H-Quest.

The client tells the nurse, "I want to be knocked out for the birth." How should the nurse respond?

"You don't want to be awake during the birth."

The husband of a client in labor asks about an indentation on his wife's abdomen. The nurse explains that it is a retraction ring (Bandl's ring). What is the next nursing action?

Explaining to him what it means and notify the practitioner [Bandl's ring is a pathological retraction ring, a sign of impending uterine rupture. There is a ridge around the uterus at the junction of the upper and lower uterine segments. The upper segment is distended and thin and the lower segment is thick. Although the ring may occur during the second stage of labor, it is not a sign that the second stage of labor is beginning. A retraction ring impedes the progress of labor; it is associated with premature rupture of the membranes, dystocia, and prolonged labor. A retraction ring is pathological, not expected.]

When assisting a client from the bed to a chair, which procedure is best for the nurse to follow?

With the nurse's feet spread apart and knees aligned with the client's knees, stand and pivot the client into the chair.

Which clinical manifestations does a nurse expect that a client with renal calculi might report? Select all that apply. 1. Blood in the urine 2. Irritability and twitching 3. Dry, itchy skin and pyuria 4. Frequency and urgency of urination 5. Pain radiating from the kidney to a shoulder

(1,4) ---Hematuria is a common clinical manifestation of renal calculi. Frequency and a sense of urgency may occur because of irritation caused by the calculi; the most common expectation is sharp, severe pain. Irritability may occur because of discomfort; twitching does not occur. Pyuria may occur when infection is present; skin problems do not occur. Pain radiates from the flank to the groin area.

A client on prolonged cortisone therapy for adrenal insufficiency is being discharged. Which side effects should the nurse teach the client and family to expect? Select all that apply. 1) Weakness 2) Oliguria 3) Anorexia 4) Moon face 5) Weight gain 6) Nervousness

(1,4,5) Weakness occurs because of muscle wasting due to the catabolic effects of cortisol. Hypokalemia may also cause weakness; potassium is lost in the urine as sodium is retained. An accumulation of adipose tissue occurs in the face (moon face), trunk (truncal obesity), and cervical area (buffalo hump). Weight gain occurs because of increased appetite and fluid retention; one liter of fluid is equal to 2.2 pounds. Cortisone increases sodium and water retention, but does not cause oliguria; glucose levels also increase which, if extreme, will cause polyuria. The appetite usually increases, not decreases. Cortisone increases blood glucose levels, which, if extreme, will cause lethargy, not nervousness.

Urinary catheterization is prescribed for a postoperative female client who has been unable to void for 8 hours. The nurse inserts the catheter, but no urine is seen in the tubing. Which action will the nurse take next? A. Clamp the catheter and recheck it in 60 minutes. B. Pull the catheter back 3 inches and redirect upward. C. Leave the catheter in place and reattempt with another catheter. D. Notify the health care provider of a possible obstruction.

(C) Rationale: It is likely that the first catheter is in the vagina, rather than the bladder. Leaving the first catheter in place will help locate the meatus when attempting the second catheterization (C). The client should have at least 240 mL of urine after 8 hours. (A) does not resolve the problem. (B) will not change the location of the catheter unless it is completely removed, in which case a new catheter must be used. There is no evidence of a urinary tract obstruction if the catheter could be easily inserted (D).

A client with *rheumatoid arthritis* is prescribed to rest in the *prone* position for 1 hour after breakfast and 1 hour before dinner. What should the nurse instruct the client regarding the purpose of this positioning? A. Keeps the spine straight. B. Serves as a splint to the hip joints. C. Strengthens the neck and back muscles. D. Ensures range of motion of the knees and ankles.

(b) For the client with rheumatoid arthritis, splints provide joint rest and prevent contractures. ---The best "splint" for the hip is lying prone for several hours a day on a firm bed. Lying prone is not used to keep the spine straight (A), strengthen neck and back muscles (C), or to ensure range of motion of the knees and ankles (D).

What clinical indicator should the nurse identify before scheduling a client for an endoscopic retrograde cholangiopancreatography (ERCP? ---Bilirubin level

---ERCP involves the insertion of a cannula into the pancreatic & common bile ducts during an endoscopy. The test is NOT performed if the client's bilirubin level is more than *3 to 5* mg/dL because cannulation may cause edema which will increase obstruction of the bile flow.

