after the epidural anesthesia is administered." "If my bladder gets full, I may need to be catheterized." "I may not feel the urge to push with this type of anesthesia." "I may need to lie flat for 6 hours and drink plenty of fluids after I give birth."

"I may need to lie flat for 6 hours and drink plenty of fluids after I give birth." Explanation: Lying flat and drinking fluids are interventions for client's experiencing headaches from spinal anesthesia. Such adverse effects do not occur with epidural anesthesia. Anesthesia and analgesia can slow the process of labor. Epidural anesthesia is associated with a decreased urge to void; therefore, catheterization of a full bladder may be necessary. Because the client is anesthetized, the client may not feel the urge to push so bearing-down efforts during the second stage of labor may be less effective.

Which of the following statements indicates that a client understands the need for routine screening to detect colorectal cancer? "I need to have an annual digital examination after age 40." "I need to have a carcinoembryonic antigen (CEA) test after age 50." "I need to have a proctosigmoidoscopy after age 30." "I need to have a barium enema after age 20."

"I need to have an annual digital examination after age 40." Explanation: The American Cancer Society (Canadian Cancer Society and Health Canada) recommends an annual digital examination after age 40 for the purpose of detecting colorectal cancer. The CEA test is performed on clients who have already been treated for colorectal cancer. It helps monitor a client's response to treatment as well as detect metastasis or recurrence. Proctosigmoidoscopy is recommended every 3 to 5 years for people older than age 50. A barium enema is not a screening test.

In preparation for discharge, the nurse teaches the mother of an infant diagnosed with bronchiolitis about the condition and its treatment. Which statement by the mother indicates successful teaching? "I need to be sure to take my child's temperature every day." "I hope I do not get a cold from my child." "Next time my child gets a cold I need to listen to the chest." "I need to wash my hands more often."

"I need to wash my hands more often." Explanation: Handwashing is the best way to prevent respiratory illnesses and the spread of disease. Bronchiolitis, a viral infection primarily affecting the bronchioles, causes swelling and mucus accumulation of the lumina and subsequent hyperinflation of the lung with air trapping. It is transmitted primarily by direct contact with respiratory secretions as a result of eye-to-hand or nose-to-hand contact or from contaminated fomites. Therefore, handwashing minimizes the risk for transmission. Taking the child's temperature is not appropriate in most cases. As long as the child is getting better, taking the temperature will not be helpful. The mother's statement that she hopes she does not get a cold from her child does not indicate understanding of what to do after discharge. For most parents, listening to the child's chest would not be helpful because the parents would not know what they were listening for. Rather, watching for an increased respiratory rate, fever, or evidence of poor eating or drinking would be more helpful in alerting the parent to potential illness.

After instructing a primiparous client who is breastfeeding on how to prevent nipple soreness during feedings, the nurse determines that the client needs further instruction when she makes which statement? "I should position the baby the same way for each feeding." "I should make sure the baby grasps the entire areola and nipple." "I should air dry my breasts and nipples for 10 to 15 minutes after the feeding." "I should not use a hand breast pump if my nipples get sore."

"I should position the baby the same way for each feeding." Explanation: The mother needs further instruction when she says, "I should position the baby the same way for each feeding." This can contribute to sore nipples. The position should vary for each feeding to prevent repeated pressure on the same area each time. Grasping the entire areola and nipple will help to decrease nipple soreness. Air drying the breasts and not using a hand pump will help to decrease nipple soreness.

he nurse is preparing a client for a cardiac catheterization. Which client statements would the nurse need to report to the health care provider immediately? "I am allergic to penicillin and midazolam." "I have not been able to eat since yesterday." "I took my metformin this morning." "I am very claustrophobic in small spaces."

"I took my metformin this morning." Explanation: The priority would be to notify the health care provider of the metformin because it cannot be taken 48 hours before or after contrast, as there is an increased risk of lactic acidosis and acute renal failure with iodinated contrast material. It would be appropriate for the client to take nothing by mouth. It is important to determine the client's allergies; however, it is not the priority. Claustrophobia would not be an issue during a cardiac catheterization.

Which statement, made by a client with a hiatal hernia, indicates that the client understands the treatment plan? "I will sit in a chair for several hours after I eat." "I will lie down for 15 minutes after I eat." "I will lie on my left side at night to decrease reflux." "I will need to have my INR/PT every two weeks."

"I will sit in a chair for several hours after I eat." Explanation: Clients with hiatal hernias should sit upright for several hours after eating to prevent gastric reflux. The other options will not help to decrease reflux with hiatal hernia.

A physician has referred a client newly diagnosed with diabetes mellitus to the diabetes nurse-educator. When the nurse brings up the subject, the client states, "I'd rather work with you than with a stranger." What is the nurse's best response? "A diabetes nurse-educator has much more knowledge than I do." "You don't have to worry. Our nurse-educator is really good with clients newly diagnosed with diabetes." "I'll set up a meeting for today. Then you and I can meet to talk about how things went." "Most clients feel this way at first, but you'll soon get over it."

"I'll set up a meeting for today. Then you and I can meet to talk about how things went." Explanation: The client may feel overwhelmed and anxious about his diagnosis. He's made a therapeutic connection with the nurse at a vulnerable time in his life when he must address many new issues. Offering to follow up with the client encourages him to move forward and gives him an opportunity to meet with a safe and trusted person afterward. Telling the client that the nurse-educator is more knowledgeable about the subject doesn't help address the client's feelings. Telling the client not to worry or that he'll get over his feelings minimizes the client's feelings and may impair the nurse-client relationship.

Two toddlers are arguing over a toy in the playroom. The nurse should say to the children: "If you cannot play together, I will have to put you back in your rooms." "Give the toy to me. Now neither of you will have it." "Let me see if I can get both of you a similar toy." "Let one of you play with it for awhile, then give it to the other."

"Let me see if I can get both of you a similar toy." Explanation: A toddler has not developed the concept of sharing, so two similar toys must be provided to prevent disagreements. Playing together in harmony is not the developmental level of a toddler. They play side by side, but not together. Threatening to put the children in their rooms does not solve the problem, nor does taking away the toy.

At 28 weeks' gestation, a client is admitted in preterm labor. An I.V. infusion of magnesium sulfate is started. Which client outcome reflects the nurse's awareness of an adverse effect of magnesium sulfate? "The client remains free from tachycardia." "The client remains free from polyuria." "The client remains free from hypertension." "The client remains free from hyporeflexia."

"The client remains free from hyporeflexia." Explanation: Terbutaline and other beta-adrenergic agonists may cause tachycardia, hypotension, bronchial dilation, increased plasma volume, increased cardiac output, arrhythmias, myocardial ischemia, reduced urine output, restlessness, headache, nausea, and vomiting. These drugs are not associated with polyuria, hypertension, or hyporeflexia.

The parent of a preschool-age child tells the nurse that the child is hyperactive and something needs to be done. Which response by the nurse would be most appropriate initially? "What makes you think your child is hyperactive?" "What do you think needs to be done?" "How does your child behave normally?" "Does the preschool teacher think your child is hyperactive?"

"What makes you think your child is hyperactive?" Explanation: The best approach by the nurse is to determine why the parent thinks the child is hyperactive. Some children are very active but do not have the necessary defining characteristics of hyperactivity. Asking what the parent thinks needs to be done, how the child behaves normally, and if the preschool teacher thinks the child is hyperactive would be an appropriate follow-up question once more information is gathered from the parent to determine whether the child indeed is hyperactive.

The nurse is preparing to administer a 75% strength tube-feeding formula. The full-strength formula is available. To prepare 500 ml of feeding, the nurse would plan to dilute how many milliliters of the full-strength formula with water? Record your answer as a whole number.

375 Explanation: To determine the amount of formula to use, multiply the 500 ml of full-strength formula by 75% (0.75): 500 ml X 0.75 = 375 ml.

Fomite

A physical object that serves to transmit an infectious agent from person to person.

A physician orders a single dose of trimethoprim/sulfamethoxazole by mouth for a client diagnosed with an uncomplicated urinary tract infection. The pharmacy sends three unit-dose tablets. The nurse verifies the physician's order. What should the nurse do next? Administer the three tablets as the single dose. Call the physician to verify the order. Give one tablet, three times per day. Call the hospital pharmacist and question the medication supplied.

Call the hospital pharmacist and question the medication supplied. Explanation: The nurse should call the hospital pharmacy and question the medication supplied. The hospital pharmacist should be able to tell the nurse whether three tablets are necessary for the single dose or whether a dispensing error occurred. It isn't clear whether the three tablets are the single dose because they were packaged as a unit-dose. The physician's order was clearly written, so clarifying the order with the physician isn't necessary. Administering the tablets without clarification might cause a medication error.

A 20-year-old nulligravid client expresses a desire to learn more about the symptothermal method of family planning. Which information would the nurse include in the teaching plan? This method has a 50% failure rate during the first year of use. Couples must abstain from coitus for 5 days after the menses. Cervical mucus is carefully monitored for changes. The male partner uses condoms for significant effectiveness.

Cervical mucus is carefully monitored for changes. Explanation: The symptothermal method is a natural method of fertility management that depends on knowing when ovulation has occurred. Because regular menstrual cycles can vary by 1 to 2 days in either direction, the symptothermal method requires daily basal body temperature assessments plus close monitoring of cervical mucus changes. The method relies on abstinence during the period of ovulation, which occurs approximately 14 days before the beginning of the next cycle. Abstinence from coitus for 5 days after menses is unnecessary because it is unlikely that ovulation will occur during this time period (days 1 through 10). Typically, the failure rate for this method is between 10% and 20%. Although a condom may increase the effectiveness of this method, most clients who choose natural methods are not interested in chemical or barrier types of family planning.

Which information would the nurse include in the teaching plan for a 32-year-old female client requesting information about using a diaphragm for family planning? Douching with an acidic solution after intercourse is recommended. Diaphragms should not be used if the client develops acute cervicitis. The diaphragm should be washed in a weak solution of bleach and water. The diaphragm should be left in place for 2 hours after intercourse.

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

Which of the responsibilities related to the care of a client with a Foley catheter are appropriate for the nurse to delegate to the unlicensed assistive personnel (UAP)? Select all that apply. Flush the catheter as needed to ensure patency. Empty drainage bag, and record output at specified times. Apply catheter-securing device to the client's leg. Perform bladder irrigation as prescribed. Provide Foley catheter and perineal care each shift. Ensure the urine drainage bag is below the level of the bladder at all times.

Empty drainage bag, and record output at specified times. Apply catheter-securing device to the client's leg. Provide Foley catheter and perineal care each shift. Ensure the urine drainage bag is below the level of the bladder at all times.

