Integrated III Exam 2

The nurse is observing children playing in the hospital playroom. She would expect to see 4-year-old children playing: A. Competitive board games with older children B. With their own toys along side with other children C. Alone with hand held computer games D. Cooperatively with other preschoolers

D. Cooperatively with other preschoolers

Which of the following is the most appropriate activity for a 5-year-old child? A. Squeeze toy. B. Board games. C. Play-Doh. D. Computer games.

C. Play-Doh. Rationale: In the preschooler, play is simple and imaginative and includes activities such as puppets, play-doh, and coloring book. Squeeze toys are appropriate for infants Board games are appropriate for the school-age child. Computer games are appropriate for an adolescent.

A company driver is found at the scene of an automobile accident in a state of emotional distress. He tells the paramedics that he feels dizzy, tingling in his fingertips, and does not remember what happened to his car. Respiratory rate is rapid at 34/minute. Which primary acid-base disturbance is the young man at risk for if medical attention is not provided? A. Metabolic Acidosis B. Metabolic Alkalosis C. Respiratory Alkalosis D. Respiratory Acidosis

C. Respiratory Alkalosis Hyperventilation is typically the underlying cause of respiratory alkalosis. Hyperventilation is also known as overbreathing. When someone is hyperventilating, they tend to breathe very deeply or very rapidly.

A male adult client is suspected of having a pulmonary embolus. A nurse assesses the client, knowing that which of the following is a common clinical manifestation of pulmonary embolism? A. Dyspnea B. Bradypnea C. Bradycardia D. Decreased respirations

A. Dyspnea

A confused client who fell out of bed because side rails were not used is an example of which type of liability? A. Assault B. Felony C. Negligence D. Battery

C. Negligence

As the nurse prepares an older client for discharge, the client states, "I don't know how I'll be able to remember all these instructions and take care of myself at home." Which action should the nurse plan to take to assist the client? A. Delay the discharge until the client can provide effective self-care. B. Ask an out-of-town relative to stay with the client for several days. C. Ask the social worker to follow up with telephone calls to the client. D. Collaborate for a home health care referral for nursing care and support.

D. Collaborate for a home health care referral for nursing care and support.

When performing nursing care for a neonate after a birth, which intervention has the highest nursing priority? A. Obtain a blood glucose reading B. Give the initial bath C. Give the vitamin K injection D. Cover the neonates head with a cap

D. Cover the neonates head with a cap Covering the neonates head with a cap helps prevent cold stress due to excessive evaporative heat loss from the neonate's wet head. Vitamin K can be given up to 4 hours after birth.

The nurse administers medications to the wrong client. During the investigation of the incident, it is determined that the nurse failed to check the client's identification bracelet before administering the medications. The nursing supervisor evaluates the situation and determines that the nurse can be guilty of negligence because of which concept of negligence? A. Strictly prohibited by the Nurse Practice Act B. Strictly prohibited by the institution's own policies C. Defined as a crime that results in the injury of a client D. Defined as the failure to meet established standards of care

D. Defined as the failure to meet established standards of care

The nurse is monitoring a closed chest tube drainage system. The nurse suspects an air leak in the system if which finding is noted? A. Continuous bubbling in the water seal chamber B. Intermittent bubbling in the water seal chamber C. Continuous bubbling in the suction control chamber D. Intermittent bubbling in the suction control chamber

A. Continuous bubbling in the water seal chamber

At the community center, the nurse leads an adolescent health information group, which often expands into other areas of discussion. She knows that these youths are trying to find out "who they are," and discussion often focuses on which directions they want to take in school and life, as well as peer relationships. According to Erikson, this stage is known as: A. identity vs. role confusion. B. relationship testing C. adolescent rebellion. D. career experimentation

A. identity vs. role confusion.

The nurse is in the cafeteria and tells a physical therapist about a client who is physically abused. During the next visit to physical therapy, the client discovers that the nurse told the therapist about the abuse and is emotionally harmed. As a result of the events in the cafeteria, which legal ramification do the nurse and physical therapist potentially face? Select all that apply. A. They can be charged with libel. B. They can be charged with slander. C. They can be charged with battery. D. None; both can receive privileged client data. E. They can be charged with a HIPAA (Health Insurance Portability and Accountability Act) violation.

B and E Defamation of a client occurs when information is communicated to a third party that causes damage to the client's reputation either verbally (slander) or in writing (libel). In addition, this situation violates the client's right to confidentiality as defined by HIPAA. Common examples of slander are discussing information about a client in public areas or speaking negatively about coworkers. Both the nurse and the therapist can receive privileged information about the client but not in this manner because communicating aspects of the medical record should not occur in a public setting. The nurse and therapist do not know with certainty that the conversation was not overheard by another person.

The nurse is planning care for a client with a chest tube drainage system. The nurse should include which interventions in the plan? Select all that apply. A. Clamping the chest tube intermittently B. Changing the client's position frequently C. Maintaining the collection chamber below the client's waist D. Adding water to the suction control chamber as it evaporates E. Taping the connection between the chest tube and the drainage system

B, C, D, E Changing the client's position frequently is necessary to promote drainage and ventilation. Maintaining the system below waist level is indicated to prevent fluid from reentering the pleural space. Adding water to the suction control chamber is an appropriate nursing action and is done as needed to maintain the full suction level prescribed. Taping the connection between the chest tube and system is also indicated to prevent accidental disconnection. To prevent a tension pneumothorax, the nurse avoids clamping the chest tube, unless specifically prescribed. In many facilities, clamping of the chest tube is contraindicated by agency policy.

Anne, who is drinking beer at a party, falls and hits her head on the ground. Her friend Liza dials "911" because Anne is unconscious, depressed ventilation (shallow and slow respirations), rapid heart rate, and is profusely bleeding from both ears. Which primary acid-base imbalance is Anne at risk for if medical attention is not provided? A. Respiratory Alkalosis B. Respiratory Acidosis C. Metabolic Acidosis D. Metabolic Alkalosis

B. Respiratory Acidosis One of the risk factors of having respiratory acidosis is hypoventilation which may be due to brain trauma, coma, and hypothyroidism or myxedema. Other risk factors include COPD, Respiratory conditions such as pneumothorax, pneumonia and status asthmaticus. Drugs such as Morphine and MgSO4 toxicity are also risk factors of respiratory acidosis

The nurse overhears a client ask the health care provider if the results of a biopsy indicated cancer. The health care provider tells the client that the results have not returned when, in fact, the health care provider is aware that the results of the biopsy indicated the presence of malignancy. The nurse is upset that the health care provider has not shared the results with the client and tells another nurse that the health care provider has lied to the client and that this health care provider probably lies to all of the clients. Which legal tort has the nurse violated by this statement? A. Libel B. Slander C. Assault D. Negligence

B. Slander

The nurse is assessing a 9-month-old boy for a well-baby check up. Which of the following observations would be of most concern? A. The baby cannot say "mama" when he wants his mother. B. The child does not sit unsupported. C. The baby cries whenever the mother goes out. D. The mother has not given him finger foods.

B. The child does not sit unsupported. Over 90% percent of babies can sit unsupported by nine months. Most babies cannot say "mama" in the sense that it refers to their mother at this time.

The nurse caring for a client with end-stage kidney failure is asked by a family member about advance directives. Which statements should the nurse include when discussing advance directives with the client's family member? Select all that apply. A. A health care proxy can write a living will for a client if the client becomes incompetent and unable to do so. B. Two witnesses, either a relative or health care provider (HCP), are needed when the client signs a living will. C. The determination of decisional capacity of a client is usually made by the health care provider and family. D. Living wills are written documents that direct treatment in accordance with a client's wishes in the event of a terminal illness or condition. E. Under the Patient Self-Determination Act (PSDA), it must be documented in the client's record whether the client has signed an advance directive. F. For advance directives to be enforceable, the client must be legally incompetent or lack decisional capacity to make decisions regarding health care treatment.