A nurse finds a victim under the wreckage of a collapsed building. The individual is conscious, supine, breathing satisfactorily, and reports back pain and inability to move the legs. Which action should the nurse take?

---Leave the individual lying on the back with instructions not to move and leave to seek additional help. --[the individual should be moved only w/a backboard to avoid additional spinal cord damage] --[Moving a person whose spinal cord has been injured may cause irreversible paralysis.] --[a back injury precludes changing the person's position] --[a flat board is indicated; however, *one rescuer* should NOT move the person without help.]

A pt. w/COPD has pleuritic, what should you do?

--assess for signs of pneumonia. ---(clients w/pleuritic disease are prone to develop pneumonia because of impaired lung expansion, air exchange & drainage.)

What nursing action will most help a client obtain maximum benefits after postural drainage?

--encourage coughing deeply.

A nurse who is working on a medical-surgical unit receives a phone call requesting information about a client who has undergone surgery. The nurse observes that the client requested a do not publish (DNP) order on any information regarding condition or presence in the hospital. What is the best response by the nurse? "We have no record of that client on our unit. Thank you for calling."

...

Staff on a cardiac unit consists of an RN, two practical nurses (PNs), and one UAP. Team 1's assignment includes two clients who are both 1 day postangioplasty and two clients with unstable angina. Team 2's assignment includes all stable clients, but two clients are bedridden and incontinent. Which staffing plan represents the best use of available staff?

Team 1: RN team leader, PN; team 2, PN team leader, UAP -Team 1 includes high-risk clients who require a higher level of assessment and decision making, which should be provided by an RN and PN (A). Team 2 has stable clients at lower risk than those on team 1. Although two clients on team 2 require frequent care, the care is routine and predictable in nature and can be managed by the PN and UAP.

A client, diagnosed with osteomalacia, asks the nurse what caused the disorder. Which of the following should the nurse explain to the client? A. It is caused by gastrointestinal malabsorption B. It is because of recurrent fractures C. Lack of calcium in the diet is the reason it develops D. Pseudomonas infection of the soft tissue surrounding the bone causes this to develop

(A)

The nurse, planning care for a client diagnosed with a histrionic personality disorder, would include which of the following in this client's plan of care? A. When the client goes out of the room wearing highly provocative clothes the nurse should take no notice of the behavior for the moment and ask the client to dress properly the following day. B. Avoid including histrionic clients in group discussions since they tend to take over the discussion and talk endlessly about themselves. C. Ignore the client's attention-seeking behavior. D. During private discussions, guide the client back to the topic when the client's answers tend to wander out of the topic.

(D)

Yesterday a female client who is delusional told the nurse that her HCP needs to be released from her case because they are going to get married on her birthday. Which statement made by the client today indicates that the client is delusional?

--"I don't talk about things like that anymore." ---(when the client states that she doesn't want to talk about things like that anymore, she is likely less delusional, because when a client begins to question the delusional belief or stops talking about it, the client is becoming less delusional.)

A college basketball player complains of a "click" in the knee when the client walks. The client states that the knee occasionally gives way when the client runs & sometimes locks. The client doe snot recall any specific injury. The nurse suspects: ---Injured cartilage in the knee

---(these adaptations are consistent w/torn cartilage, this injury is common among basketball players)

For what complication should a nurse assess a newborn after a precipitate birth? 1. Brachial Palsy 2. Dislocated hip 3. Fractured clavicle 4. Intracranial hemorrhage

--Intracranial hemorrhage A rapid birth does not give the fetal head adequate time for molding; therefore pressure against the head is increased and blood vessels may burst. -Brachial palsy and fractured clavicle are the results of excessive pulling on the head and shoulders during a delivery involving shoulder dystocia delivery. -A dislocated hip is more likely to occur in a footling breech birth.

Which biological practices are federally (OSHA) regulated for Health Care Workers? ---Standard Precautions ---N-95 TB Standard--(droplet) ---Blood-borne pathogen standard--(annual TB or x-ray updated for blood borne pathogens for healthcare workers.) ---Resource Conservation & Recovery Act--(labeling storage, transportation & disposal of biological waste.)

...

A patient w/newly diagnosed acquired immunodeficiency syndrome (AIDS) has a negative result on a skin test for tuberculosis (TB). Which action will you anticipate taking next? 1. Obtain a chest radiograph and sputum smear. 2. Tell the patient that the TB test results are negative. 3. Teach the patient about the anti-TB drug isoniazid. 4. Schedule TB testing again in 12 months.