Hegar's sign

Hegar sign is a non-sensitive indication of pregnancy in women — its absence does not exclude pregnancy. It pertains to the features of the cervix and the uterine isthmus. It is demonstrated as a softening in the consistency of the uterus, and the uterus and cervix seem to be two separate regions; probable sign

A 7-year-old with a history of tonic-clonic seizures has been actively seizing for 10 minutes. The child weighs 22 kg and currently has an IV of D5 NS + 20 mEq KCl/L running at 60 mL/h. The vital signs are temperature 100.4°F (38°C), heart rate 120 bpm, respiratory rate 28 breaths/min, and oxygen saturation 92%. Using the SBAR (situation-background-assessment-recommendation) technique for communication, the nurse calls the health care provider (HCP) with the recommendation for which medication? rectal diazepam. IV lorazepam. rectal acetaminophen. IV fosphenytoin.

IV lorazepam. Explanation: IV lorazepam is the benzodiazepine of choice for treating prolonged seizure activity. IV benzodiazepines act to potentiate the action of the gamma-aminobutyric acid (GABA) neurotransmitter; stopping seizure activity. If an IV is not available, rectal diazepam is the benzodiazepine of choice. The child does have a low-grade fever; however, this is likely caused by the excessive motor activity. The primary goal for the child is to stop the seizure in order to reduce neurologic damage. Benzodiazepines are used for the initial treatment of prolonged seizures. Once the seizure has ended, a loading dose of fosphenytoin is given.

A client is diagnosed with dependent personality disorder. Which behavior is most likely to be evidence of Ineffective coping? Inability to make choices and decisions without advice Showing interest only in solitary activities Avoiding developing relationships Recurrent self-destructive behavior with history of depression

Inability to make choices and decisions without advice Explanation: Individuals with dependent personality disorder typically show indecisiveness, submissiveness, and clinging behaviors so that others will make decisions for them. These clients feel helpless and uncomfortable when alone and don't show interest in solitary activities. They also pursue relationships in order to have someone to take care of them. Although clients with dependent personality disorder may become depressed and suicidal if their needs aren't met, these aren't typical responses.

A 3-year-old is seen in the well child clinic. The mother is concerned that the child may be autistic. Which of the following assessment data would indicate a concern to the nurse? Select all that apply. Inability to separate from mother Inability to stay on task Lack of communication abilities Withdrawing into a private world Inability to develop social skills

Lack of communication abilities Withdrawing into a private world Inability to develop social skills Explanation: Children with autism spectrum disorder (ASD) fail to develop interpersonal skills. The child with ASD withdraws into a private world and is not able to develop social skills and communication abilities. Inability to separate is a behavior found in children with separation anxiety. Inattention is associated with children who are diagnosed with Attention Deficit Disorder (ADD).

A nurse is assigned to a client with catatonic schizophrenia. Which intervention should the nurse include in this client's care plan? Meeting all of the client's physical needs Giving the client an opportunity to express concerns Administering lithium carbonate as ordered Providing a quiet environment in which the client can be alone

Meeting all of the client's physical needs Explanation: Because a client with catatonic schizophrenia can't meet his physical needs independently, the nurse must provide for all of these needs, including adequate food and fluid intake, exercise, and elimination. Although this client is incapable of expressing concerns, the nurse should try to verbalize the message his nonverbal behavior conveys. Lithium is used to treat mania, not catatonic schizophrenia. Despite the client's mute, unresponsive state, the nurse should provide nonthreatening stimulation and should spend time with him, not leave him alone all the time. Although aware of the environment, the client doesn't actively interact with it; the nurse's support and presence can be reassuring.

Quickening

Movements of the fetus that can be felt by the mother

The chart entry for a client with a fungal infection in the maxillary sinus reads: Progress notes 10/15/16 1530 Client reports increased nasal discharge, a productive cough with green discharge, and increasing facial pain 60 minutes after pain medication was given. Recent vital signs: Temperature 98.2° F (37° C), Pulse 120, and Respirations 26. What is the priority nursing action? Assess for any type of vision changes Limit the intake of oral fluids Instruct the client to mouth breathe Obtain a sputum sample

Obtain a sputum sample Explanation: The nurse should obtain a sputum sample and document the color and consistency of the discharge. The provider would indicate if the sputum needs to go to the lab for analysis. Vision changes are uncommon with fungal infections of the maxillary sinus. Oral fluids do not need to be limited. The nurse needs to monitor fluid intake and the client's state of hydration. The nurse would not encourage the client to mouth breath.

The nurse is caring for a client who is 12 weeks pregnant and speaks Spanish only. Which interventions should the nurse include in the plan of care at the client's initial visit? Select all that apply. Provide brochures in the client's native language. Refer the client to a high-risk clinic. Discuss cultural differences and emphasize the differences between cultures. Arrange for an interpreter for her appointments. Discuss contraception and options. Review dietary intake and discuss nutrition.

Provide brochures in the client's native language. Arrange for an interpreter for her appointments. Review dietary intake and discuss nutrition. Explanation: Providing culturally sensitive care includes providing printed material in the client's native language. There is nothing to indicate that this client is a high-risk pregnancy. Discussing cultural differences is not a priority or important at the first visit. Clients need to have an interpreter for each prenatal visit to translate and interpret questions. Contraceptive options are not a priority for the first prenatal visit. Reviewing dietary intake and discussing nutrition are an important component of early prenatal care.

A nurse is caring for another nurse's clients while that nurse is on break. While making rounds of the other nurse's clients, the nurse found medications left at a client's bedside stand. How should the nurse best address this problem?

Speak to the coworker when she returns to the unit.

A client with end-stage chronic obstructive pulmonary disease (COPD) requires bi-level positive airway pressure (BiPAP). While caring for the client, the nurse determines that bilateral wrist restraints are required to prevent compromised care. Which client care outcome is best associated with restraint use in the client who requires BiPAP? The client will remain safe. The client will maintain adequate oxygenation. The client will understand the rationale for restraints. The client, in collaboration with the health care team, will begin discharge planning.

The client will maintain adequate oxygenation. Explanation: BiPAP is a type of continuous positive airway pressure in which both inspiratory and expiratory pressures are set above atmospheric pressure. This type of ventilatory support assists clients with COPD who retain PaCO2. Restraints are necessary in this client to maintain BiPAP therapy if the client attempts to dislodge the mask despite instruction not to do so. Maintaining oxygenation is the expected outcome in this client. Remaining safe, understanding the rationale for restraints, and collaborating with the health care team to begin discharge planning are important, but not the best outcome with relation to BiPap.

The nurse notices that a client with Parkinson's disease is coughing frequently when eating. Which intervention should the nurse consider? Have the client hyperextend the neck when swallowing. Tell the client to place the chin firmly against the chest when eating. Thicken all liquids before offering to the client. Place the client on a clear liquid diet.

Thicken all liquids before offering to the client. Explanation: Clients with Parkinson's disease can experience dysphagia. Thickening liquids assists with swallowing, preventing aspiration. Hyperextending the neck opens the airway and can increase risk of aspiration. Pressing the chin firmly on the chest makes swallowing more difficult. The chin should be slightly tucked to promote swallowing. The nurse should suggest a speech therapy consult for evaluation of the client's ability to swallow.

A client is scheduled for a cardiac catheterization. The nurse should do which preprocedure tasks? Select all that apply. Verify the client has stopped taking anticoagulants if instructed by the health care provider. Check for iodine sensitivity. Verify that written consent has been obtained. Withhold food and oral fluids before the procedure. Insert a urinary drainage catheter.

Verify the client has stopped taking anticoagulants if instructed by the health care provider. Check for iodine sensitivity. Verify that written consent has been obtained. Withhold food and oral fluids before the procedure. Explanation: For clients scheduled for a cardiac catheterization, it is important to assess for iodine sensitivity, verify written consent<glicon>, and instruct the client to take nothing by mouth for 6 to 18 hours before the procedure. If the client is taking anticoagulant drugs, the nurse should ask the client if the health care provider has given instructions to withhold these medications. Oral medications are withheld unless specifically prescribed. A urinary drainage catheter is rarely required for this procedure.

Ballottement

a sharp upward pushing against the uterine wall with a finger inserted into the vagina for diagnosing pregnancy by feeling the return impact of the displaced fetus

A client receiving haloperidol reports a stiff jaw and difficulty swallowing. The nurse's first action should be to: reassure the client and administer as-needed lorazepam I.M. administer an as-needed dose of benztropine I.M. as ordered. administer an as-needed dose of benztropine as ordered. administer an as-needed dose of haloperidol.

administer an as-needed dose of benztropine I.M. as ordered. Explanation: The client is most likely suffering from muscle rigidity caused by haloperidol. I.M. benztropine should be administered to prevent asphyxia or aspiration. Lorazepam treats anxiety, not extrapyramidal effects. Another dose of haloperidol would intensify the severity of the client's reaction.

Which intervention is the highest priority for the therapeutic management of a child with congestive heart failure (CHF) resulting from pulmonary stenosis? educating the family about the signs and symptoms of CHF administering enoxparin to improve left ventricular contractility assessing heart rate and blood pressure every 2 hours administering furosemide to decrease systemic venous congestion

administering furosemide to decrease systemic venous congestion Explanation: Pulmonary stenosis can cause right-sided CHF, resulting in venous congestion. Removing accumulated fluid is a primary goal of treatment in right-sided CHF. Furosemide is used to reduce venous congestion. It is important to educate the family about signs and symptoms of CHF, but treating the client's CHF is the priority. Enoxaparin is an anticoagulant and will not help improve left ventricular contractility. It is important to assess vital signs frequently in the child with CHF, but assessments do not treat the problem.

A nurse is caring for a client diagnosed with acute renal failure. The nurse notes on the intake and output record that the total urine output for the previous 24 hours was 35 ml. Urine output that's less than 50 ml in 24 hours is known as: oliguria. polyuria. anuria. hematuria.

anuria. Explanation: Urine output less than 50 ml in 24 hours is called anuria. Urine output of less than 400 ml in 24 hours is called oliguria. Polyuria is excessive urination. Hematuria is the presence of blood in the urine.

APGAR score components

appearance, pulse, grimace, activity, respiration *Look more into this!

An adult with type 2 diabetes mellitus has been NPO since 2200 in preparation for having a nephrectomy the next day. At 0600 on the day of surgery, the nurse reviews the client's medical record and laboratory results. Which finding should the nurse report to the health care provider (HCP)? urine output of 350 mL in 8 hours. urine specific gravity of 1.015 potassium of 4.0 mEq (4.0 mmol/L) blood glucose of 140 mg/dL (7.8 mmol/L)

blood glucose of 140 mg/dL (7.8 mmol/L) Explanation: The client's blood glucose level is elevated, beyond levels accepted for fasting; normal blood glucose range is 70 to 120 mg/dL (3.9 to 6.7 mmol/L). The specific gravity is within normal range (1.001 to 1.030). Urine output should be 30 to 50 mL/h; thus, 350 mL is a normal urinary output over 8 hours. The potassium level is normal.