C, D, E, F -The two basic advance directives are living wills and durable powers of attorney for health care. -Under the PSDA, it must be documented in the client's record whether the client has signed an advance directive. -For living wills or durable powers of attorney for health care to be enforceable, the client must be legally incompetent or lack decisional capacity to make decisions regarding health care treatment. -The determination of decisional capacity is usually made by the HCP and family, whereas the determination of legal competency is made by a judge. -Living wills are written documents that direct treatment in accordance with a client's wishes in the event of a terminal illness or condition. -Generally, two witnesses, neither of whom can be a relative or HCP, are needed when the client signs the document. -A durable power of attorney for health care designates an agent, surrogate, or proxy to make health care decisions if and when the client is no longer able to make decisions on his or her own behalf; however, a health care proxy cannot legally write a living will for a client.

The nurse is caring for the following group of clients on the clinical nursing unit. Which of these clients does the nurse interpret to be most at risk for the development of pulmonary embolism? A. A 25-year-old woman with diabetic ketoacidosis B. A 65-year-old man out of bed 1 day after prostate resection C. A 73-year-old woman who has just had a pinning of a hip fracture D. A 38-year-old man with a closed pneumothorax after an auto accident

C. A 73-year-old woman who has just had a pinning of a hip fracture Pulmonary embolism occurs when a thrombus forms, detaches, travels to the right side of the heart, and then lodges in a branch of the pulmonary artery. Clients frequently at risk for pulmonary embolism include those who are immobilized, especially postoperative clients. Other causes include those with conditions that are characterized by hypercoagulability, endothelial disease, and advancing age.

The client's potassium level is 6.7 mEq/L. Which intervention should you delegate to the student nurse under your supervision? A. Administer spironolactone 25 mg orally B. Assess ECG strip for tall T waves C. Administer Kayexalate 15 g orally D. Administer potassium 10 mEq orally

C. Administer Kayexalate 15 g orally The client's potassium level is high (normal range 3.5-5.0). Kayexalate removes potassium from the body through the gastrointestinal system. Spironolactone is a potassium-sparing diuretic that may cause the client's potassium level to go even higher. The nursing student may not have the skill to assess ECG strips and this should be done by the RN.

Which of the following is an appropriate toy for an 18-month-old? A. Multiple-piece puzzle B. Miniature cars C. Finger paints D. Comic book

C. Finger paints Rationale: Young toddlers are still sensorimotor learners and they enjoy the experience of feeling different textures. Thus, finger paints would be an appropriate toy choice. Multiple-piece toys, such as puzzle, are too difficult to manipulate and may be hazardous if the pieces are small enough to be aspirated. Miniature cars also have a high potential for aspiration. Comic books are on too high a level for toddlers. Although they may enjoy looking at some of the pictures, toddlers are more likely to rip a comic book apart.

A mother is admitted in the emergency department following complaints of fever and chills. The nurse on duty took her vital signs and noted the following: Temp = 100 °F; apical pulse = 95; respiration = 20 and deep. Measurement of arterial blood gas shows pH 7.37, PaO2 90 mm Hg, PaCO2 40 mm Hg, and HCO3 24 mmol/L. What is your assessment? A. Hyperthermia and Respiratory Alkalosis B. Hypothermia and Respiratory Alkalosis C. Hyperthermia D. Hypothermia

C. Hyperthermia An individual is considered to have hyperthermia if he or she has a temperature of >37.5 or 38.3 °C (99.5 or 100.9 °F). Measurement of arterial blood gases are normal.

Dave, a 6-year-old boy, was rushed to the hospital following her mother's complaint that her son has been vomiting, nauseated and has overall weakness. After series of tests, the nurse notes the laboratory results: potassium: 2.9 mEq. Which primary acid-base imbalance is this boy at risk for if medical intervention is not carried out? A. Respiratory Acidosis B. Metabolic Acidosis C. Metabolic Alkalosis D. Respiratory Alkalosis

C. Metabolic Alkalosis Vomiting, hypokalemia, overdosage of NaHCO3 and NGT suctioning are considered risk factors of metabolic alkalosis.

The nurse is caring for a child hospitalized with laryngotracheal bronchitis (LTB). Which sign/symptom, if noted in the child, indicates respiratory distress? A. Agitation B. Dehydration C. Nasal flaring D. Brassy respirations

C. Nasal flaring Rationale: Signs of respiratory distress include nasal flaring; the use of accessory muscles; substernal, intercostal, and suprasternal retractions; and restlessness. Option 1 may be an indication of increasing respiratory distress, but it can also indicate several other clinical problems. Option 2 is not a sign of respiratory distress. Option 4 describes an early and classic manifestation of LTB.

A nurse is assessing a client in the 4th stage if labor and notes that the fundus is firm but that bleeding is excessive. The initial nursing action would be which of the following? A. Massage the fundus B. Place the mother in the Trendelenburg's position C. Notify the physician D. Record the findings

C. Notify the physician If the bleeding is excessive, the cause may be laceration of the cervix or birth canal. Massaging the fundus if it is firm will not assist in controlling the bleeding. Trendelenburg's position is to be avoided because it may interfere with cardiac function.

All of the following are important in the immediate care of the premature neonate. Which nursing activity should have the greatest priority? A. Instillation of antibiotic in the eyes B. Identification by bracelet and foot prints C. Placement in a warm environment D. Neurological assessment to determine gestational age

C. Placement in a warm environment

The nurse notes that a postoperative client has not been obtaining relief from pain with the prescribed opioid analgesics when a particular licensed coworker is assigned to the client. Which action is most appropriate for the nurse to take? A. Reassign the coworker to the care of clients not receiving opioids. B. Notify the health care provider that the client needs an increase in opioid dosage. C. Review the client's medication administration record immediately and discuss the observations with the nursing supervisor. D. Confront the coworker with the information about the client having pain control problems and ask if the coworker is using the opioids personally.

C. Review the client's medication administration record immediately and discuss the observations with the nursing supervisor. In this situation, the nurse has noted an unusual occurrence, but before deciding what action to take next, the nurse needs more data than just suspicion. This can be obtained by reviewing the client's record. State and federal labor and opioid regulations, as well as institutional policies and procedures, must be followed. It is therefore most appropriate that the nurse discuss the situation with the nursing supervisor before taking further action. To reassign the coworker to clients not receiving opioids ignores the issue. The client does not need an increase in opioids. A confrontation is not the most advisable action because it could result in an argumentative situation.

The nurse assesses a client who was involved in a motor vehicle crash. Which manifestations, if exhibited by the client, should lead the nurse to determine the need to prepare for chest tube insertion? A. Chest pain and shortness of breath B. Peripheral cyanosis and hypotension C. Shortness of breath and tracheal deviation D. Decreasing oxygen saturation and bradypnea

C. Shortness of breath and tracheal deviation Shortness of breath and tracheal deviation result when lung tissue and alveoli have collapsed. The trachea deviates to the unaffected side in the presence of a tension pneumothorax. Air entering the pleural cavity causes the lung to lose its normal negative pressure. The increasing pressure in the affected side displaces contents to the unaffected side. Shortness of breath results from a decreased area available for diffusion of gases. Chest pain and shortness of breath are more commonly associated with myocardial ischemia or infarction. Peripheral cyanosis is caused by circulatory disorders. Hypotension may be a result of tracheal shift and impedance of venous return to the heart. However, it may also be the result of other problems, such as a failing heart. Clients requiring chest tubes exhibit decreasing oxygen saturation but will more likely experience tachypnea related to the hypoxia.