(1) --Patients w/severe immunodeficiency may be unable to produce an immune response, so a negative TB skin test result does not completely rule out a TB diagnosis for this patient. ---The next steps in diagnosis are chest radiograph and sputum culture.

The nurse provides care to the client with syndrome of inappropriate antidiuretic hormone (SIADH) by: Select all that apply. 1. Providing frequent oral care 2. Instituting fall risk precautions 3. Restricting fluids to 2 L per day 4. Placing the client in high-Fowler position 5. Monitoring for and reporting neurologic changes

(1, 2, 5) ---The excess production of antidiuretic hormone associated with SIADH leads to increased water reabsorption by the kidneys. ---Increased water reabsorption results in decreased urinary output, increased intravascular fluid volume, serum hypoosmolality, and dilutional hyponatremia. ---Because treatment includes restricting fluids, frequent oral care is provided to increase client comfort. ---Fall risk precautions are instituted to protect the client from injury that might occur as a result of neurologic changes associated with declining serum sodium. ---The nurse monitors for and reports changes in neurologic status resulting from cerebral edema and hyponatremia. ---Immediate treatment goals are to restore normal fluid balance and normal serum osmolality. ---Fluids are restricted to *no more* than *1000 mL* and to no more than 500 mL for the client with severe hyponatremia. ---Treatment of SIADH includes placing the *bed flat* or elevating the head of the bed no more than *10 degrees*. --This position promotes venous return to the heart, which increases left ventricular filling pressure. Increasing left ventricular filling pressure stimulates osmoreceptors to send a message to the pituitary (via the hypothalamus) that antidiuretic hormone release should be decreased.

The nurse provides postoperative care to the client following subtotal thyroidectomy by: Select all that apply. 1. Assessing for frequent swallowing 2. Ambulating the client the evening of surgery 3. Assessing for facial spasms, apprehension, or tingling of the lips, fingers, or toes 4. Instructing the client to support the head and maintain the neck in a flexed position 5. Ensuring that oxygen, suction equipment, and a tracheosomy tray are at the bedside

(1,2,3,5) --Frequent swallowing in the postoperative period following subtotal thyroidectomy may indicate hemorrhage. In the absence of complications, the client should be ambulated within a few hours following surgery. Facial spasms, apprehension, and tingling of the lips, fingers, or toes are indicative of tetany. Tetany is caused by hypocalcemia, resulting from damage to or removal of the parathyroid glands during thyroidectomy. Tetany is a medical emergency. Oxygen, suction equipment, and a tracheostomy tray must be kept at the bedside in case of airway edema. The bed should be placed in semi-Fowler position and the client should avoid neck flexion to prevent tension on the suture line.

The nurse is making rounds on a client who has developed severe bone marrow depression after receiving chemotherapy for cancer. Which of these actions by the nurse is appropriate? Select all that apply. 1) Wash hands before entering the client's room. 2) Monitor for signs of alopecia. 3) Encourage an increase in fluids. 4) Advise use of a soft toothbrush for oral hygiene. 5) Report an elevation in temperature immediately. 6) Encourage the client to eat raw, fresh fruits and vegetables.

(1,4,5) It is essential to prevent infection in a client with severe bone marrow depression; thorough hand-washing before touching the client or client's belongings is important. Thrombocytopenia occurs with most chemotherapy treatment programs; using a soft toothbrush helps prevent bleeding gums. Any temperature elevation in a client with neutropenia must be reported to the health care provider immediately as it may be a sign of infection. Although alopecia does occur with chemotherapy, it is not related to bone marrow suppression. Increasing fluids will neither reverse bone marrow suppression nor stimulate hematopoiesis. This is not related to bone marrow suppression. Clients who have severe bone marrow depression must avoid eating raw fruits and vegetables, and undercooked meat, eggs, and fish to avoid possible exposure to microbes.