A client is undergoing a complete physical examination as a requirement for college. When checking the client's respiratory status, the nurse observes respiratory excursion to help assess: lung vibrations. vocal sounds. breath sounds. chest movements.

chest movements. Explanation: The nurse observes respiratory excursion to help assess chest movements. Normally, thoracic expansion is symmetrical; unequal expansion may indicate pleural effusion, atelectasis, pulmonary embolus, or a rib or sternum fracture. The nurse assesses vocal sounds to evaluate air flow when checking for tactile fremitus; after asking the client to say the word "ninety-nine" the nurse palpates the vibrations transmitted from the bronchopulmonary system along the solid surfaces of the chest wall to the nurse's palms. The nurse assesses breath sounds during auscultation.

Which is characteristic of cardiogenic shock? hypovolemia increased cardiac output decreased myocardial contractility infarction

decreased myocardial contractility Explanation: Cardiogenic shock occurs when myocardial contractility decreases and cardiac output greatly decreases. The circulating blood volume is within normal limits or increased. Infarction is not always the cause of cardiogenic shock.

The nurse is admitting a 4-year old with a possible meningococcal infection. Which type of isolation is indicated?

droplet precautions

Which lifestyle modification should the nurse encourage the client with a hiatal hernia to include in activities of daily living? engaging in daily aerobic exercise eliminating smoking and alcohol use balancing activity and rest avoiding high-stress situations

eliminating smoking and alcohol use Explanation: Smoking and alcohol use both reduce esophageal sphincter tone and can result in reflux. They therefore should be avoided by clients with hiatal hernia. Daily aerobic exercise, balancing activity and rest, and avoiding high-stress situations may increase the client's general health and well-being, but they are not directly associated with hiatal hernia.

The nurse is instructing a college student with Addison's disease how to adjust the dose of glucocorticoids. The nurse should explain that the client may need an increased dosage of glucocorticoids in which situation? completing course work gaining 4 lb (1.8 kg) becoming engaged having wisdom teeth extracted

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

The nurse administers mannitol to the client with increased intracranial pressure. Which parameter requires close monitoring? muscle relaxation intake and output widening of the pulse pressure pupil dilation

intake and output Explanation: After administering mannitol, the nurse closely monitors intake and output because mannitol promotes diuresis and is given primarily to pull water from the extracellular fluid of the edematous brain. Mannitol can cause hypokalemia and may lead to muscle contractions, not muscle relaxation. Signs and symptoms, such as widening pulse pressure and pupil dilation, should not occur because mannitol serves to decrease ICP.

A multiparous client thought to be at 14 weeks' gestation based on uterine size has such severe morning sickness that she has "not been able to keep anything down for a week." The nurse should review the results of the urinalysis for: white blood cells. albumin. glucose. ketones.

ketones. Explanation: When a client is not able to eat, the intake of carbohydrates is dramatically reduced, causing fat to be burned for energy. Improper fat metabolism results in ketones in the urine from the starvation this client is experiencing. Presence of white blood cells in the urine would suggest a possible urinary tract infection. Albumin in the urine is associated with kidney or heart disease. Glucose in the urine is associated with diabetes mellitus.

A nurse is teaching the mother of an ill child about childhood immunizations. The nurse should tell the mother that live virus vaccines are contraindicated in children with: diabetes mellitus. leukemia. asthma. cystic fibrosis.

leukemia explanation: The nurse should tell the mother that live virus vaccines shouldn't be administered to children with leukemia because they cause immunosuppression. Inactivated — rather than live — viruses should be administered. Children with diabetes mellitus, asthma, or cystic fibrosis can receive live virus vaccines because they aren't immunosuppressed.

A multigravid client at 32 weeks' gestation has experienced hemolytic disease of the newborn in a previous pregnancy. The nurse should prepare the client for frequent antibody titer evaluations obtained from which source? placental blood amniotic fluid fetal blood maternal blood

maternal blood Explanation: For the Rh-negative client who may be pregnant with an Rh-positive fetus, an indirect Coombs test measures antibodies in the maternal blood. Titers should be performed monthly during the first and second trimesters and biweekly during the third trimester and the week before the due date.

Alert and Oriented x3

person, place, time

Alert and oriented x 4

person, place, time, situation

A client receiving chemotherapy has pruritus. Which shouldn't client do? wearing clothes made from 100% cotton sleeping in a cool, humidified room increasing fluid intake to at least 3,000 mL per day taking daily baths with a deodorant soap

taking daily baths with a deodorant soap Explanation: Use of deodorant or fragrant soaps is drying to the skin. Cotton clothing gives the least irritation to skin. A cool, humidified environment adds to the client's comfort as well as providing hydration for skin comfort. Fluid intake of 3,000 mL/day is recommended for adequate hydration.

laminectomy

the surgical removal of a lamina, or posterior portion, of a vertebra

A diabetic primigravid client at 38 weeks' gestation asks the nurse why she had a fetal acoustic stimulation during her last nonstress test. Which should the nurse include as the rationale for this test? to listen to the fetal heart rate to startle and awaken the fetus to stimulate mild contractions to confirm amniotic fluid amount

to startle and awaken the fetus Explanation: Fetal acoustic stimulation involves the use of an instrument that emits sound levels of approximately 80 dB at a frequency of 80 Hz. The sharp sound startles and awakens the fetus and is used with nonstress testing as a method to evaluate fetal well-being. A fetoscope or Doppler stethoscope is used to listen to the fetal heart rate. Nipple stimulation or intravenous oxytocin is used to stimulate contractions. Ultrasound testing is used to determine amniotic fluid volume.

The rate at which IV fluids are infused is based on the burn client's: lean muscle mass and body surface area (BSA) burned. total body weight and BSA burned. total BSA and BSA burned. height and weight and BSA burned.

total body weight and BSA burned. Explanation: During the first 24 hours, fluid replacement for an adult burn client is based on total body weight and BSA burned. Lean muscle mass considers only muscle mass; replacement is based on total body weight. Total surface area is estimated by taking into account the individual's height and weight. Height is not a common variable used in formulas for fluid replacement.

An airplane crash results in mass casualties. The nurse is directing personnel to tag all victims. Which information should be placed on the tag? Select all that apply. triage priority identifying information when possible (such as name and age) medications and treatments administered presence of jewelry next of kin

triage priority identifying information when possible (such as name and age) medications and treatments administered Explanation: Tracking victims of disasters is important for casualty planning and management. All victims should receive a tag, securely attached, that indicates the triage priority, any available identifying information, and what care, if any, has been given along with time and date. Tag information should be recorded in a disaster log and used to track victims and inform families. It is not necessary to document the presence of jewelry or next of kin.

Which statement made by a client who is taking misoprostol, indicates a therapeutic outcome of therapy? "My stomach feels better." "My heart doesn't beat as fast now." "I can breathe easier." "My blood pressure is normal."

"My stomach feels better." Explanation: Misoprostol is used to protect the stomach's lining when a client has a peptic ulcer. Misoprostol does not affect the cardiac or respiratory systems.

As a client is being admitted to the facility, her husband asks the nurse why she must sign a statement confirming that she has been told of her rights to communicate her wishes about life support and resuscitation. How should the nurse respond? "Everyone who is admitted to this facility must sign this. We need to know what we should do in case something unexpected happens." "I hate talking about this because it may upset you. Federal law requires your wife to sign this and there is nothing we can do about that." "We make sure our clients know they have the right to specify advance directives and appoint someone to speak for them." "Hospital policy requires us to have your wife sign this. That doesn't mean that we expect anything to go wrong."

"We make sure our clients know they have the right to specify advance directives and appoint someone to speak for them."

A client is admitted to the health care facility with abdominal pain, a low-grade fever, abdominal distention, and weight loss. Based on the diagnosis of acute pancreatitis the nurse will provide which explanation for the prescribed interventions? "I can offer you ibuprofen for pain with a small sip of water." "You are not allowed anything by mouth so that your pancreas can rest." "I will be starting antibiotic therapy once the blood cultures are obtained." "Activity is important, so you will be scheduled for physical therapy."

"You are not allowed anything by mouth so that your pancreas can rest." Explanation: The predominant clinical feature of acute pancreatitis is abdominal pain, which usually reaches peak intensity several hours after onset of the illness. Interventions include parenteral pain management preferably with an opioid, NPO status to decrease pancreatic activity, and bed rest to decrease body metabolism. Antibiotics are not usually indicated. The focus is on pain management, fluid replacement intraveneously. Because acute pancreatitis causes nausea and vomiting, the nurse should try to prevent fluid volume deficit, not overload. The nurse cannot help the client achieve adequate nutrition or understand the disease and its treatment until the client is comfortable and no longer in pain.

A nurse is providing teaching to a postpartum client who has decided to breast-feed her neonate. She has questions regarding her nutritional intake and wants to know how many extra calories she should eat. What number of additional calories should the nurse instruct the client to eat per day? Record your answer using a whole number.

500 Explanation: The recommended energy intake for a lactating client is 500 calories more than her nonpregnant intake.

hiatal hernia

A hiatal hernia is a condition in which the upper part of your stomach bulges through an opening in your diaphragm. Your diaphragm is the thin muscle that separates your chest from your abdomen.

Enoxaparin (Lovenox)

Anticoagulant, Low Molecular Weight Heparin

Metformin (Glucophage)

Antidiabetic

During the first 24 hours after a client is diagnosed with addisonian crisis, which intervention should the nurse perform frequently? Weigh the client. Test urine for ketones. Assess vital signs. Administer oral hydrocortisone.

Assess vital signs. Explanation: Because the client in addisonian crisis is unstable, vital signs and fluid and electrolyte balance should be assessed every 30 minutes until he's stable. Daily weights are sufficient when assessing the client's condition. The client shouldn't have ketones in his urine, so there is no need to assess the urine for their presence. Oral hydrocortisone isn't administered during the first 24 hours in severe adrenal insufficiency.

A client who's 19 weeks pregnant comes to the clinic for a routine prenatal visit. In addition to checking the client's fundal height, weight, and blood pressure, what should the nurse assess for at each prenatal visit? Edema Pelvic adequacy Rh factor changes Hemoglobin alterations

Edema Explanation: At each prenatal visit, the nurse should assess the client for edema because edema, increased blood pressure, and proteinuria are cardinal signs of gestational hypertension. Pelvic measurements and Rh typing are determined at the first visit only because they don't change. The nurse should monitor the hemoglobin level on the client's first visit, at 24 to 28 weeks' gestation, and at 36 weeks' gestation.

A nurse is performing a physical examination of a primigravid client who's 8 weeks pregnant. At this time, the nurse expects to assess: Hegar's sign. fetal outline. ballottement. quickening.