A client has a nasogastric tube connected to intermittent wall suction. The student nurse asks why the client's respiratory rate has increased. What your best response? A. "The client is hyperventilating because of anxiety and we will have to stay alert for development of a respiratory acidosis." B. "Whenever a client develops a respiratory acid-base problem, increasing the respiratory rate helps correct the problem." C. "It's common for clients with uncomfortable procedures such as nasogastric tubes to have a higher rate to breathing." D. "The client may have a metabolic alkalosis due to the NG suctioning and the increased respiratory rate is a compensatory mechanism."

D. "The client may have a metabolic alkalosis due to the NG suctioning and the increased respiratory rate is a compensatory mechanism." Nasogastric suctioning can result in a decrease in acid components and metabolic alkalosis. The client's increase in rate and depth of ventilation is an attempt to compensate by blowing off CO2. the first response maybe true but does not address all the components of the question. The third and fourth answers are inaccurate.

An old beggar was admitted to the emergency department due to shortness of breath, fever, and a productive cough. Upon examination, crackles and wheezes are noted in the lower lobes; he appears to be tachycardic and has a bounding pulse. Measurement of arterial blood gas shows pH 7.2, PaCO2 66 mm Hg, HCO3 27 mmol/L, and PaO2 65 mm Hg. As a knowledgeable nurse, you know that the normal value for pH is: A. 7.50 B. 7.20 C. 7.30 D. 7.40

D. 7.40 Normal blood pH must be maintained within a narrow range of 7.35-7.45 to ensure the proper functioning of metabolic processes and the delivery of the right amount of oxygen to tissues. Acidosis refers to an excess of acid in the blood that causes the pH to fall below 7.35, and alkalosis refers to an excess of base in the blood that causes the pH to rise above 7.45.

A client undergoing hemodialysis becomes hypotensive. What action should the nurse immediately prepare to take? A. Administer 100 mL D5W. B. Lower the client's legs and feet. C. Increase the blood flow into the dialyzer. D. Administer a 250-mL normal saline bolus.

D. Administer a 250-mL normal saline bolus. To treat hypotension during hemodialysis, a normal saline bolus of up to 500 mL may be given. D5W is not prescribed because it is less likely to improve the circulating volume and blood pressure. The client's feet and legs are raised to enhance cardiac return. Albumin may be given as per protocol to increase colloid oncotic pressure. The blood flow rate into the dialyzer may be decreased. All these measures should improve the circulating volume and blood pressure.

Nurses agree to be advocates for their patients. Practice of advocacy calls for the nurse to: A. Work to understand the law as it applies to the client's clinical condition. B. Seek out the nursing supervisor in conflicting situations C. Document all clinical changes in the medical record in a timely manner. D. Assess the client's point of view and prepare to articulate this point of view.

D. Assess the client's point of view and prepare to articulate this point of view.

The nurse assesses the vital signs of a client, 4 hours' postpartum that are as follows: BP 90/60; temperature 100.4ºF; pulse 100 weak, thready; R 20 per minute. Which of the following should the nurse do first? A. Report the temperature to the physician B. Recheck the blood pressure with another cuff C. Assess the uterus for firmness and position D. Determine the amount of lochia

D. Determine the amount of lochia A weak, thready pulse elevated to 100 BPM may indicate impending hemorrhagic shock. An increased pulse is a compensatory mechanism of the body in response to decreased fluid volume. Thus, the nurse should check the amount of lochia present. Temperatures up to 100.48F in the first 24 hours after birth are related to the dehydrating effects of labor and are considered normal. Although rechecking the blood pressure may be a correct choice of action, it is not the first action that should be implemented in light of the other data. The data indicate a potential impending hemorrhage. Assessing the uterus for firmness and position in relation to the umbilicus and midline is important, but the nurse should check the extent of vaginal bleeding first. Then it would be appropriate to check the uterus, which may be a possible cause of the hemorrhage.

The nurse notices that a colleague's behaviors have changed during the past month. Which behaviors could indicate signs of impairment? Select all that apply A. Is increasingly absent from the nursing unit during the shift. B. Interacts well with others C. "Forgets" to sign out for administration of controlled substances. D. Offers to administer prn opiates for other nurse's clients E. Is able to say "no" to requests to work more shifts.

A, C, D Rationale: Interacting with others (versus isolating self from others) and setting limits on the number of hours working are positive behaviors and not indicative of possible impairment. The other options are warning signs for impairment

On completing a fundal assessment, the nurse notes the fundus is situated on the client's left abdomen. Which of the following actions is appropriate? A. Ask the client to empty her bladder B. Straight catheterize the client immediately C. Notify the provider D. Straight catheterize the client for half of her uterine volume

A. Ask the client to empty her bladder A full bladder may displace the uterine fundus to the left or right side of the abdomen. Catheterization is unnecessary invasive if the woman can void on her own.

In a patient undergoing surgery, it was vital to aspirate the contents of the upper gastrointestinal tract. After the operation, the following values were acquired from an arterial blood sample: pH 7.55, PCO2 52 mm Hg and HCO3- 40 mmol/l. What is the underlying disorder? A. Metabolic Alkalosis B. Respiratory Acidosis C. Metabolic Acidosis D. Respiratory Alkalosis

A. Metabolic Alkalosis NGT suctioning, vomiting, hypokalemia and overdosage of NaHCO3 are considered risk factors of metabolic alkalosis.

While examining a 2-year-old child, the nurse in charge sees that the anterior fontanel is open. The nurse should: A. Notify the doctor B. Look for other signs of abuse C. Recognize this as a normal finding D. Ask about family history

A. Notify the doctor Rationale: Because the anterior fontanel normally closes between ages 12 and 18 months, the nurse should notify the doctor promptly of this finding. An open fontanel does not indicate abuse

A client with acute kidney injury is prescribed to be on a fluid restriction of 1500 mL per day. Which step is best for the nurse to take in assisting the client in maintaining this restriction? A. Removing the water pitcher from the bedside B. Using mouthwash with alcohol for mouth care C. Prohibiting beverages with sugar to minimize thirst D. Asking the client to calculate the IV fluids into the total daily allotment

A. Removing the water pitcher from the bedside

Which clinical situation should be viewed as assault? A. The nurse threatens to apply restraints to a client who is exhibiting aggressive behavior. B. The client requests a medical discharge, but the nurse physically forces the client to stay. C. The charge nurse sends an email to a staff member which includes a poor performance evaluation about another person. D. The nurse overhears the health care provider making derogatory remarks to the client about the nurse's level of competency.

A. The nurse threatens to apply restraints to a client who is exhibiting aggressive behavior. -An assault occurs when a person puts another person in fear of a harmful or offensive act. -Battery involves offensive touching or the use of force by a perpetrator without the permission of the victim. -Defamation takes place when a falsehood is said (slander) or written (libel) about a person that results in injury to that person's good name and reputation.

Otoscopy examination on a 2-year old? The nurse should pull the pinna.... A. down and back B. down and forward C. up and back D. up and forward

A. down and back

The nurse does not intervene when a client becomes hypotensive after surgery. The client requires emergency surgery to stop postoperative bleeding later that night. The nurse could potentially face which types of prosecution for failing to act? Select all that apply. A. Felony B. Tort law C. Malpractice D. Statutory law E. Misdemeanor

B and C Tort law deals with wrongful acts intentionally or unintentionally committed against a person or the person's property. The nurse commits a tort offense by failing to act when the client became hypotensive. Malpractice occurs when a duty to the client is established and the nurse neglects to act responsibly and injury or complications occur. Options 1 and 5 are offenses under criminal law. Option 4 describes laws enacted by state, federal, or local governments.