Which clinical findings indicate to the nurse that a 6-year-old child has nephrotic syndrome (NS) rather than acute glomerulonephritis (AGN)? Select all that apply. 1. 3 Generalized edema 2. Lethargy 3. Gross hematuria 4. Massive proteinuria 5. Unchanged blood pressure

(1,4,5) The child with NS is grossly edematous because the glomerular membrane becomes permeable, leading to decreased filtration of plasma and resulting in the accumulation of fluid and sodium. Although the child with AGN has edema, the nephritic edema is most noticeable in the face, especially around the eyes. Massive proteinuria occurs mainly in children with NS because the permeable capillary membrane allows protein to be excreted by the kidneys. The blood pressure of a child with NS is unchanged or may be decreased. Hypertension is typical of children with AGN, most likely because of renal arteriole vasospasm. Lethargy occurs in children with nephrotic syndrome (NS) because the gross edema increases oxygen demands. Children with acute glomerulonephritis (AGN) become irritable and lethargic because of malaise, hypertension, and headaches. Gross hematuria occurs in children with AGN because capillary lumens of the affected glomeruli become occluded, altering the permeability of the capillary membrane, which allows large molecules to pass through.

A client is admitted for an exacerbation of emphysema. The client has a fever, chills, and difficulty breathing on exertion. What is the priority nursing action based on the client's history and present status? 1. Checking for capillary refill 2. Encouraging increased fluid intake 3. Suctioning secretions from the airway 4. Administering a high concentration of oxygen

(2) --Fluids will replace fluid loss from fever and decrease viscosity of secretions. ---Capillary refill relates to peripheral tissue perfusion. There are no data to suggest that secretions are blocking the airway; there is no support that suctioning is needed. ---High concentrations of oxygen generally are not administered to clients with chronic obstructive pulmonary disease (COPD); traditionally, the reason given for this was that clients with COPD become desensitized to carbon dioxide as a respiratory stimulus so that reduced oxygen levels act as the stimulus and high concentrations of oxygen levels may actually depress respirations. The newer theory suggests that the hypoxic drive is valid for a small number. The majority of cases involve the Haldane effect; as hemoglobin molecules become more saturated with oxygen, they are unable to transport carbon dioxide out of the body, leading to hypercapnia.

The nurse has gathered data on a newly admitted client and is attempting to write the nursing diagnoses and develop a plan of care. In doing so, the nurse is aware that in the problem-etiology-signs and symptoms (PES) format: 1. Signs and symptoms come last in the diagnostic process. 2. Nursing interventions are derived from the etiology statement. 3. The only allowable diagnoses are nursing diagnoses. 4. Nursing diagnoses deal only with actual or potential illness problems.

(2) --The etiology, or cause, of the problem provides direction for selection of nursing interventions. It is important to remember that gathering the "S" comes first in the diagnostic process, even though the format is described as PES. Collaborative problems are potential or actual complications, diseases, or treatment that nurses treat most frequently with other health care providers. A wellness diagnosis may be identified when an individual is in transition from a specific level of wellness to a higher level of wellness. This diagnosis begins with "Readiness for enhanced," followed by the higher level of wellness desired.

The nurse is caring for a group of patients who require various Interventions. What patient care may be delegated to unlicensed assistive personnel (UAP)? 1. Playing with an infant who had a seizure 1 hour ago 2. Bathing a child with an intravenous line and a PCA pump 3. Taking vital signs from a child who received a PRN albuterol nebulizer treatment 15 minutes ago 4. Feeding an infant with a respiratory rate of 60 breaths/min who underwent cardiac surgery 1 day ago

(2) The UAP may bathe a child with an intravenous line and patient-controlled analgesia; neither intervention prohibits bathing, and the activity is within the realm of the UAP's job description. ---Stimulating a client who experienced a seizure 1 hour ago is not good nursing practice; the child could experience another seizure. --- Clients who receive as-needed treatments should be followed up and assessed by the registered nurse, not the UAP. ---A respiratory rate of 60 breaths/min in an infant is too high for bottle feeding, and the child underwent surgery just 1 day ago, making this client the least likely to be cared for by the UAP.

A physically ill client is being verbally aggressive to the nursing staff. What is the most appropriate initial nursing response? 1) Accept the client's behavior. 2) Explore the situation with the client. 3) Withdraw from contact with the client. 4) Tell the client the reason for the staff's actions.

(2) --At this time the client is using this behavior as a defense mechanism. Acceptance can be an effective interpersonal technique because it is nonjudgmental. Eventually, limits may need to be set to address the behavior if it becomes more aggressive or hostile. During periods of overt hostility, perceptions are altered, making it difficult for the client to evaluate the situation rationally. Withdrawal signifies non-acceptance and rejection. The staff may be the target of a broad array of emotions; by focusing on only behaviors that affect the staff, the full scope of the client's feelings are not considered.