Hegar's sign. Explanation: When performing a vaginal or rectovaginal examination, the nurse may assess Hegar's sign (softening of the uterine isthmus) between the 6th and 8th weeks of pregnancy. The fetal outline may be palpated after 24 weeks. Ballottement isn't elicited until the fourth or fifth month of pregnancy. Quickening typically is reported after 16 to 20 weeks.

A female client enjoys wearing men's clothing. Her sister tells the nurse that the client would like to have gender reassignment surgery. The client tells the nurse that she just wants to be left alone. Which nursing intervention should the nurse take first? Tell the client that she is repressing her true feelings Encourage the client to change her clothes Inform the client's sister of medical privacy laws Recommend that the client avoid her sister

Inform the client's sister of medical privacy laws Explanation: The client's sister must understand that her sister's health care is private and cannot be discussed with her. The client needs to verbalize her feelings regarding wearing male attire, as well as her desire to be left alone. Telling the client that she is repressing her true feelings is judgmental. It's inappropriate for a nurse to have the client change her clothes for no safety or therapeutic reason, or to advise the client to avoid her sister.

The nurse is caring for a pregnant client. The nurse notes hypotension and a nonreassuring fetal heart tracing. Which of the following would the nurse include in the client's plan of care? Position the client on her left side Have the client empty her bladder Encourage the client to hold her breath Call the healthcare provider

Position the client on her left side Explanation: The supine position causes compression of the client's aorta and inferior vena cava by the fetus. The compression, in turn, inhibits maternal circulation. The appropriate intervention would be to position the client on her left side. If that did not work, calling the healthcare provider would be the next option. Because the client is already hypotensive, having the client empty out their bladder would not be an appropriate option. Having the client hold her breath would make the hypotension worse.

A client is being discharged with a prescription for enoxaparin. What will the nurse document to address that medication teaching occurred? Select all that apply. The client's response to teaching The client knows the time for the next dose The client's ability to pay for the medication The client can select a site for injection The client knows adverse effects such as bleeding, bloody or black stools.

The client's response to teaching The client knows the time for the next dose The client can select a site for injection The client knows adverse effects such as bleeding, bloody or black stools. Explanation: The nurse has a legal duty to do teaching with the client including reporting adverse effects such as bleeding, bloody or black stools. The nurse will document client's ability to select site for injection and the client's response to teaching as well as confirming the next scheduled dose with client. The client's ability to pay for the medication is not part of the teaching obligation.

A client in cardiac rehabilitation would like to eat the right foods to ensure adequate endurance on the treadmill. Which nutrient is most helpful for promoting endurance during sustained activity? protein carbohydrate fat water

carbohydrate Explanation: The stored glucose of muscle glycogen is the major fuel during sustained activity. Glucose production slows as the body begins to depend on fat stores for glucose and fatty acids. Protein is not the body's preferred energy source. Fat is a secondary source of energy. Water is not an energy source, although sufficient water is required to engage in aerobic activity without causing dehydration.

Which client's response should the nurse address first? "My life is over if I gain weight." "I feel dizzy and light-headed when I get up." "I cannot eat because my teeth hurt." "I do not have the same energy that I used to have."

"I feel dizzy and light-headed when I get up." Explanation: The priority intervention, by the nurse, would be to assess the client's vital signs to note any alterations. Answer one is an example of catastrophizing. Dental erosion and caries are commonly found in a client with an eating disorder. Muscle weakness is also commonly found in a client with an eating disorder.

A teenage client is to be admitted for a fractured shoulder after being impaled on a fence running away from local police. The nurse learns that the teen lives on the street with surrogate parents. Once the client is assessed and treated, which would be the most appropriate action? Notify the police that the client is being released. Have security escort the client out of the hospital. Contact social services to advocate for the teen. Arrange visiting nurse services for follow-up care.

Contact social services to advocate for the teen. Explanation: As this client is a minor and was running from the police, it is likely that the teen is a runaway who is not an emancipated teenager. The nurse should recognize that social services is the appropriate first point of contact to advocate on the teen's behalf and coordinate with necessary persons. Based on the information presented, it is inappropriate to notify the police. There is no information suggesting that hospital security should be involved, or that the teen must be escorted from the facility. Arranging visiting nurse services is unhelpful as the teen is homeless. It might be more helpful to refer the client to an area clinic that services the homeless.

A child with hemophilia is hospitalized after falling. Now the child complains of severe pain in the left wrist. What should the nurse do first? Perform passive range-of-motion (ROM) exercises on the wrist. Massage the wrist and apply a warm compress. Elevate the affected arm and apply ice to the injury site. Notify the physician.

Elevate the affected arm and apply ice to the injury site. Explanation: Severe joint pain in a child with hemophilia indicates bleeding; therefore, the nurse should first elevate the affected extremity and apply ice to the injury site to promote vasoconstriction. ROM exercises may worsen discomfort and bleeding. Massage and warm compresses also may increase bleeding. The nurse should notify the physician only after taking measures to stop the bleeding.

Which step must be done first when administering a blood transfusion? Verify the blood product and client identity. Verify the physician's order. Verify client identity and blood product with another nurse. Assess the I.V. site.

Verify the physician's order. Explanation: The nurse must first verify the physician's order and then make sure the informed consent form is signed. Next, the nurse should make sure that an appropriate-size I.V. catheter is in place and she should assess the site for patency. After doing so, the nurse should verify the blood product and client identity with another nurse.

Which type of restraint is best for the nurse to use for a child in the immediate postoperative period after cleft palate repair? safety jacket elbow restraints wrist restraints body restraints

elbow restraints Explanation: Recommended restraints for a child who has had palate surgery are elbow restraints. They minimize the limitation placed on the child but still prevent the child from injuring the repair with fingers and hands. A safety jacket or wrist or body restraints restrict the child unnecessarily.

Important teaching for a client receiving risperidone should include advising the client to: maintain a therapeutic level by doubling a dose if he misses a dose. be sure to take the drug with a meal because it can severely irritate the stomach. discontinue the drug if he gains weight. notify the physician if he notices an increase in bruising.

notify the physician if he notices an increase in bruising. Explanation: Bruising may indicate blood dyscrasias, so notifying the physician about increased bruising is very important. The client shouldn't double the drug dose. This drug doesn't irritate the stomach, and weight gain isn't an adverse effect of risperidone therapy.

A client undergoes surgery to repair lung injuries. Postoperative orders include the transfusion of one unit of packed red blood cells at a rate of 60 ml/hour. How long will this transfusion take to infuse? 2 hours 4 hours 6 hours 8 hours

4 hours Explanation: One unit of packed red blood cells is about 250 mL. If the blood is delivered at a rate of 60 mL/h, it will take about 4 hours to infuse the entire unit. The transfusion of a single unit of packed red blood cells should not exceed 4 hours to prevent the growth of bacteria and minimize the risk of septicemia.

A client is experiencing an acute exacerbation of rheumatoid arthritis. What should the nursing priority be? Providing comprehensive client teaching; including symptoms of the disorder, treatment options, and expected outcomes Administering ordered analgesics and monitoring their effects Performing meticulous skin care Supplying adaptive devices, such as a zipper-pull, easy-to-open beverage cartons, lightweight cups, and unpackaged silverware

Administering ordered analgesics and monitoring their effects Explanation: An acute exacerbation of rheumatoid arthritis can be very painful, and the nurse should make pain management the priority. Client teaching, skin care, and supplying adaptive devices are important, but these actions don't not take priority over pain management.

A neonate is 4 hours of age. Nursing assessment reveals a heart murmur. What should the nurse do? Call the health care provider (HCP) immediately. Continue routine care. Feed the neonate. Further assess for signs of distress.

Further assess for signs of distress. Explanation: Further assessment for signs of distress is necessary. At 4 hours of age a transient murmur may be heard as the fetal shunts are closing. This is a normal finding. If no other distress is noted, the HCP does not need to be called. Result can be noted on the medical record. Further assessment is needed to know if continuing routine care and feeding are appropriate and safe for the neonate.

A nurse is assessing a client who gave birth yesterday. Where should the nurse expect to find the top of the client's fundus? One fingerbreadth above the umbilicus One fingerbreadth below the umbilicus At the level of the umbilicus Below the symphysis pubis

One fingerbreadth below the umbilicus Explanation: After a client gives birth, the height of her fundus should decrease about one fingerbreadth (about 1 cm) each day. Immediately after birth, the fundus may be above the umbilicus. At 6 to 12 hours after birth, it should be at the level of the umbilicus. By the end of the first postpartum day, the fundus should be one fingerbreadth below the umbilicus. After 10 days, it should be below the symphysis pubis.

radiculopathy

Radiculopathy, also commonly referred to as pinched nerve, refers to a set of conditions in which one or more nerves are affected and do not work properly (a neuropathy). This can result in pain (radicular pain), weakness, numbness, or difficulty controlling specific muscles.

A client with acute bronchitis is admitted to the health care facility and is receiving supplemental oxygen via nasal cannula. When monitoring this client, the nurse suddenly hears a high-pitched whistling sound. What is the most likely cause of this sound? The water level in the humidifier reservoir is too low. The oxygen tubing is pinched. The client has a nasal obstruction. The oxygen concentration is above 44%.

The oxygen tubing is pinched. Explanation: Pinching of the tubing used to deliver oxygen causes a high-pitched whistling sound. When the water level in the humidifier reservoir is too low, the oxygen tubing appears dry but doesn't make noise. A client with a nasal obstruction becomes more uncomfortable with nasal prongs in place and doesn't experience relief from oxygen therapy; the client's complaints, not an abnormal sound, would alert the nurse to this problem. A nasal cannula can't deliver oxygen concentrations above 44%.

A client discusses with the nurse the possibility of using alternative therapies for management of hypertension and diabetes. Which is an expected alternative therapy used by the client? kava jojoba ginseng melatonin

ginseng Explanation: Ginseng is used as an antihypertensive and lowers blood glucose. Kava is used for the treatment of anxiety and stress. Jojoba promotes hair growth and relief of skin problems. Melatonin aids in the treatment of insomnia.

A client with a history of hypertension and peripheral vascular disease underwent an aortobifemoral bypass graft. Preoperative medications included pentoxifylline, metoprolol, and furosemide. On postoperative day 1, the 1200 vital signs are: temperature 98.9° F (37.2° C); heart rate 132 bpm; respiratory rate 20 breaths/min; blood pressure 126/78 mm hg. Urine output is 50 to 70 mL/h. The hemoglobin and the hematocrit are stable. The medications have not been prescribed for administration after surgery. Using the SBAR (Situation-Background-Assessment-Recommendation) technique for communication, the nurse contacts the health care provider (HCP) and recommends to: continue the pentoxifylline. increase the IV fluids. restart the metoprolol. resume the furosemide.

restart the metoprolol. Explanation: The client is experiencing a rebound tachycardia from abrupt withdrawal of the beta blocker. The beta blocker should be restarted due to the tachycardia, history of hypertension, and the desire to reduce the risk of postoperative myocardial morbidity. The bypass surgery should correct the claudication and need for pentoxifylline. The furosemide and increase in fluids are not indicated since the client's urine output and blood pressure are satisfactory and there is no indication of bleeding. The nurse should also determine the potassium level before starting the furosemi

A client with peptic ulcer disease is ordered aluminum-magnesium complex. When teaching about this antacid preparation, the nurse should instruct the client to take it with: fruit juice. water. a food rich in vitamin C. a food rich in vitamin D.

water. Explanation: The nurse should instruct the client to take antacids with water because water helps transport an antacid to the stomach. The client shouldn't take an antacid with fruit juice or a food rich in vitamin C or D because the antacid may impair absorption of important nutrients in the juice or food.