When caring for a patient in acute septic shock, the nurse would anticipate A) Administering osmotic and/or loop diuretics. B) Infusing large amounts of intravenous fluids. C) Administering intravenous diphenhydramine (Benadryl). D) Assisting with insertion of a ventricular assist device (VAD).

B) Infusing large amounts of intravenous fluids. Septic shock is characterized by a decreased circulating blood volume. Volume expansion with the administration of intravenous fluids is the cornerstone of therapy. The administration of diuretics is inappropriate. VADs are useful for cardiogenic shock, not septic shock. Diphenhydramine (Benadryl) may be used for anaphylactic shock, but would not be helpful with septic shock.

A client has a total serum calcium level of 7.5 mg/dL. Which clinical manifestations should the nurse expect to note on assessment of the client? Select all that apply. A. Constipation B. Muscle twitches C. Hypoactive bowel sounds D. Hyperactive deep tendon reflexes E. Positive Trousseau's sign and positive Chvostek's sign F. Prolonged ST interval and QT interval on electrocardiogram (ECG)

B, D, E, F

Cheska, the mother of an 11-month-old girl, KC, is in the clinic for her daughter's immunizations. She expresses concern to the nurse that Shannon cannot yet walk. The nurse correctly replies that, according to the Denver Developmental Screen, the median age for walking is: A. 15 months. B. 12 months. C. 10 months. D. 14 months

B. 12 months.

A parent brings a 6-month-old infant to the pediatric clinic for her well-baby examination. Her birth weight was 8 pounds, 2 ounces. The nurse weighing the infant today would expect her weight to be at least _____ pounds. A. 12 B. 16 C. 20 D. 24

B. 16 Rationale: Birth weight is usually doubled by 6 months of age.

When administering a liquid medication to an uncooperative toddler, the nurse should implement which strategy? A. Restrain the child in a high chair. B. Allow the parents to remain in the room. C. Restrain the child in a papoose-type device. D. Remove the child to another room away from the parents.

B. Allow the parents to remain in the room. Rationale: Allowing the parents to remain in the room will promote positive parent-child relationships as well as decrease the irrational fears that are so common in this age-group. Option 4 is incorrect, because separation anxiety will only increase the child's fears. Options 1 and 3 are unnecessarily restrictive and will not increase cooperation.

The nurse puts a restraint jacket on a client without the client's permission and without the physicians order. The nurse may be guilty of assault. A. True B. False

B. False Rationale: Battery is physical in nature. Assault is a threat.

The registered nurse is discussing care of a child with acute laryngotracheobronchitis (LTB) with a nursing student. The registered nurse determines that the nursing student needs further teaching regarding this disorder if the student states that which finding is a clinical characteristic of LTB? A. Is usually viral but may be bacterial in nature B. Has a sudden onset and usually occurs during the day C. Causes swelling and inflammation of the vocal cords D. Child awakens with a harsh cough and inspiratory stridor

B. Has a sudden onset and usually occurs during the day Rationale: Laryngotracheobronchitis (LTB) typically has a gradual onset and usually occurs at night. Options 1, 3, and 4 are correct descriptions of this disorder.

A woman dressed in a business suit with no visible identification is at the nurses station looking at client charts. What nursing action is most appropriate? A. Immediately call security for this breach in client confidentiality B. Request to see identification and an explanation as to why the woman is viewing client charts C. Ignore the person; many outside vendors check charts to set up a transfer or to coordinate care D. Report to the nurse manager about the witnessed suspicious activity

B. Request to see identification and an explanation as to why the woman is viewing client charts Nurses have a duty to protect the confidentiality of client records. In fact, HIPAA and other confidentiality laws require that nurses verify the identity and authority of individuals requesting information. Acceptable verification may include a photo ID and a copy of the documentation supporting legal authority to access information. The nurse needs to determine who the person is, ask to see a valid ID, and ask for the reason for reading the chart. Security may need to be called, but the nurse first needs more information. It is each nurse's duty to do this and no one should pass it off to a manager or ignore the situation

A nurse in the newborn nursery is monitoring a preterm newborn infant for respiratory distress syndrome. Which assessment signs if noted in the newborn infant would alert the nurse to the possibility of this syndrome? A. Hypotension and Bradycardia B. Tachypnea and retractions C. Acrocyanosis and grunting D. The presence of a barrel chest with grunting

B. Tachypnea and retractions The infant with respiratory distress syndrome may present with signs of cyanosis, tachypnea or apnea, nasal flaring, chest wall retractions, or audible grunts.

The nurse is caring for a child with a suspected diagnosis of acute laryngotracheobronchitis (LTB). The nurse reviews the assessment data in the child's record, knowing that which findings are characteristic of this disorder? Select all that apply. A. Is always bacterial in nature B. Causes an occasional dry cough C. Associated with inspiratory stridor D. Causes swelling and inflammation of the vocal cords E. Has a gradual onset that usually worsens during the night

C, D, E Rationale: The child presents with a harsh seal-like cough and inspiratory stridor, and it causes swelling and inflammation of the vocal cords. Laryngotracheobronchitis (LTB) has a gradual onset and normally occurs at night. It is usually viral in nature.

A client taking diuretics is at risk for hypokalemia. The nurse monitors for which clinical manifestations of hypokalemia? Select all that apply. A. Muscle twitches B. Tall T waves on electrocardiogram (ECG) C. Deep tendon hyporeflexia D. Prominent U wave on ECG E. General skeletal muscle weakness F. Hypoactive to absent bowel sounds

C, D, E, F

Which interventions should be used for anaphylactic shock (select all that apply)? a. Antibiotics b. Vasodilator c. Antihistamine d. Oxygen supplementation e. Colloid volume expansion f. Epinephrine

C, D, E, F

A nurse is providing instructions to a mother who has a child with congestive heart failure regarding Digoxin (Lanoxin). Which statement made by the mother indicates further teaching? A. "I will administer the medication 1 hour before or 2 hours after meal". B. "I will use a special dose-measuring spoon or cup, not a regular table spoon for the liquid preparation". C. "If my child vomits after administration, I will repeat the dose". D. "If more than one dose is missed, I will inform the physician"

C. "If my child vomits after administration, I will repeat the dose". Rationale: Digoxin is a cardiac glycoside. The mother needs to be instructed not to repeat the dose once the child vomits it. Options A, B, and D are correct instructions regarding this medicine.

A child who weighs 44 lb has been given an order for amoxicillin 500 mg b.i.d. The drug text notes that the daily dose of amoxicillin is 50 mg/kg/day in two divided doses. What dose in milligrams is safest for this child? A. 1000 mg B. 750 mg C. 500 mg D. 250 mg

C. 500 mg Rationale: C: First, calculate the child's weight in kg: 44/2.2 = 20 kg. Then calculate the appropriate daily dose according to the drug text: 50 mg/kg/day = 50 mg x 20 kg = 1,000 mg/day. the abbreviation b.i.d. means twice daily; therefore 1,000 divided by 2 equals 500 mg.

The nurse's partner/spouse undergoes exploratory surgery at the hospital where the nurse is employed. Which practice is most appropriate A. Because the nurse is an employee, access to the chart is allowed. B. The relationship with the client provides the nurse special access to the chart. C. Access to the chart requires a signed release form D. The nurse can ask the surgeon to discuss the outcome of the surgery.