A nurse is presenting a community education program about osteoporosis at a women's health conference. What factor should the nurse explain has contributed to the increased incidence of fractures associated with osteoporosis in the United States? 1) Dietary use of fat-free milk 2) Aging of the American population 3) Increased number of hysterectomies 4) Immobility associated with early retirement

(2) Because more people are living longer, the problem of osteoporosis in older adults, especially older women, is increasing. The dietary use of fat-free milk is unrelated to osteoporosis; the fat that is removed from milk does not contain calcium. The increase in the number of hysterectomies is unrelated to osteoporosis. Only the uterus is removed with a hysterectomy. Early retirement does not imply inactivity or immobility.

After morning report the nurse is prioritizing the client assignment. Which client should the nurse assess first? 1) Client with a CVA having difficulty sitting up in bed independently. 2) Client receiving a heparin infusion experiencing epistaxis after sneezing. 3) Child with otitis media complaining of yellow green fluid coming out of the ear. 4) Client recovering from total knee replacement surgery reporting difficulty bending the knee.

(2) The client with epistaxis or a nose bleed while receiving a heparin infusion is the client that the nurse should assess first. The client could be receiving too much heparin which caused the nose bleed. The client with a CVA having difficulty sitting up in bed independently (A) can be helped by unlicensed assistive personnel. The yellow-green fluid coming out of the child's ear (C) is a common finding in otitis media. Difficulty bending the knee in a client recovering from a total knee replacement (D) is an expected finding.

A client has surgery to repair a fractured right hip. Where should the nurse stand when assisting the client to ambulate? 1. Behind the client 2. In front of the client 3. On the client's left side 4. On the client's right side

(3) --When ambulating a client, the nurse walks on the client's stronger or unaffected side. This provides a wide base of support and therefore increases stability during the phase of ambulation that calls for weight bearing on the affected side as the unaffected limb moves forward. Behind or in front of the client positions tend to change the center of gravity from directly above the feet and may cause instability. On the client's right side will not support the client as the strong leg moves forward and weight bearing is on the affected side.

After an abdominal cholecystectomy, a client has a T-tube attached to a collection device. On *the day* of surgery, at 10:30 PM, 300 mL of bile is emptied from the collection bag. At 6:30 AM the next day, the bag contains 60 mL of bile. What should the nurse consider in response to this information? 1.) The T-tube may have to be irrigated. 2.) The bile is now draining into the duodenum. 3.) Mechanical problems may have developed with the T-tube. 4.) Suction must be reestablished in the portable drainage system.

(3) ---This amount of drainage is inadequate; 1000 mL of bile is expected in 24 hours via this surgically implanted tube. The presence of a mechanical obstruction (tube compression or kinking) should be determined. ---Irrigating the T-tube is unlikely; also, this is not an independent nursing function. ---The bile draining into the duodenum is unlikely; common bile duct edema takes several days to subside. --- A T-tube drains by gravity, not by suction.

The unlicensed assistive personnel (UAP) assigned to the 7 am shift has not been coming to work until 8 am. Nursing care is delayed and assignments are started late. What is the most appropriate action by the charge nurse/team leader? 1) Discuss the issue with a friend from another unit. 2) Remind the UAP of the expected start time. 3) Report the problem to the Human Resources department. 4) Document the information before discussing it with the UAP.

(4) --Documentation is the best initial response; documentation should include both the missed time and the effect on client care. Discussing the issue with a friend from another unit is not a professional or appropriate response to the problem. Reminding the UAP of the expected start time may be helpful but will not address the issue if the problem continues. Reporting the event to the Human Resources department may be a later response to the problem.

A nurse is applying a dressing to a client's surgical wound using sterile technique. While engaging in this activity, the nurse accidentally places a moist sterile gauze pad on the cloth sterile field. What physical principle is applicable for causing the sterile field to become contaminated? 1. Dialysis 2. Osmosis 3. Diffusion 4. Capillarity

(4) --When a sterile surface becomes wet, microorganisms from the unsterile surface below the sterile field will be drawn up, contaminating the sterile field. The absorption of fluids by gauze results from the adhesion of water to the gauze threads; the surface tension of water causes contraction of the fiber, pulling fluid up the threads. --Dialysis is separation of substances in solution using their differing rates of diffusion through a membrane. --Osmosis refers to movement of water through a semipermeable membrane. --Diffusion is movement of molecules from a high to a low concentration.