A nurse is teaching the parents of an infant with clubfeet about cast care. Which statement by the parent indicates the need for further teaching? "I hope this cast will cure the feet in the next several weeks." "I know I will have to be careful when changing the diapers." "I will have to be careful how I hold the baby." "Immunizations will have to be delayed until the casts come off."

"Immunizations will have to be delayed until the casts come off." Explanation: The parent's statement about delaying immunizations indicates the need for further teaching. Immunizations can be administered in the thighs because the casts cover only the lower legs and feet. The other responses are correct statements, indicating effective teaching.

Which statement by the parent of a toddler diagnosed with nephrotic syndrome indicates that the parent has understood the nurse's teaching about this disease? "My child really likes chips and bologna. I guess we will have to find something else." "We will have to encourage lots of liquids. Did you say about 4 liters every day?" "We worry about the surgery. Do you think we should do direct donation of blood?" "We understand the need for antibiotics. I just wish the antibiotics could be given by mouth."

"My child really likes chips and bologna. I guess we will have to find something else." Explanation: Children with nephrotic syndrome usually require sodium restriction. Because potato chips and bologna are high in sodium, the mother's statement about finding something else reflects understanding of this need. Although fluid intake is not restricted in children with nephrotic syndrome, 4 L is an excessive amount for a toddler. The typical fluid requirement for a toddler is 115 mL/kg. Surgical intervention and antibiotic therapy are not parts of the treatment plan for nephrotic syndrome.

A nurse is working within the managed care delivery model. Which of the following is true regarding managed care? All plans have the same values underlying the delivery of care. Their values are not reflected in the decision making. All systems reflect the values of efficiency and effectiveness. There are no conflicts between cost-effectiveness and respectful care.

All systems reflect the values of efficiency and effectiveness. Explanation: All systems in the managed care delivery model reflect the values of efficiency and effectiveness. Different plans may have different values underlying the delivery of care. However, they all reflect the business plan values of efficiency and effectiveness. Their values are reflected in the decision making and the policy development of the organization. Value conflicts between cost-effectiveness and respectful care may be seen.

A client admitted with acute pyelonephritis now reports having a severe migraine, but declines PRN analgesics. What should the nurse discuss with this client? (Select all that apply.) The client with pyelonephritis cannot use analgesics. Ask the client which migraine treatments are helpful when at home. Alternative therapies such as relaxation or music can help. Short-term use of opioids has a high addiction risk. Using opioids will prolong the inpatient hospital stay.

Ask the client which migraine treatments are helpful when at home. Alternative therapies such as relaxation or music can help. Explanation: The nurse should respect the client's opposition to analgesics, but this should be explored. A discussion will likely reveal a variety of alternative options, many of which may be known to the client already. Opioids are not the best drug of choice for migraines. Short-term use of opioids will not independently prolong the hospital stay and do not carry a higher risk of addiction.

A client is about to have a tympanoplasty and asks the nurse what the surgical procedure involves. What should the nurse do first when answering the question? Assess the client's understanding of what the healthcare provider has explained. Describe the surgical procedure. Tell the client that the procedure will close the perforation and prevent recurrent infection. Explain that the procedure will improve hearing.

Assess the client's understanding of what the healthcare provider has explained.

A client has been unable to void since having abdominal surgery 7 hours ago. What should the nurse do first? Encourage the client to increase oral fluid intake. Insert an intermittent urinary catheter. Use an ultrasound bladder scanner to determine urine volume in the bladder. Assist the client up to the toilet to attempt to void.

Assist the client up to the toilet to attempt to void. Explanation: Urinary retention is common following abdominal surgery. The nurse should first assist the client to an anatomically comfortable position to void prior to resorting to other strategies such as cauterization. If the client is unable to void, the nurse can use a bladder scanner to determine the volume of retained urine, and then, if necessary, use an intermittent urinary catheter. While increasing fluid intake is important, it will not help the client void now.

A client is scheduled to undergo right axillary-to-axillary artery bypass surgery. Immediately following surgery, what should the nurse do as a priority to prevent infection? Assess the temperature in the right arm. Monitor the radial pulse in the right arm. Protect the extremity from cold. Avoid using the arm for a venipuncture.

Avoid using the arm for a venipuncture. Explanation: If surgery is scheduled, the nurse should avoid venipunctures in the affected extremity. The goal should be to prevent unnecessary trauma and possible infection in the affected arm. Disruptions in skin integrity and even minor skin irritations can cause the surgery to be canceled. The nurse can continue to monitor the temperature and radial pulse in the affected arm; however, doing so is not the priority. Keeping the client warm is important but is not the priority at this time.

A nurse is assessing a client using light palpation. How does a nurse perform light palpation? By indenting the client's skin ½″ to ¾″ (1.3 to 1.9 cm) By indenting the client's skin 1″ to 2″ (2.5 to 5 cm) By indenting the client's skin 1″, using both hands By indenting the client's skin 1″ and then releasing the pressure quickly

By indenting the client's skin ½″ to ¾″ (1.3 to 1.9 cm) Explanation: To perform light palpation, the nurse indents the client's skin ½″ to ¾″, using the tips and pads of her fingers. She indents the skin approximately 1½″ (3.8 cm) when performing deep palpation. She indents the skin 1″ and then releases the pressure quickly when eliciting rebound tenderness.

Tinel's sign:

Carpal tunnel syndrome is compression of the median nerve in the wrist that supplies feeling and movement to parts of the hand. Tinel's sign may be used to help identify carpal tunnel syndrome. It is elicited by percussing lightly over the median nerve, located on the inner aspect of the wrist. If the client reports tingling, numbness, and pain, the test is considered positive.

Cerebral Palsy (CP)

Cerebral palsy (CP) affects a person's body movement as well as muscle control and coordination throughout his or her entire life. There are different levels of severity, and the symptoms may not be noticeable until months or years down the line. If a child has difficulty walking, sitting, or crawling, there is a possibility he or she may have cerebral palsy. A loss or deficiency of motor control with involuntary spasms caused by permanent brain damage present at birth; birth injury; doe not become progressively worse over time

A client with bipolar disorder, manic phase, shows little interest in eating. To help the client meet recommended daily allowances of nutrients, the nurse should:

give the client half of a meat and cheese sandwich to carry with him. Explanation: The best nursing intervention is giving the client finger foods high in protein and calories that he can eat while he paces or walks.

The nurse conducts a wellness screening on a 9-year-old client Which finding most suggests that that the client has typical social development? thinks independently is able to organize and plan has a best friend enjoys active play

has a best friend Explanation: During the school-age years children learn to socialize with children of the same age. The "best friend" stage, which occurs around 9 or 10 years of age, is important in providing a foundation for self-esteem and later relationships. Thinking independently, organizing, and planning are cognitive skills. Active play relates to motor skills.

A nurse-manager appropriately behaves as an autocrat in which situation? Planning vacation time for staff Directing staff activities if a client experiences a cardiac arrest Evaluating a new medication-administration process Identifying the strengths and weaknesses of a client-education video

Directing staff activities if a client experiences a cardiac arrest Explanation: In a crisis situation, the nurse-manager should take command for the benefit of the client. Planning vacation time and evaluating procedures and client resources require staff input and are actions characteristic of a democratic or participative manager.

The nurse reviews the medical record of an adolescent with a history of losing weight and fatigue is admitted to the hospital with a diagnosis of stage I chronic renal failure (see exhibit). Day 1: intake 1,850 mL. output 1,550 mL. Day 2: intake 2,200 mL. output 1,150 mL. Continue monitoring intake and output. Notify the health care provider (HCP). Restrict the client's fluids. Increase the client's fluids.

Notify the health care provider (HCP). Explanation: The nurse would expect a person with a normal glomerular filtration rate (GFR) to have approximately equal inputs and outputs. Chronic renal failure has five stages. In stage I, the GFR is approximately ?90 mL/min/1.73 m2. In stage II, the GFR decreases to approximately 60 to 89 mL/min/1.73 m2. The decreased urine output may indicate worsening disease and should be reported. Assessing the client's intake and output is still important, but notifying the provider is the priority. Fluids are restricted based on decreased sodium. Clients are encouraged to drink to thirst. Therefore, there is not enough information to suggest increasing or restricting fluids.

The nurse is preparing to discharge a client with asthma. Which intervention is most important for the nurse to perform prior to discharge? Obtain additional equipment and medication that can be provided at the school Arrange for a thorough, deep cleaning of the home Discuss appropriate sports activities that the child can be involved in Counsel the family in making arrangements to remove the family pet

Obtain additional equipment and medication that can be provided at the school Explanation: The child needs to have equipment and medication available at school to treat and prevent asthma attacks. A discussion should be held with the child and family to motivate the child to be involved in as many normal childhood activities as possible. The house should be kept as clean as possible to prevent exacerbations due to dust and pet dander. If the child is allergic to the family pet, the nurse should provide counseling on ways to minimize the risks.

The nurse is caring for a group of clients on a medical-surgical nursing unit. Which task(s) could the nurse delegate to unlicensed assistive personnel (UAP)? Select all that apply. Assess pedal pulses on a client who just returned from a cardiac angiogram. Administer oxygen via nasal cannula to a client with a saturation of 89%. Administer acetaminophen to a client with a pain level of "5" out of "10." Perform vital signs and oxygen saturation on a client returning from the catheterization lab. Obtain intake and outputs on a client experiencing heart failure.

Perform vital signs and oxygen saturation on a client returning from the catheterization lab. Obtain intake and outputs on a client experiencing heart failure. Explanation: Performing vital signs and obtaining intake and outputs are tasks that can be delegated to UAP. Assessing pedal pulses, administering medications, and oxygen are skills that require nursing judgments.

Which action should the nurse take to provide the most effective emergency care at the accident site for a victim with a heat burn? Pour cool water over the burned area. Apply clean, dry dressings to the area. Rinse the area with a warm, mild soap solution. Apply a mild antiseptic ointment to the area.