C. Access to the chart requires a signed release form Rationale: The only person entitled to information without written consent is the client and those providing direct care. The nurse has open access to information regarding assigned clients only.

A patient's localized infection has progressed to the point where septic shock is now suspected. What medication is an appropriate treatment modality for this patient? A. Insulin infusion B. IV administration of epinephrine C. Aggressive IV crystalloid fluid resuscitation D. Administration of nitrates and β-adrenergic blockers

C. Aggressive IV crystalloid fluid resuscitation

Nurses agree to be advocates for their patients. Practice of advocacy calls for the nurse to: A. Seek out the nursing supervisor in conflicting situations B. Work to understand the law as it applies to the client's clinical condition. C. Assess the client's point of view and prepare to articulate this point of view. D. Document all clinical changes in the medical record in a timely manner.

C. Assess the client's point of view and prepare to articulate this point of view. Rationale: Nurses strengthen their ability to advocate for a client when nurses are able to identify personal values and then accurately identify the values of the client and articulate the client's point of view.

Which of the following would the nurse suppose to regard as a cardinal manifestation or symptom of digoxin toxicity to his patient, a child diagnosed with heart failure? A. Headache B. Respiratory distress C. Extreme bradycardia D. Constipation

C. Extreme bradycardia Rationale: C: Extreme bradycardia is a cardinal sign of digoxin toxicity A,B,D: Headache, respiratory distress, and constipation are not related to digoxin toxicity.

Magical Thinking is an attribute of which age group? A. Infants (birth - 1 year) B. Toddlers (1 -3 years) C. Preschoolers (3 - 6 years) D. School-Age Children (6 - 12 years)

C. Preschoolers (3 - 6 years)

The primary care provider wrote a do-not-resuscitate (DNR) order. The nurse recognizes that which applies in the planning of nursing care for this client? A. The client may no longer make decisions regarding his or her own health care. B. The client and family know that the client will most likely die within the next 48 hours. C. The nurses will continue to implement all treatments focused on comfort and symptom management. D. A DNR order from a previous admission is valid for the current admission

C. The nurses will continue to implement all treatments focused on comfort and symptom management. Rationale: A DNR order only controls CPR and similar life-saving treatments. All other care continues as previously ordered. Competent clients can still decide about their own care (including the DNR order.)

Which of the following circumstances is most likely to cause uterine atony and lead to PP hemorrhage? A. Hypertension B. Cervical and vaginal tears C. Urine retention D. Endometritis

C. Urine retention Urine retention causes a distended bladder to displace the uterus above the umbilicus and to the side, which prevents the uterus from contracting. The uterus needs to remain contracted if bleeding is to stay within normal limits. Cervical and vaginal tears can cause PP hemorrhage but are less common occurrences in the PP period.

The healthcare provider is teaching the parents of an 18-month-old child with bronchiolitis how to take their child's temperature. Which of these statements provides the most accurate information? A. "Rectal temperatures tend to be lower than oral or axillary temperatures." B. "Axillary temperatures are more accurate than oral temperature or rectal temperatures." C. "When taking a rectal temperature, advance the thermometer slightly past where resistance is felt." D. "For a tympanic temperature, pull the pinna down and back before inserting the probe into the ear."

D. "For a tympanic temperature, pull the pinna down and back before inserting the probe into the ear."

Which of the following suggestions should the nurse offer the parents of a 4-year-old boy who resists going to bed at night? A. "Allow him to fall asleep in your room, then move him to his own bed." B. "Tell him that you will lock him in his room if he gets out of bed one more time." C. "Encourage active play at bedtime to tire him out so he will fall asleep faster." D. "Read him a story and allow him to play quietly in his bed until he falls asleep."

D. "Read him a story and allow him to play quietly in his bed until he falls asleep." Rationale: Preschoolers commonly have fears of the dark, being left alone especially at bedtime, and ghosts, which may affect the child's going to bed at night. Quiet play and time with parents is a positive bedtime routine that provides security and also readies the child for sleep. The child should sleep in his own bed. Telling the child about locking him in his room will viewed by the child as a threat. Additionally, a locked door is frightening and potentially hazardous. Vigorous activity at bedtime stirs up the child and makes more difficult to fall asleep.

The nurse is assisting in the care of several patients in the critical care unit. Which patient is at greatest risk for developing multiple organ dysfunction syndrome (MODS)? A. 22-year-old patient with systemic lupus erythematosus who is admitted with a pelvic fracture after a motor vehicle accident B. 48-year-old patient with lung cancer who is admitted for syndrome of inappropriate antidiuretic hormone and hyponatremia C. 65-year-old patient with coronary artery disease, dyslipidemia, and primary hypertension who is admitted for unstable angina D. 82-year-old patient with type 2 diabetes mellitus and chronic kidney disease who is admitted for peritonitis related to a peritoneal dialysis catheter infection

D. 82-year-old patient with type 2 diabetes mellitus and chronic kidney disease who is admitted for peritonitis related to a peritoneal dialysis catheter infection A patient with peritonitis is at high risk for developing sepsis. In addition, a patient with diabetes is at high risk for infections and impaired healing. Sepsis and septic shock are the most common causes of MODS. Individuals at greatest risk for developing MODS are older adults and persons with significant tissue injury or preexisting disease. MODS can be initiated by any severe injury or disease process that activates a massive systemic inflammatory response

Although the client refused the procedure, the nurse insisted and inserted a nasogastric tube in the right nostril. The administrator of the hospital decides to settle the lawsuit because the nurse is most likely to be found guilty of which of the following? A. An unintentional tort B. Assault C. Invasion of Privacy D. Battery

D. Battery Rationale: Battery is the willful touching of a person without permission. Another name for an unintentional tort is malpractice. This situation is an intentional tort because the nurse executed the act on purpose.

A parent brings a toddler, age 19 months, to the clinic for a regular check-up. When palpating the toddler's fontanels, what should the nurse expects to find? A. Open anterior and fontanel and closed posterior fontanel B. Open anterior and posterior fontanels C. Closed anterior fontanel and open posterior fontanel D. Closed anterior and posterior fontanels

D. Closed anterior and posterior fontanels Rationale: By age 18 months, the anterior and posterior fontanels should be closed. The diamond-shaped anterior fontanel normally closes between ages 9 and 18 months. The triangular posterior fontanel normally closes between ages 2 and 3 months.

A client who has been receiving long-term diuretic therapy is admitted to the hospital with a diagnosis of dehydration. The nurse should assess for which sign that correlates with this fluid imbalance? A. Decreased pulse B. Bibasilar crackles C. Increased blood pressure D. Increased urinary specific gravity

D. Increased urinary specific gravity

The healthcare provider is planning care for a child with a diagnosis of bronchiolitis. Which of the following interventions should be included in the child's plan of care? A.Performing chest physiotherapy B. Drawing blood for blood cultures C. Administering a cough suppressant D. Promoting hydration and nutrition

D. Promoting hydration and nutrition

When administering an I.M. injection to an infant, the nurse in charge should use which site? A. Deltoid B. Dorsogluteal C. Ventrogluteal D. Vastus lateralis

D. Vastus lateralis Rationale: The recommended injection site for an infant is the vastus lateralis or rectus femoris muscles. The deltoid is inappropriate. The dorsogluteal and ventrogluteal sites can be used only in toddlers who have been walking for about 1 year.