The home care nurse is deciding the order in which to see assigned clients. Which client should the nurse make a priority? 1) Client with kidney stones who reports pink urine. 2) Client with sleep apnea and heart failure experiencing slight edema of the left ankle. 3) Client with chronic renal failure with a blood pressure of 90/60 mm Hg after dialysis. 4) Client with diabetes mellitus who spoke with slurred speech when contacted this morning.

(4) The client with diabetes mellitus who has slurred speech could be experiencing hypoglycemia. This is the client that the nurse should see first. ---Pink urine is a common finding in a client with kidney stones (A). --The client with sleep apnea and slight ankle edema (B) is in no acute distress and can be seen later in the day. --The client with chronic renal failure with a blood pressure after dialysis of 90/60 mm Hg (C) is not experiencing any additional symptoms and can be seen later in the day.

A client with a history of stabbing pain in the eyes and blurring and gradual loss of vision is examined by an ophthalmologist, a neurologist, and an internist, all of whom find no organic cause. When eye complaints increase, the client is admitted to a mental health unit. What is the priority nursing intervention? 1) Encouraging involvement in group activities. 2) Requesting a description of the eye discomfort. 3) Exploring feelings about possible impending blindness. 4) Focusing on daily activities while avoiding discussion of the eye discomfort.

(4) The client's eye problems are a conversion reaction. Avoiding discussion of the physical problems prevents the client from using this topic to avoid an exploration of feelings. Focusing on the safe topic of activities may eventually progress to a discussion of emotion-laden topics such as feelings. --It is too early for encouraging involvement in group activities; the client is too introspective to become involved with group activities at this time. Focusing on the physical problem allows the client to avoid feelings. The data do not indicate that the client has an organic problem and is going blind.

A nurse is concerned that the nurse-client ratio is excessively high for a medical-surgical care area. Which of the following can the nurse do to improve this staffing ratio? A . Write an article about the situation and submit it to a nursing journal B. Raise the concern to the state board of nursing C. Write a letter to the office of the American Nurses Association regarding the situation D. Tell a client to express concern to the hospital's nursing management

(B)

During the active labor of a client, a loop of the umbilical cord visibly prolapses. After the presenting part was pushed off of the cord, which of the following should the nurse do to assist the client? A . Assist the client to ambulate B. Prepare the client for cesarean birth C. Time the client's contractions and assess fetal heart rate D. Turn the client onto the left side

(B)

The nurse realizes that pathologic changes in the brain that are unique to Alzheimer's disease include which of the following? A. Presence of prion proteins causing spongiform degeneration in the brain. B. Amyloid beta precursor protein causing neurofibrillary tangles. C. Degeneration of glia and neurons. D. Status spongiosum in the cerebral grey matter.

(B)

The nurse teaches the use of a gait belt to a male caregiver whose wife has right-sided weakness and needs assistance with ambulation. The caregiver performs a return demonstration of the skill. Which observation indicates that the caregiver has learned how to perform this procedure correctly? A. Standing on his wife's strong side, the caregiver is ready to hold the gait belt if any evidence of weakness is observed. B. Standing on his wife's weak side, the caregiver provides security by holding the gait belt from the back. C. Standing behind his wife, the caregiver provides balance by holding both sides of the gait belt. D. Standing slightly in front and to the right of his wife, the caregiver guides her forward by gently pulling on the gait belt.

(B) Rationale: His wife is most likely to lean toward the weak side and needs extra support on that side and *from the back* (B) to prevent falling. (A, C, and D) provide less security for her.

An elderly client frequently awakens at night to urinate. Which nursing intervention will help the client with nocturia? A. Restricting fluids. B. Providing a bedside commode. C. Elevating the legs during the day. D. Inserting an indwelling urinary catheter.

(C) --If your frequent nighttime urination is caused by edema, or swelling in your legs, there are some preventive measures you can take. Try elevating your legs throughout the day. Taking a nap can help with nocturia too, so have an afternoon nap with your legs up. Wearing compression stockings can also help to prevent the fluid buildup.

A resident in a skilled nursing facility asks the nurse for medication for excruciating foot pain. The nurse assesses the resident's foot and can find no reason for the discomfort. The client does not have peripheral nerve damage or a disease process that affects the nervous system. Which type of pain is this resident demonstrating to the nurse? A. Transient. B. Superficial. C. Psychogenic. D. Breakthrough.