Pour cool water over the burned area. Explanation: The recommended emergency treatment for a heat burn is immersion in cool water or application of clean, cool wet packs. This treatment helps relieve pain and diminishes tissue damage by cooling the tissue. The burn should be kept moist to prevent the dressing adhering to the wound. Warm, mild soap solutions would be contraindicated because they are irritating to the injured tissue. Antiseptics or ointments are contraindicated because they can lead to further tissue damage.

A nurse is examining the abdomen of a client with suspected peritonitis. How does the nurse elicit rebound tenderness? Pressing the affected area firmly with one hand, releasing pressure quickly, and noting any increased tenderness on release Using light palpation, noting any tenderness over an area Using deep ballottement, noting any tenderness over an area Pressing firmly with one hand, releasing pressure while maintaining fingertip contact with the skin, and noting increased tenderness on release

Pressing the affected area firmly with one hand, releasing pressure quickly, and noting any increased tenderness on release Explanation: The nurse elicits rebound tenderness by pressing the affected area firmly with one hand, releasing pressure quickly, and noting any tenderness on release. She doesn't use light palpation or deep ballottment or maintain fingertip contact with skin to elicit rebound tenderness.

A registered nurse (RN) instructs the unlicensed assistive personnel (UAP) to check the urine intake and output (I&O;) on clients on the oncology unit at the end of the 8-hour shift. It is important for the nurse to instruct the UAP to do what? Ask the clients if they are thirsty when calculating the I&O;. Report back to the nurse immediately if any client has an output less than 240 mL. Document the I&O;results on the medical records. Write the I&O;results down for the nurse to give report to the next shift.

Report back to the nurse immediately if any client has an output less than 240 mL. Explanation: The RN is responsible for describing to the UAP when to report to the RN a result that indicates a potential client problem with dehydration. The RN must assess and interpret results, but must give concrete feedback to the UAP on what is an expected situation or a specific result to report back to the RN. Urine output should be at least 30 mL/h, or 240 mL over the 8-hour shift. Dehydrated clients may be thirsty, and the UAP can ask if the client is thirsty and offer water if permitted. However, because urine output is the critical indicator of dehydration, the UAP should document I&O;and give results outside the normal range to the nurse. The nurse is specifically assessing dehydration and should request to receive this information from the UAP before it is charted and reported to the next shift.

A nurse suspects an infant may have a tracheoesophageal fistula or esophageal atresia. What is the most important intervention by the nurse? Give oxygen Tell the parents Put the neonate in an isolette or on a radiant warmer Report the suspicion to the health care provider

Report the suspicion to the health care provider Explanation: The provider needs to be told so that immediate diagnostic tests can be done to determine a definitive diagnosis with surgical correction. Oxygen should be given only after notifying the provider, except in an emergency. It is not the nurse's responsibility to inform the parents of the suspected finding. By the time tracheoesophageal fistula or esophageal atresia is suspected, the neonate would have already been placed in an isolette or a radiant warmer.

A client with end-stage heart failure is preparing for discharge. The client and his caregiver meet with the home care nurse and voice their concern that setting up a hospital bed in the bedroom will leave him feeling isolated. Which suggestion by the home care nurse best addresses this concern? Place a chair in the bedroom so guests can visit with the client. Set up the hospital bed in the family room so the client can be part of household activities. Set up the hospital bed in the bedroom so the client can rest in a quiet environment. Set up the hospital bed in the bedroom so the client can be assessed in a quiet environment.

Set up the hospital bed in the family room so the client can be part of household activities. Explanation: The client should be kept actively involved in the household to prevent feelings of isolation. This can be accomplished by setting up the hospital bed in the family room. Placing a chair in the bedroom allows the client periods of isolation when visitors aren't present. It's important for the client to have periods of rest; however, rest can be accomplished without keeping the client isolated in a bedroom. The needs of the client should be considered before the needs of the nurse who assesses the client during an occasional visit.

Suicidal thoughts. Explanation: The nurse should first determine if the client is suicidal. If the client is suicidal, it is crucial to know what the client plans to do. The seriousness of intent to die would determine the level of suicidal precautions required to maintain safety. Understanding about access to means for suicide is more important as the client is preparing for discharge.

Suicidal thoughts. Explanation: The nurse should first determine if the client is suicidal. If the client is suicidal, it is crucial to know what the client plans to do. The seriousness of intent to die would determine the level of suicidal precautions required to maintain safety. Understanding about access to means for suicide is more important as the client is preparing for discharge.

A client with bladder cancer had his bladder removed and an ileal conduit created for urine diversion. While changing this client's pouch, the nurse observes that the area around the stoma is red, weeping, and painful. What should the nurse conclude? The skin wasn't lubricated before the pouch was applied. The pouch faceplate doesn't fit the stoma. A skin barrier was applied properly. Stoma dilation wasn't performed.

The pouch faceplate doesn't fit the stoma. Explanation: If the pouch faceplate doesn't fit the stoma properly, the skin around the stoma will be exposed to continuous urine flow from the stoma, causing excoriation and red, weeping, and painful skin. A lubricant shouldn't be used because it would prevent the pouch from adhering to the skin. When properly applied, a skin barrier prevents skin excoriation. Stoma dilation isn't performed with an ileal conduit, although it may be done with a colostomy if ordered.

The nurse is teaching a small community group regarding methods to decrease the risk of burns. What is the priority method to decrease burn risks in the home? Use of smoke detectors Placement of fire extinguishers Ease of initiating an emergency response system Elimination of the use of candles in the home

Use of smoke detectors Explanation: The majority of burns that occur in the home can be prevented with the use of working smoke detectors. The nurse should encourage members of the community to have working smoke detectors throughout the home. Although placement and accessibility of fire extinguishers, ease of initiating an emergency response system, and eliminating the use of candles may all aid in reducing the risk of burns in the home, they are not as effective as the use of smoke detectors.

An adolescent client is having surgery to repair a fractured left femur. As a part of the preoperative safety checklist, what should the nurse do? Ask the teen to point to the surgery site. Verify that the site, side, and level are marked. Ask the parents if they have signed the operative permit. Restate the surgery risks to the parents.

Verify that the site, side, and level are marked. Explanation: As part of a surgery safety checklist, the nurse must verify that the site, side, and level are marked. Pointing to the area is not sufficient identification of the surgery site. The nurse must verify the form has been signed by reviewing the form. The surgeon holds primary responsibility for explaining the risks of surgery.

After administering an I.M. injection, a nurse notices there isn't a sharps-disposal container nearby. Which action should the nurse take? Hold the barrel of the syringe in one hand. With the other hand, push the cap into place over the needle. With one hand, use the needle to scoop up the cap. Holding the barrel in one hand, carry the syringe to the closest sharps-disposal container. With one hand, use the needle to scoop up the cap. Holding the barrel in one hand, carry the syringe to the closest trash container. Hold the barrel of the syringe in one hand. With the other hand, push the cap into place over the needle. Carry the syringe to the closest sharps-disposal container.

With one hand, use the needle to scoop up the cap. Holding the barrel in one hand, carry the syringe to the closest sharps-disposal container.

A nurse is teaching a client with a long leg cast how to use crutches properly while descending a staircase. The nurse should tell the client to transfer body weight to the unaffected leg, and then: advance both legs. advance the unaffected leg. advance the affected leg. advance both crutches.

advance both crutches. Explanation: The nurse should instruct the client to advance both crutches to the step below, then transfer his body weight to the crutches as he brings the affected leg to the step. The client should then bring the unaffected leg down to the step.

An assessment of a client's orientation is best obtained by:

asking the client's name, where he lives, and what time it is. Explanation: To help assess orientation, the nurse asks the client direct questions about time, place, and person, such as what day or time of day it is, where the client lives, and his name. Asking the client to repeat a series of digits assesses memory, not orientation. Pointing to common objects and asking the client to name them assesses language deficits. The Glasgow Coma Scale assesses level of consciousness, not orientation

A 39-year-old multiparous client at 39 weeks' gestation diagnosed with class II heart disease is admitted to the hospital in active labor. What should the nurse assess first after admission to the birthing area? time of last food and fluid intake fetal position and station contraction frequency and intensity ability to follow directions

contraction frequency and intensity Explanation: When admitting a multigravid client to the birthing area, the nurse needs to obtain information about the frequency, intensity, and duration of labor contractions; the time when the labor began; whether the membranes have ruptured; and the client's estimated childbirth date. From this information, the nurse gets a quick overview of the client's status and can then proceed to plan effective care. Although the time when the client last had food or fluids is important, this information can be obtained later because it is less influential in determining the initial plans for care. Although information about the fetal position is important, this information is less influential in determining the initial plans for care. The client's ability to follow directions is important, but this information can be obtained later because it plays a less influential role in initial plans for care.

A client, diagnosed with active tuberculosis (TB), asks the nurse if he will be admitted to the hospital. The nurse responds that hospitalization would most likely occur to:

prevent the spread of the disease.

A client with a history of an anterior wall myocardial infarction is being transferred from the coronary care unit (CCU) to the cardiac step-down unit (CSU). While giving a report to the CSU nurse, the CCU nurse says, "His pulmonary artery wedge pressures have been in the high normal range." The CSU nurse should be especially observant for: hypertension. high urine output. dry mucous membranes. pulmonary crackles.

pulmonary crackles. Explanation: High pulmonary artery wedge pressures are diagnostic for left-sided heart failure. With left-sided heart failure, pulmonary edema can develop causing pulmonary crackles. In left-sided heart failure, hypotension may result and urine output will decline. Dry mucous membranes aren't directly associated with elevated pulmonary artery wedge pressures.

Propylthiouracil (PTU) is prescribed for a client with Graves' disease. Which symptom should the nurse teach the client to report? sore throat excessive menstruation constipation increased urine output

sore throat Explanation: The most serious adverse effects of PTU are leukopenia and agranulocytosis, which usually occur within the first 3 months of treatment. The client should be taught to promptly report to the health care provider (HCP) signs and symptoms of infection, such as a sore throat and fever. Clients having a sore throat and fever should have an immediate white blood cell count and differential performed, and the drug must be withheld until the results are obtained. Painful menstruation, constipation, and increased urine output are not associated with PTU therapy.

The client with depression who is taking imipramine states to the nurse, "My health care provider (HCP) wants me to have an electrocardiogram (ECG) in 2 weeks, but my heart is fine." Which response by the nurse is most appropriate? "It's routine practice to have an ECG periodically because there is a slight chance that the drug may affect the heart." "It's probably a precautionary measure because I'm not aware that you have a cardiac condition." "Try not to worry too much about this. Your health care provider (HCP) is just being very thorough in monitoring your condition." "You had an ECG before you were prescribed imipramine, and the procedure will be the same."