The health care provider prescribes these actions for a patient who has possible septic shock with a BP of 70/42 mm Hg and oxygen saturation of 90%. In which order will the nurse implement the actions? a. Obtain blood and urine cultures. b. Give vancomycin (Vancocin) 1 g IV. c. Infuse vasopressin (Pitressin) 0.01 units/min. d. Administer normal saline 1000 mL over 30 minutes. e. Titrate oxygen administration to keep O2 saturation >95%.

E, D, C, A, B The initial action for this hypotensive and hypoxemic patient should be to improve the oxygen saturation, followed by infusion of IV fluids and vasopressors to improve perfusion. Cultures should be obtained before administration of antibiotics.

The nurse is giving instructions to an 8-year-old child regarding measures to take to identify the early signs of an asthma episode. What instruction would be important for the nurse to give the child? A. Perform chest percussion and postural drainage. B. Open the airway passages by using a hand-held nebulizer. C. Use a peak flowmeter to measure for a drop in the expiratory flow rate. D. Deliver a dose of a bronchodilator by a metered-dose inhaler to see if it helps.

The nurse clarifies to the parents of a 4-year-old child recovering from rheumatic fever that the child will need to receive monthly injections of penicillin G for a minimum of _____ year(s). a. 1 b. 2 c. 5 d. 10 c. 5 Children who recover from rheumatic fever should have a chemoprophylaxis protocol of penicillin G injections (about 200,000 units per dose) for a minimum of 5 years, to an indefinite amount of time. The nurse is giving instructions to an 8-year-old child regarding measures to take to identify the early signs of an asthma episode. What instruction would be important for the nurse to give the child? A. Perform chest percussion and postural drainage. B. Open the airway passages by using a hand-held nebulizer. C. Use a peak flowmeter to measure for a drop in the expiratory flow rate. D. Deliver a dose of a bronchodilator by a metered-dose inhaler to see if it helps. C. Use a peak flowmeter to measure for a drop in the expiratory flow rate. Rationale: An asthmatic child older than the age of 4 should be able to measure the expiratory flow. A drop in expiratory flow is the most reliable early sign of an asthma episode. Chest percussion and postural drainage are normally used to clear air passages for children with cystic fibrosis, not asthma. Medications would be administered by a metered-dose inhaler or by a hand-held nebulizer if an asthma attack actually occurs.

Which are the characteristics of case management? Select all that apply. A. A case manager usually does not provide direct care. B. Critical pathways and CareMaps are types of case management. C. A case manager does not need to be concerned with standards of cost management. D. A case manager collaborates with and supervises the care delivered by other staff members. E. The evaluation process involves continuous monitoring and analysis of the needs of the client and services provided. F. A case manager coordinates a hospitalized client's acute care and follows up with the client after discharge to home.

The nurse performs an admission assessment on a child and suspects physical abuse. Based on this suspicion, what is the primary legal nursing responsibility? A. Refer the family to the appropriate support groups. B. Assist the family in identifying resources and support systems. C. Report the case in which the abuse is suspected to the local authorities. D. Document the child's physical assessment findings accurately and thoroughly. C. Report the case in which the abuse is suspected to the local authorities. Abuse is the nonaccidental physical injury or the nonaccidental act of omission of care by a parent or person responsible for a child. It includes neglect and physical, sexual, and emotional maltreatment. The primary legal nursing responsibility when child abuse is suspected is to report the case. Suspected child abuse should be reported to the local authorities. Although documentation of assessment findings, assisting the family, and referring the family to appropriate resources and support groups are important, the primary legal responsibility is to report the suspected case. Which are the characteristics of case management? Select all that apply. A. A case manager usually does not provide direct care. B. Critical pathways and CareMaps are types of case management. C. A case manager does not need to be concerned with standards of cost management. D. A case manager collaborates with and supervises the care delivered by other staff members. E. The evaluation process involves continuous monitoring and analysis of the needs of the client and services provided. F. A case manager coordinates a hospitalized client's acute care and follows up with the client after discharge to home. A, D, E, F Case management is a care management approach that coordinates health care services to clients and their families while maintaining quality of care and minimizing health care costs. Case managers usually do not provide direct care; instead they collaborate with and supervise the care delivered by other staff members and actively coordinate client discharge planning. A case manager is usually held accountable for some standard of cost management. A case manager coordinates a hospitalized client's acute care, follows up with the client after discharge to home, and is responsible and accountable for appraising the overall usefulness and effectiveness of the case managed services. This evaluation process involves continuous monitoring and analysis of the client's needs and services provided. Critical pathways or CareMaps are not types of case management; rather, they are multidisciplinary treatment plans used in a case management delivery system to implement timely interventions in a coordinated care plan.

A nurse provides medication instructions to a first-time mother. Which statement made by the mother indicates a need for further instructions? A. "I should mix the medication in the baby food and give it when I feed the child". B. "I should administer the oral medication sitting in an upright position and with the head elevated". C. "I will give my child a toy after giving the medication". D. "I will offer my child a juice drink after swallowing the medication".

When administering an I.M. injection to an infant, the nurse in charge should use which site? A. Deltoid B. Dorsogluteal C. Ventrogluteal D. Vastus lateralis D. Vastus lateralis Rationale: The recommended injection site for an infant is the vastus lateralis or rectus femoris muscles. The deltoid is inappropriate. The dorsogluteal and ventrogluteal sites can be used only in toddlers who have been walking for about 1 year. A nurse provides medication instructions to a first-time mother. Which statement made by the mother indicates a need for further instructions? A. "I should mix the medication in the baby food and give it when I feed the child". B. "I should administer the oral medication sitting in an upright position and with the head elevated". C. "I will give my child a toy after giving the medication". D. "I will offer my child a juice drink after swallowing the medication". A. "I should mix the medication in the baby food and give it when I feed the child". Rationale: The nurse would teach the mother to avoid putting medications in foods because it may cause an unpleasant taste to the food, and the child may refuse to accept the same food in the future. Additionally, the child may not consume the entire serving and would not receive require medication dosage. Option B: Administering the medication in an upright position and head elevation will prevent the risk of aspiration. Option C: Offering a toy will provide comfort measures to the child. Option D: The mother should offer drink such as juice or a soft drink to lessen the aftertaste of the medication.

The nurse explained how to position an infant with tetralogy of Fallot if the infant suddenly becomes cyanotic. The nurse can determine the father understood the instructions when he states "If the baby turns blue, I will: a. hold him against my shoulder with his knees bent up toward his chest." b. lay him down on a firm surface with his head lower than the rest of his body." c. immediately put the baby upright in an infant seat." d. put the baby in supine position with his head elevated."

a. hold him against my shoulder with his knees bent up toward his chest." In the event of a paroxysmal hypercyanotic or "tet" spell, the infant should be placed in a knee-chest position.

A nursing instructor is teaching about changes the newborn must make to survive outside of the uterus. The instructor realizes that further teaching is needed when a student says which of the following? a) "When the umbilical cord is clamped the first breath is taken." b) "When the baby is ready to leave the uterus, it takes its first breath." c) "The first breath is taken when the baby is stimulated by a slight slap." d) "When the umbilical cord is clamped the lungs begin to function."

b) "When the baby is ready to leave the uterus, it takes its first breath." Explanation: Changes in circulation begin immediately at birth as the fetus separates from the placenta. When the umbilical cord is clamped, the first breath is taken and the lungs begin to function.

When caring for a newborn several hours after birth, you assess his respiratory rate. In a normal newborn, this would be a) 16 to 20 breaths/min. b) 30 to 60 breaths/min. c) 20 to 30 breaths/min. d) 12 to 16 breaths/min.

b) 30 to 60 breaths/min. Newborns typically breathe more rapidly than adults or older children, at a rate of 30 to 60 breaths/min. 12 to 16 breaths/min is a normal respiratory rate for an adult; 16 to 20 breaths/min is normal for older children; 20 to 30 breaths/min is normal for preschoolers; and 30 to 60 breaths/min is normal for infants.