(C) Chronic pain that is not due to past disease or injury or any visible sign of damage inside or outside of the nervous system is *psychogenic* in origin. ---Transient pain (A) is acute, brief, and resolves completely. ---Superficial pain (B) originates in the skin and subcutaneous tissue. ---Breakthrough pain (D) is intense increases in pain that occur with a rapid onset when pain control medication is being provided.

The charge nurse is determining the best client assignment for an LPN who has been assigned to assist with care on a medical-surgical unit. Which client should the charge nurse assign to the LPN? A. Client recovering from a radical mastectomy receiving chemotherapy and radiation. B. Client with type 2 diabetes mellitus needing to learn how to provide insulin injections. C. Client with a newly placed ileostomy requiring teaching on changing the bag and skin care. D. Client with a right cerebral vascular accident prescribed oral medications and subcutaneous heparin.

(D) The client recovering from a right cerebral vascular accident is prescribed oral medications and subcutaneous heparin. The care this client requires is within the scope of practice of a licensed practical nurse. The client recovering from a radical mastectomy receiving chemotherapy and radiation will require an RN to provide teaching, medication, and emotional support (A). The client with type 2 diabetes mellitus needs an RN to provide teaching on administration of insulin injections (B). The client with a newly placed ileostomy needs an RN to provide teaching on bag and skin care (C).

The team leader is identifying clients to assign to a licensed practical nurse during the evening shift. Which client can the team leader safely assign to this caregiver? A. Client recovering from surgery to repair a fractured hip. B. Client receiving bladder irrigation after prostate surgery. C. Client needing gastrostomy tube feedings and enteral medications. D. Client recovering from abdominal surgery with an elevated temperature.

(c) The client needing gastrostomy tube feedings and enteral medications is within the licensed practical nurse's scope of practice. Clients recovering from surgery (A, B, D) will need the skills of a registered nurse to provide care. The client recovering from hip surgery is at risk for pulmonary or a fat embolism. The client recovering from prostate surgery is at risk for bleeding. The client recovering from abdominal surgery is at risk for wound dehiscence or peritonitis with an elevated temperature.

The primary health care provider has prescribed a stat chest x-ray and electrocardiogram for an 85-year-old client with a history of congestive heart failure. The pulse oximeter has changed from 90% to 86% oxygen saturation. The nurse's immediate actions include which of the following? Select all that apply. 1) Tell a staff member to get the electrocardiogram machine. 2) Notify the x-ray department that a chest x-ray must be done stat. 3) Increase the supplemental oxygen without a prescription from 2 L nasal cannula to 4 L nasal cannula and notify the health care provider. 4) Have a staff member notify the nursing supervisor of the change in client status. 5) Notify the health care provider of the change in the oxygen saturation to ask what to do. 6) Tell the certified nursing assistant to get a prescription from the health care provider to increase the oxygen.

--(1,2,3,4) ----A staff member can get the electrocardiogram machine and start the procedure. Ancillary personnel are trained to do electrocardiograms even if they are not able to interpret the results. ---Anyone can notify the x-ray department that the chest x-ray must be done. It is important to delegate the tasks to a specific person. ---Increasing the oxygen without a prescription is appropriate in the short term, but the nurse must obtain a prescription when notifying the health care provider. Notifying the health care provider of the change in oxygen saturation is appropriate, but it would be expected that nursing judgment had taken place and the oxygen already was increased from 2 L/min. ---Telling the certified nursing assistant (CNA) to get a prescription is an inappropriate action as a CNA is not allowed to take medical prescriptions. Taking a medical prescription is a nursing role.

Which assessment finding supports the nurse's conclusion that a prosthesis for a client w/an above-the-knee amputation fits correctly? ---even darkened skin of the residual limb.

---(even distribution of *hemosiderin*{iron rich pigment} in the tissue in response to pressure of the prosthesis indicates a proper fit.)

What reason should the nurse identify for the HCP prescription of edrophonium (Enlen). ----to rule out cholinergic crisis

----edrophonium improves muscle strength in myasthenic crisis; weakness persists if symptoms are caused by cholinergic crisis, which can result from the toxic levels of neostigmine.

A client is receiving a continuous bladder irrigation at 1000mL/hr. after a prostatectomy. The nurse determines the client's urine output for the past hour is 200 mL. What action should the nurse implement first?

---STOP the irrigation flow--- --(The urinary output should be at least the volume of irrigation input plus the clients actual urine. A significant decrease in output indicates obstruction in the drainage system.)