"It's routine practice to have an ECG periodically because there is a slight chance that the drug may affect the heart." Explanation: Telling the client that ECGs are done routinely for all clients taking imipramine, a tricyclic antidepressant, is an honest and direct response. Additionally, it provides some reassurance for the client. Commonly, a client with depression will ruminate, leading to needless increased anxiety. Tricyclic antidepressants may cause tachycardia, ECG changes, and cardiotoxicity. Telling the client that it is probably a precautionary measure because the nurse is not aware of a cardiac condition instills doubt and may cause undue anxiety for the client. Telling the client not to worry because the HCP is very thorough dismisses the client's concern and does not give the client adequate information. Explaining that the client had an ECG before initiating therapy with imipramine and that the procedure will be the same does not answer the client's question.

The nurse finds a client lying on the floor next to the bed. After returning the client to bed, assessing for injury, and notifying the health care provider (HCP), the nurse fills out an incident report. What should the nurse do next? Give the incident report to the nurse-manager. Place the incident report on the medical record. Call the family to inform them. Omit mentioning the fall in the medical record documentation.

Give the incident report to the nurse-manager. Explanation: The incident report should be given to the nurse-manager. The incident report should not be placed on the medical record because it is considered a confidential communication and cannot be subpoenaed by a client or used as evidence in lawsuits. It is appropriate, ethical, and legally required that the fall be documented in the medical record. Unless there is a change in the client's condition reflecting an injury from the fall, there is no need to notify the family. If the family does need to be notified, the nurse-manager or the HCP should place the call.

A diagnosis of hemophilia A is confirmed in an infant. Which of the instructions should the nurse provide the parents as the infant becomes more mobile and starts to crawl?

Sew thick padding into the elbows and knees of the child's clothing.

When assessing a hospitalized client diagnosed with Major Depression and Borderline Personality Disorder, the nurse should ask the client about which of the following first? Access to pills and weapons. Suicidal plans. Suicidal thoughts. Seriousness of the client's intent to die.

Suicidal thoughts. Explanation: The nurse should first determine if the client is suicidal. If the client is suicidal, it is crucial to know what the client plans to do. The seriousness of intent to die would determine the level of suicidal precautions required to maintain safety. Understanding about access to means for suicide is more important as the client is preparing for discharge.

To examine an infant's thyroid gland, the nurse should place the infant in which position? Prone Sitting Standing Supine

Supine Explanation: The nurse should place the infant in the supine position on the caregiver's lap because it hyperextends the infant's neck, promoting thyroid palpation. A prone position wouldn't allow an adequate area for palpation. A sitting position is appropriate when assessing the thyroid gland of an older child or an adult. An infant can't stand, so this position is inappropriate.

A nurse is teaching a parent of a toddler diagnosed with conjunctivitis to administer the ophthalmic ointment. Which action by the mother indicates that further instruction is necessary? The mother washes her hands before and after administration. The mother applies the ointment to the lower conjunctival sac. The mother holds the eyelids open with her fingers. The mother cleans the eye prior to medication administration.

The mother holds the eyelids open with her fingers. Explanation: Washing hands before and after administration to an infected eye is very important to prevent the spread of conjunctivitis. Applying the ointment to the lower conjunctival sac ensures the medication will adequately cover the eye. Cleaning the eye prior to administration helps the medication be absorbed and decreases the bacteria in the eye. Holding the eyelids open will not allow application of the medication to the lower conjunctival sac.

A child has discomfort and swelling around the IV insertion site. The nurse should first determine if the: angiocatheter has come out of the vein. IV site has been used too long. child is allergic to the plastic in the angiocatheter. rate of fluid administration is too rapid for the vein size.

angiocatheter has come out of the vein. Explanation: Pain and swelling around the IV insertion site most likely indicates that the angiocatheter has come out of the vein. Swelling occurs as the fluid infuses into subcutaneous tissues. Other typical signs of infiltration include skin pallor and coldness around the insertion site. Signs of inflammation, such as redness and warmth, are likely if the IV site is used too long. Because inert plastic is used for manufacturing IV catheters, the risk of an allergic reaction is remote. If fluid is administered too rapidly for the vein size, the fluid would most probably leak around the angiocatheter at the area of connection with the tubing.

While assessing a neonate at 4 hours after birth, the nurse observes an indentation with a small tuft of hair at the base of the neonate's spine. The nurse should document this finding as what finding? spina bifida cystica spina bifida occulta meningocele myelomeningocele

spina bifida occulta Explanation: A small tuft of hair and an indentation at the base of the neonate's spine is termed spina bifida occulta. This condition usually occurs between the L5 and S1 vertebrae with failure of the vertebrae to completely fuse. There are usually no sensory or motor deficits with this condition. Spina bifida cystica includes meningocele, myelomeningocele, and lipomeningocele. Meningocele is characterized by a saclike protrusion filled with spinal fluid and meninges. Usually, this condition is associated with sensory and motor deficits. Myelomeningocele is characterized by a saclike protrusion filled with spinal fluid, meninges, nerve roots, and spinal cord. With myelomeningocele, there are usually sensory and motor deficits.

While the nurse is assisting a client to ambulate as part of a cardiac rehabilitation program, the client has midsternal burning. The nurse should: stop and assess the client further. measure the client's blood pressure and heart rate. call for help and place the client in a wheelchair. administer nitroglycerin.

stop and assess the client further. Explanation: The nurse should stop and assess the client further. A chair should be available for the client to sit down. Obtaining the client's blood pressure and heart rate are important when exercising. These values can be used to predict when the oxygen demand becomes greater than the oxygen supply. Calling for help is not necessary for the midsternal burning. If the health care provider (HCP) has prescribed nitroglycerin, the nurse can administer it; however, stopping the activity may restore the oxygen balance.

A nurse is performing an assessment on an adult with hypertension who falls into the middle-old elderly population. Which findings would be reported to the health care provider? nails are thickened, brittle, and yellow urine output of 600mL/24 hours lower peripheral pulses +1 bilaterally increased sensitivity to glare

urine output of 600mL/24 hours Explanation: Normal urinary output ranges from 30-80mL/hour. An output of 600mL/24 hours indicates a problem with urinary elimination because it is less than 30mL/hour. Normal physiologic changes associated with aging include thickened, brittle, yellow nails, diminished peripheral pulses, and increased sensitivity to glare.

A 15-year-old primiparous client is being cared for in the hospital's birthing center after vaginal birth of a viable neonate. The neonate is being placed for adoption through a social service agency. Four hours postpartum, the client asks if she can feed her baby. Which response would be most appropriate? "I'll bring the baby to you for feeding." "I think we should ask your health care provider if this is a good idea." "It's not a good idea for you to have any contact with the baby." "I'll check with the social worker to see if the adopting parents will permit this."

"I'll bring the baby to you for feeding." Explanation: After birth, the client should make the decision about how much she would like to participate in the neonate's care. Seeing and caring for the neonate commonly facilitates the grief process. The nurse should be nonjudgmental and should allow the client any opportunity to see, hold, and care for the neonate. The health care provider (HCP) does not need to be contacted about the client's desire to see the baby, which is a normal reaction. The social worker and the adoptive parents do not need to give the client permission to feed the baby.

A parent asks the nurse about the nutritional needs of her toddler. Which response by the nurse would be most appropriate? "Toddlers usually do not have a good appetite." "Toddlers have definite food preferences." "Toddlers usually consume large quantities of milk." "Toddlers are inquisitive, willing to try new foods."

"Toddlers have definite food preferences." Explanation: Toddlers have definite food preferences, typically wanting the same food item for several days in a row. Because toddlers experience a slow and steady growth rate, they usually have a good appetite. Toddlers should consume 2 to 3 servings of milk per day. The majority of their nutrients should come from table foods. Toddlers typically are not interested in trying new foods.

A nurse is caring for a neonate with congenital clubfoot. The child has a cast to correct the defect. Before discharge, what should the nurse tell the parents? The cast will be removed in 6 weeks. A new cast is needed every 1 to 2 weeks. A short leg cast is applied when the baby is ready to walk. The cast will be removed when the baby begins to crawl.

A new cast is needed every 1 to 2 weeks. Explanation: Because a neonate grows so quickly, the cast may need to be changed as often as every 1 to 2 weeks. A cast for congenital clubfoot isn't left on for 6 weeks because of the rapid rate of the infant's growth. By the time an infant is crawling or ready to walk, the final cast has long since been removed. After the cast is permanently removed, the baby may wear a Denis Browne splint until he's 1 year old.

The nurse is preparing a client who has had a knee replacement with a metal joint to go home. What should the nurse instruct the client to do? Select all that apply. Notify health care provider (HCP) about the joint prior to invasive procedures. Inform the HCP prior to having magnetic resonance imaging (MRI) scans. Notify airport security that the joint may set off alarms on metal detectors. Refrain from carrying items weighing more than 5 pounds (2.3 kg). Eat a low-fat, low-carbohydrate diet.

Notify health care provider (HCP) about the joint prior to invasive procedures. Inform the HCP prior to having magnetic resonance imaging (MRI) scans. Notify airport security that the joint may set off alarms on metal detectors. Explanation: The nurse should instruct the client to notify the dentist and other HCPs of the need to take prophylactic antibiotics if undergoing any procedure (e.g., tooth extraction) due to the potential of bacteremia. The nurse should also advise the client that the metal components of the joint may set off the metal-detector alarms in airports. The client should also report having the metal joint prior to having MRI studies because, depending on the type of joint replacement, the implanted metal components could be pulled toward the large magnet core of the MRI. Any weight bearing that is permitted is prescribed by the orthopedic surgeon and is usually not limited to 5 lb (2.3 kg). After surgery, the client can resume a normal diet with regular fluid intake.

When caring for an adolescent diagnosed with depression, the nurse should remember that depression manifests differently in adolescents than it does in adults. In an adolescent, signs and symptoms of depression are likely to include: helplessness, hopelessness, hypersomnolence, and anorexia. truancy, a change of friends, social withdrawal, and oppositional behavior. curfew breaking, stealing from family members, truancy, and oppositional behavior. hypersomnolence, obsession with body image, and valuing of peers' opinions.

truancy, a change of friends, social withdrawal, and oppositional behavior. Explanation: In adolescents, depression typically manifests as truancy, a change of friends, social withdrawal, and oppositional behavior. In adults, depression usually produces helplessness, hopelessness, hypersomnolence, and anorexia. Drug use may lead to curfew breaking, stealing, truancy, and oppositional behavior. Adolescents normally display hypersomnolence, an obsession with body image, and valuing of peers' opinions.

A health care provider is legally and ethically required to disclose certain information. Which confidential information should the nurse disclose? A single male client's HIV status to his family members A client's pancreatic cancer diagnosis to the significant other A taxi driver's diagnosis of an uncontrolled seizure disorder to his licensing agency The client is 32 weeks pregnant with twins and is legally separated

A taxi driver's diagnosis of an uncontrolled seizure disorder to his licensing agency Explanation: The health care provider may lawfully disclose confidential information about a client when the welfare of others is at stake. The health care provider is required to inform the Department of Motor Vehicles that the taxi driver has an uncontrolled seizure disorder because it's in the best interest of the public's and client's safety. Confidentiality of HIV testing is required. Disclosing a client's cancer diagnosis to a significant other or pregnancy to a legally separated partner do not affect the welfare of person.