When assessing infant reflexes the nurse documents a startled response and extension of the arms and legs as which reflex? a) Rooting b) Moro c) Tonic neck d) Fencing

b) Moro

What is the best way for the nurse to assess the newborn's heartbeat? a) Palpating the femoral pulse for 30 seconds and multiplying by 2 b) Palpating the brachial pulse for 60 seconds c) Auscultating the apical pulse for 30 seconds and multiplying by 2 d) Auscultating the apical pulse for 60 seconds

d) Auscultating the apical pulse for 60 seconds Explanation: The best way for the nurse to assess the newborn's heart rate is to listen at the apical pulse for a full minute.

The nurse is documenting assessment of infant reflexes. She strokes the side of the infants face and the baby turns toward the stroke. What reflex has the nurse elicited? a) Moro b) Tonic neck c) Startle d) Rooting

d) Rooting This is the rooting reflex and is used to encourage the infant to feed. This reflex and the sucking reflex work together to assist the infant with cues for feeding at the breast. The tonic neck (or fencing) reflex and the Moro (or startle reflex) are total body reflexes and assess neurologic function in the newborn.

Which assessment is most important for the nurse to make in order to evaluate whether treatment of a patient with anaphylactic shock has been effective? a. Pulse rate b. Orientation c. Blood pressure d. Oxygen saturation

d. Oxygen saturation Because the airway edema that is associated with anaphylaxis can affect airway and breathing, the oxygen saturation is the most critical assessment. Improvements in the other assessments also will be expected with effective treatment of anaphylactic shock.

The nurse is caring for a patient admitted with a urinary tract infection and sepsis. Which information obtained in the assessment indicates a need for a change in therapy? a. The patient is restless and anxious. b. The patient has a heart rate of 134. c. The patient has hypotonic bowel sounds. d. The patient has a temperature of 94.1° F.

d. The patient has a temperature of 94.1° F.

An infant with congestive heart failure is receiving digoxin (Lanoxin). The nurse recognizes a sign of digoxin toxicity, which is: a. restlessness. b. decreased respiratory rate. c. increased urinary output. d. vomiting.

d. vomiting. Symptoms of digoxin toxicity include: nausea, vomiting, anorexia, irregularity in pulse rate and rhythm, and a sudden change in pulse.

Nurse Oliver observes constant bubbling in the water-seal chamber of a closed chest drainage system. What should the nurse conclude? A. The system is functioning normally B. The client has a pneumothorax C. The system has an air leak D. The chest tube is obstructed

C. The system has an air leak

The nurse is monitoring the function of a client's chest tube. The chest tube is attached to a chest drainage system. The nurse notes that the fluid in the water-seal chamber is below the 2-cm mark. What should the nurse determine based on this finding? A. There is a leak in the system. B. Suction should be added to the system. C. This is caused by client pneumothorax. D. Water should be added to the chamber.

D. Water should be added to the chamber.

The nurse teaches a postpartum client about observation of lochia. The nurse determines the client's understanding when the client says that on the second day postpartum, the lochia should be which color? A. Red B. Pink C. White D. Yellow

A. Red

A client is admitted to the unit for chemotherapy. To prevent an acid-base problem, which of the following would you instruct the nursing assistant to report? A. Repeated episodes of nausea and vomiting B. Complaints of pain associated with exertion C. Failure to eat all food on breakfast tray D. Client hair loss during morning bath

A. Repeated episodes of nausea and vomiting Prolonged nausea and vomiting can result in acid deficit that can lead to metabolic alkalosis. The other findings are important and need to be assessed but are not related to acid-base imbalances.

The nurse is assessing the vital signs of a 3-year-old child and notes that the respiratory rate is 28 breaths per minute. Based on this finding, which nursing action is appropriate? A. Administer oxygen. B. Document the findings. C. Notify the health care provider. D. Reassess the respiratory rate in 15 minutes.

B. Document the findings. Rationale: The normal respiratory rate for a 3-year-old child is approximately 20 to 30 breaths per minute. Because the respiratory rate is normal, options 1, 3, and 4 are unnecessary actions. The nurse would document the findings.

The nurse caring for a hospitalized client helps the family prepare a birthday party for the client. When the family arrives and the party starts, the nurse enters the room and takes photographs of the client and the family. What violation has the nurse committed? A. Assault B. Negligence C. Invasion of privacy D. Breach of confidentiality

A client had a colon resection. A nasogastric tube was in place when a regular diet was brought to the client's room. The client did not want to eat solid food and asked that the health care provider be called. The nurse insisted that the solid food was the correct diet. The client ate and subsequently had additional surgery as a result of complications. The determination of negligence is based on which premise? A. The nurse's persistence B. A duty existed and it was breached C. Not notifying the health care provider D. The dietary department sending the wrong food B. A duty existed and it was breached -For negligence to be proved, there must be a duty, and then a breach of duty; the breach of duty must cause the injury, and damages or injury must be experienced. -Options A, C, and D do not fall under the criteria for negligence. Option B is the only option that fits the criteria of negligence. The nurse caring for a hospitalized client helps the family prepare a birthday party for the client. When the family arrives and the party starts, the nurse enters the room and takes photographs of the client and the family. What violation has the nurse committed? A. Assault B. Negligence C. Invasion of privacy D. Breach of confidentiality C. Invasion of privacy Invasion of privacy takes place when an individual's private affairs are unreasonably intruded upon. Invasion of privacy includes taking photographs of the client without the client's consent. Assault occurs when a person puts another person in fear of a harmful or offensive contact. Negligence involves actions that are below the standards of care. Confidentiality is threatened when the nurse discusses the client's private issue or health care issues with another without consent.

The normal respiration of a newborn immediately after birth is characterized as: A. Shallow and irregular with short periods of apnea lasting not longer than 15 seconds, 30-60 breaths per minute B. 20-40 breaths per minute, abdominal breathing with active use of intercostals muscles C. 30-60 breaths per minute with apnea lasting more than 15 seconds, abdominal breathing D. 30-50 breaths per minute, active use of abdominal and intercostal muscles

A. Shallow and irregular with short periods of apnea lasting not longer than 15 seconds, 30-60 breaths per minute A newly born baby still is adjusting to extra uterine life and the lungs are just beginning to function as a respiratory organ. The respiration of the baby at this time is characterized as usually shallow and irregular with short periods of apnea, 30-60 breaths per minute. The apneic periods should be brief lasting not more than 15 seconds otherwise it will be considered abnormal.

Which of the following is the best method for performing a physical examination on a toddler? A. Distally to proximally B. From least to most invasive C. From head to toe D. From abdomen to toes, the to head

B. From least to most invasive

The nurse is aware that a neonate of a mother with diabetes is at risk for what complication? A. Nitrogen loss B. Hypoglycemia C. Thrombosis D. Anemia

B. Hypoglycemia Neonates of mothers with diabetes are at risk for hypoglycemia due to increased insulin levels. During gestation, an increased amount of glucose is transferred to the fetus across the placenta. The neonate's liver cannot initially adjust to the changing glucose levels after birth. This may result in an overabundance of insulin in the neonate, resulting in hypoglycemia.

When teaching a mother about introducing solid foods to her child, which of the following indicates the earliest age at which this should be done? A. 1 month B. 2 months C. 3 months D. 4 months

D. 4 months Rationale: Solid foods are not recommended before age 4 to 6 months because of the sucking reflex and the immaturity of the gastrointestinal tract and immune system. Therefore, the earliest age at which to introduce foods is 4 months. Any time earlier would be inappropriate.