A HCP prescribes intermittent NG tube feedings to supplement a client's oral nutritional intake. Which hazard associated with an NG tube feeding will be reduced if the nurse administers this feeding over 30 min.? --Regurgitation

---because the cardiac sphincter of the stomach is slightly opened to admit the NG tube, rapid instillation may result in regurgitation.

A registered nurse (RN) in charge of a mental health unit has two additional staff members: a licensed practical nurse (LPN) and a nursing assistant (NA). The unit has 20 clients, with one client on constant observation for acute suicidality. What should the nurse in charge do when making the daily assignments? 1. Administer medications and assign the LPN to maintain observation of the suicidal client and the nursing assistant to provide client care. 2. Maintain constant observation of the suicidal client and assign the LPN to administer medications and the nursing assistant to provide client care. 3. Perform client care and administrative duties and assign the nursing assistant to administer medications and the LPN to maintain observation of the suicidal client. 4. Provide client care and administrative duties and assign the LPN to administer medications and the nursing assistant to maintain constant observation of the suicidal client.

--Provide client care and administrative duties and assign the ***LPN to administer medications*** and the ***nursing assistant to maintain constant observation*** of the suicidal client. --[Assigning the LPN to administer medications utilizes the LPN's skills; providing constant observation of a client is within the role of NAs and frees the RN to perform client care and administrative duties.] -Administering medications will keep the RN from performing administrative duties; having the LPN perform direct client observation will underutilize the abilities of the LPN. Providing suicide observation will prevent the RN from performing required administrative duties. Having an NA administer medications is illegal in many states. NAs are not educated about the actions and side effects of medications.

A health care provider prescribes an intermittent enteral tube feeding for a client with a nasogastric tube. Place the nursing interventions in the order in which they should be implemented.

1. Verify the health care provider's prescription. 2. Elevate the head of the bed 90 degrees. 3. Inject 20 mL of air into the tube and auscultate over the epigastric area of the abdomen. 4. Check the volume of residual against the parameters prescribed. 5. Administer the volume of feeding as per the prescription. 6. Flush the tube with 30 mL of water after the feeding.

A client with myasthenia gravis who is taking a cholinesterase inhibitor is admitted to the emergency department in crisis. To distinguish between myasthenic crisis and cholinergic crisis, the nurse expects the health care provider to prescribe: 1. Atropine sulfate. 2. Protamine sulfate. 3. Naloxone (Narcan). 4.*** Edrophonium chloride (Tensilon).***

A decrease in symptoms in response to the administration of edrophonium chloride indicates myasthenic crisis; an increase in the severity of symptoms indicates cholinergic crisis. Atropine sulfate is the treatment for cholinergic crisis. Protamine sulfate is the antidote for heparin. Naloxone is an opioid antagonist.

Because of census overload, the charge nurse of an acute care medical unit must select a client who can be transferred back to a residential facility. The client with which symptomology is the most stable?

A stage 3 sacral pressure ulcer, with colonized methicillin-resistant Staphylococcus aureus (MRSA) -The client with colonized MRSA (A) is the most stable client, because colonization does not cause symptomatic disease.

The nurse is conducting a physical examination of a client's respiratory status. In which order should the nurse palpate the client's anterior thorax? (Place the actions in order of completion.) A. Palpate for tactile fremitus. C. Position in the supine position. B. Palpate the anterior thorax. D. Palpate for respiratory expansion. E. Palpate the sternum, ribs, and intercostal spaces.

C. Position in the supine position. E. Palpate the sternum, ribs, and intercostal spaces. B. Palpate the anterior thorax. D. Palpate for respiratory expansion. A. Palpate for tactile fremitus. When palpating a client's anterior thorax during a respiratory physical examination, the nurse should begin by positioning the client in the supine position. Then the nurse should begin the examination by palpating the sternum, ribs, and intercostal spaces. Next, the nurse should palpate the anterior thorax region. After this the nurse will palpate for respiratory expansion and complete this part of the examination by palpating for tactile fremitus.

The nurse is developing a health risk assessment protocol for use in a well-baby clinic in a low-income neighborhood. Which information is most important for the nurse to include in the assessment?

Immunization history - Rationale: The Centers for Disease Control and Prevention indicate that vaccines are among the most widely used, effective, and safe medical products in use today. Assessing the infant immunization histories in clients from disadvantaged socioeconomic groups (B) is the most effective method for determining these infants' susceptibilities to vaccine-preventable diseases.