The nurse is caring for a client on the urinary unit. When providing report to the next shift, it is noted that the client has osteopenia and history of renal calculi. Which disorder would the nurse suspect? hyperparathyroidism hypoparathyroidism hypopituitarism hypothyroidism

hyperparathyroidism Explanation: Hyperparathyroidism is characterized by osteopenia and renal calculi secondary to overproduction of parathyroid hormone. The hallmark symptom of hypoparathyroidism is tetany from hypocalcemia. Hypopituitarism presents with extreme weight loss and atrophy of all endocrine glands. Symptoms of hypothyroidism include hair loss, weight gain, and cold intolerance.

The nurse is caring for a child receiving a blood transfusion. The child becomes flushed and is wheezing. What should the nurse do first? Notify the health care provider (HCP). Administer oxygen. Switch the transfusion to normal saline solution. Take the child's vital signs

Switch the transfusion to normal saline solution. Explanation: The child is having a reaction to the blood transfusion. The priority is to stop the blood transfusion but maintain an open venous access for medication or high fluid volume delivery. Thus, switching the transfusion to normal saline solution would be done first. Since the child is having difficulty breathing, applying oxygen would be the next action. Additionally, vital signs are taken to determine the extent of circulatory involvement. Then the HCP would be notified and, if necessary, the crash cart would be obtained.

The nurse recognizes that teaching about the need for an exchange transfusion in a neonate with erythroblastosis fetalis has been effective if the parents describe the purpose of the transfusion is what? to replenish the neonate's leukocytes to restore the fluid and electrolyte balance to correct the neonate's anemia to replace Rh-negative blood with Rh-positive blood

to correct the neonate's anemia Explanation: An exchange transfusion is done to reduce the blood concentration of bilirubin and correct the anemia. The exchange transfusion does not replenish the white blood cells or restore the fluid and electrolyte balance. The neonate's Rh-positive blood is replaced by Rh-negative blood.

The nurse is caring for a client with a nasogastric tube and in mitt restraints. Which nursing action is required every one to two hours? Assist the client to the bathroom. Assess cognitive status. Offer the client sips of clear liquids. Remove restraints and assess skin and circulation.

Remove restraints and assess skin and circulation. Explanation: Placing a client in any type of restraint is a controversial issue. Strict guidelines exist. The client in restraints must have the skin integrity and circulation assessed every 1-2 hours. It is also appropriate to massage the area and provide range of motion exercises. On a regular basis, the client would be offered to use a bedpan or ambulate to the bathroom and the nurse would assess the cognitive status. A client with a nasogastric tube would not be offered fluids.

The nurse is making team assignments and is assigning tasks to the unlicensed assistive personnel (UAP). unit. What information should the nurse know before delegating tasks to the UAP? All nursing activities performed by the UAP should be directly supervised by a registered nurse. Some nursing activities performed by the UAP should be directly supervised by a registered nurse. The UAP's level of knowledge and comfort level in performing specific nursing activities should be considered. Whether the UAP has previously completed and practiced the delegated activities.

The UAP's level of knowledge and comfort level in performing specific nursing activities should be considered. Explanation: The RN is responsible for providing, delegating, and at times supervising others to ensure safe nursing care. They remain responsible when delegating nursing tasks to other members of the health care team. The nurse should delegate tasks in collaboration with the UAP, considering their knowledge level and comfort when performing various aspects of care, regardless of whether the UAP has previously completed these activities.

The nurse is teaching the client to self-administer insulin. Learning goals most likely will be attained when they are established by the: nurse and client because both need to be responsible for teaching. health care provider and client because the health care provider is the manager of care and the client is the main participant. client because the client is best able to identify his or her own needs and how to meet those needs. client, nurse, pharmacist, and health care provider so the client can participate in planning care with the entire team.

client, nurse, pharmacist, and health care provider so the client can participate in planning care with the entire team. Explanation: Learning goals are most likely to be attained when they are established mutually by the client and members of the health care team, including the nurse, pharmacist, and health care provider. Learning is motivated by perceived problems or goals arising from unmet needs. The perception of the unmet needs must be the client's; however, the nurse, pharmacist, and health care provider help the client arrive at his or her own perception of the need or reason to learn.

When caring for a client with head trauma, a nurse notes a small amount of clear, watery fluid oozing from the client's nose. What should the nurse do first? Test the nasal drainage for glucose. Look for a halo sign after the drainage dries. Have the client blow his nose. Contact the physician.

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

The risk for injury during an attack of Ménière's 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." Explanation: 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.

The nurse assesses a client with a 5 inch × 2 inch (12.7 cm x 5 cm) stasis ulcer just above the left malleolus. The wound is open with irregular, reddened, swollen edges, and there is a moderate amount of yellowish tan drainage coming from the wound. The client verbalizes pressure-type pain and rates the discomfort at 7 on a scale of 0 to 10. What is the primary nursing goal for this client? administering prescribed analgesics. applying lanolin lotions to the left ankle stasis ulcer. encouraging the client to sit up in a chair four times per day. keeping pressure of bed linens off the area.

keeping pressure of bed linens off the area. Explanation: The nurse should keep bed linens off of the stasis ulcer to decrease the amount of pressure that the linens exert upon the lower extremity and prevent further tissue breakdown. Administering prescribed analgesics would be an intervention for reducing the pain. Applying lanolin lotions to the left ankle ulcer will not promote healing. Encouraging the client to sit up in a chair four times per day is an intervention to promote activity. The nurse would elevate the involved extremity while the client is sitting up to reduce venous stasis and capillary pressure.

A 20-year-old client with paranoid schizophrenia is in the fourth day of hospitalization. The client's parents visit and state to the nurse, "What did we do wrong? What caused this awful thing to happen?" Which explanation by the nurse is most accurate and therapeutic? "We really do not know. There are many theories about schizophrenia." "Let us talk about your family background. Schizophrenia is often genetic." "You did not cause schizophrenia by doing something wrong. Schizophrenia is a brain disease." "Schizophrenia often appears for the first time in early adulthood when people with a predisposition experiment with drugs and alcohol."

"You did not cause schizophrenia by doing something wrong. Schizophrenia is a brain disease." Explanation: The nurse is sensitive to the parents' feeling of guilt and lack of knowledge about the etiologies of schizophrenia. The nurse reassures the parents that they are not to blame for their child's illness. The nurse then begins to educate them by explaining the biological theories of the disease in a simple, straightforward manner. Telling the parents that the cause of schizophrenia is unknown ignores the their concerns and diminishes trust in the nurse by not offering accurate information about the disorder. Stating that schizophrenia is genetic implies that the parents are to blame and offers an incomplete explanation of the disorder. Telling the parents schizophrenia is related to drug and alcohol use makes an inappropriate suggestion that the client's behavior caused the disease.

A client tells the nurse about having numbness from the back of the left buttock to the dorsum of the foot and big toe. The client is scheduled to undergo a laminectomy, and the operative consent form states "a left lumbar laminectomy of L3-L4." What should the nurse do next? Have the client sign the consent form. Call the surgeon. Change the consent form. Review the client's history.

Call the surgeon. Explanation: Based on the client's comments, the nurse should call the surgeon to verify the location of the surgery. The client's comments indicate radiculopathy of L4-L5, but the informed consent form states L3-L4. Radiculopathy of L3-L4 involves pain radiating from the back to the buttocks to the posterior thigh to the inner calf. The nurse must act as a client advocate and not ask the client to sign the consent until the correct procedure is identified and confirmed on the consent. The nurse has no legal authority or responsibility to change the consent. The history is a source of information, but when the client is coherent and the history is contradictory, the health care provider (HCP) should be contacted to clarify the situation. Ultimately, it is the surgeon's responsibility to identify the site of surgery specified on the surgical consent form.

A client who is 34 weeks pregnant is experiencing bleeding caused by placenta previa. The fetal heart sounds are normal and the client is not in labor. Which nursing intervention should the nurse perform? Allow the client to ambulate with assistance. Perform a vaginal examination to check for cervical dilation. Monitor the amount of vaginal blood loss. Notify the physician for a fetal heart rate of 130 beats/minute.

Monitor the amount of vaginal blood loss. Explanation: The nurse should estimate the amount of blood loss by such measures as weighing perineal pads or counting the amount of pads saturated over a period of time. The physician should be notified of continued blood loss, an increase in blood flow, or vital signs indicative of shock (such as hypotension and tachycardia). The woman should be placed on bed rest and not allowed to ambulate. A vaginal examination should never be performed when placenta previa is suspected because manipulation of the cervix can cause hemorrhage. A normal fetal heart rate is 120 to 160 beats/minute; therefore, the physician doesn't need to be notified of a fetal heart rate of 130 beats/minute.

Immediately after birth, a nurse assesses the neonate's respiratory effort as slow. The neonate is actively moving but grimaces in response to stimulation. His fingers and toes are bluish, and his heart rate is 130 bpm. Which step should the nurse take next? Tell the provider that the neonate appears abnormal Assign an Apgar score of 8 Wrap the infant in a warm blanket Provide oxygen and stimulate the baby to cry

Provide oxygen and stimulate the baby to cry Explanation: The nurse should stimulate the baby to cry, provide oxygen, and call the provider to evaluate reflex irritability. It would be inappropriate to tell the provider that the neonate appears abnormal. The neonate's Apgar score is 7. Of a maximum possible Apgar score of 10, the nurse deducts one point for acrocyanosis, one point for slow respiratory effort, and one point for the grimace. Although keeping the infant warm is important, the infant clearly needs more aggressive interventions such as oxygen and stimulation

The nurse is admitting a child who has been diagnosed with bacterial meningitis to the pediatric unit. The nurse should implement which type of isolation? standard or routine precautions contact precautions airborne precautions droplet precautions

droplet precautions Explanation: Bacterial meningitis is caused by one of three organisms, Haemophilus influenzae type b, Neisseria meningitidis, or Streptococcus pneumoniae. All three organisms may be transmitted through contact with respiratory droplets. These droplets are heavy and typically fall within 3 feet (91.4 cm) of the client. Droplet precautions require, in addition to standard (routine) precautions, that HCPs wear masks when coming into close contact with the client. Standard or routine precautions, previously referred to as universal precautions, are general measures used for all clients. Contact precautions are used when direct or indirect contact with the client causes disease transmission. Gowns and gloves are needed but not masks. Airborne precautions differ from droplet in that the particles are smaller and may stay suspended in the air for longer periods of time. These clients require negative pressure rooms, and all heath care workers must wear respirators.