The ideal site for vitamin K injection in the newborn is: A. Right upper arm B. Left upper arm C. Either right or left buttocks D. Middle third of the thigh

D. Middle third of the thigh

A mother tells the nurse that she is very worried because her 2-year old child does not finish his meals. What should the nurse advise the mother? A. make the child seat with the family in the dining room until he finishes his meal B. provide quiet environment for the child before meals C. put the child on a chair and feed him D. do not give snacks to the child before meals

D. do not give snacks to the child before meals If the child is hungry he/she more likely would finish his meals. Therefore, the mother should be advised not to give snacks to the child. The child is a "busy toddler." He/she will not able to keep still for a long time.

Based on knowledge of the developmental tasks of Erikson's Industry versus Inferiority, the nurse emphasizes proper technique for use of an inhaler with a 10-year-old boy so he will: A. Increase his self-esteem with mastery of a new skill. B. Accept changes in his appearance and physical endurance. C. Experience success in role transitions and increased responsibilities. D. Appreciate his body appearance and function.

A. Increase his self-esteem with mastery of a new skill

A client with respiratory failure is receiving mechanical ventilation and continues to produce ABG results indicating respiratory acidosis. Which action should you expect to correct this problem? A. Increase the ventilator rate from 6 to 10 per minute B. Increase the oxygen concentration from 30% to 40% C. Decrease the ventilator rate from 10 to 6 per minute D. Decrease the oxygen concentration from 40% to 30%

A. Increase the ventilator rate from 6 to 10 per minute the blood gas component responsible for respiratory acidosis is CO2 (Carbon dioxide). Increasing the ventilator rate will blow off more CO2 and decrease the acidosis. Changes in the oxygen setting may improve oxygenation but will not affect respiratory acidosis.

A nurse is preparing to assess the uterine fundus of a client in the immediate postpartum period. When the nurse locates the fundus, she notes that the uterus feels soft and boggy. Which of the following nursing interventions would be most appropriate initially? A. Massage the fundus until it is firm B. Elevate the mothers legs C. Push on the uterus to assist in expressing clots D. Encourage the mother to void

A. Massage the fundus until it is firm If the uterus is not contracted firmly, the first intervention is to massage the fundus until it is firm and to express clots that may have accumulated in the uterus. Pushing on an uncontracted uterus can invert the uterus and cause massive hemorrhage. Elevating the client's legs and encouraging the client to void will not assist in managing uterine atony. If the uterus does not remain contracted as a result of the uterine massage, the problem may be distended bladder and the nurse should assist the mother to urinate, but this would not be the initial action.

A newborn has small, whitish, pinpoint spots over the nose, which the nurse knows are caused by retained sebaceous secretions. When charting this observation, the nurse identifies it as: A. Milia B. Lanugo C. Whiteheads D. Mongolian spots

A. Milia

A hospitalized client wants to leave the hospital before being discharged by the health care provider (HCP). Which is the priority nursing intervention? A. Notify the nursing supervisor of the client's plans to leave. B. Ask the client about transportation plans from the hospital. C. Arrange medication prescriptions at the client's preferred pharmacy. D. Discuss the potential consequences of the plans for leaving with the client.

A. Notify the nursing supervisor of the client's plans to leave. -The nurse notifies the nursing supervisor of the client's plan to leave without the health care provider's approval to ensure client safety and to help the nurse manage the situation. This will help the nurse manage the situation in a thoughtful, comprehensive manner and complete nursing interventions that include asking about transportation, arranging medication prescriptions, and discussing the risks and benefits of leaving or remaining in the hospital. -The HCP should be contacted and the client encouraged to remain until the HCP arrives. -The nurse avoids coercion, restraint, or security measures meant to prohibit the client's exit to prevent claims of false imprisonment

The nurse identifies which clinical situation as slander? A. The health care provider tells a client that the nurse "does not know anything." B. The nurse tells a client that a nasogastric tube will be inserted if the client continues to refuse to eat. C. The nurse restrains a client at bedtime because the client gets up during the night and wanders around. D. The laboratory technician restrains the arm of a client refusing to have blood drawn so that the specimen can be obtained.

A. The health care provider tells a client that the nurse "does not know anything." Defamation takes place when a falsehood is said (slander) or written (libel) about a person that results in injury to that person's good name and reputation. Battery involves offensive touching or the use of force by a perpetrator without the permission of the victim. An assault occurs when a person puts another person in fear of a harmful or offensive act.

On auscultation, which finding suggests a right pneumothorax? A. Bilateral inspiratory and expiratory crackles B. Absence of breaths sound in the right thorax C. Inspiratory wheezes in the right thorax D. Bilateral pleural friction rub

B. Absence of breaths sound in the right thorax In pneumothorax, the alveoli are deflated and no air exchange occurs in the lungs. Therefore, breath sounds in the affected lung field are absent. None of the other options are associated with pneumothorax. Bilateral crackles may result from pulmonary congestion, inspiratory wheezes may signal asthma, and a pleural friction rub may indicate pleural inflammation.

A nurse is monitoring a new mother in the PP period for signs of hemorrhage. Which of the following signs, if noted in the mother, would be an early sign of excessive blood loss? A. A temperature of 100.4*F B. An increase in the pulse from 88 to 102 BPM C. An increase in the respiratory rate from 18 to 22 breaths per minute D. A blood pressure change from 130/88 to 124/80 mm Hg

B. An increase in the pulse from 88 to 102 BPM During the 4th stage of labor, the maternal blood pressure, pulse, and respiration should be checked every 15 minutes during the first hour. A rising pulse is an early sign of excessive blood loss because the heart pumps faster to compensate for reduced blood volume. The blood pressure will fall as the blood volume diminishes, but a decreased blood pressure would not be the earliest sign of hemorrhage. A slight rise in temperature is normal. The respiratory rate is increased slightly.

The nurse is caring for a client who is receiving intravenous (IV) antibiotics. The nurse enters the client's room to administer the prescribed antibiotic, and the client tells the nurse that the medication burns and that he does not want the medication to be given. The nurse tells the client that the medication is necessary and administers the medication. What can the client legally charge the nurse with as a result of the nursing action? A. Assault B. Battery C. Negligence D. Invasion of privacy

B. Battery

Nurse Maureen has assisted a physician with the insertion of a chest tube. The nurse monitors the client and notes fluctuation of the fluid level in the water seal chamber after the tube is inserted. Based on this assessment, which action would be appropriate? A. Inform the physician B. Continue to monitor the client C. Reinforce the occlusive dressing D. Encourage the client to deep-breathe

B. Continue to monitor the client The presence of fluctuation of the fluid level in the water seal chamber indicates a patent drainage system. With normal breathing, the water level rises with inspiration and falls with expiration. Fluctuation stops if the tube is obstructed, if a dependent loop exists, if the suction is not working properly, or if the lung has reexpanded. Options A, C, and D are incorrect.

On which of the postpartum days can the client expect lochia serosa? A. Days 3 and 4 PP B. Days 3 to 10 PP C. Days 10-14 PP D. Days 14 to 42 PP

B. Days 3 to 10 PP On the third and fourth PP days, the lochia becomes a pale pink or brown and contains old blood, serum, leukocytes, and tissue debris. This type of lochia usually lasts until PP day 10. Lochia rubra usually last for the first 3 to 4 days PP. Lochia alba, which contain leukocytes, decidua, epithelial cells, mucus, and bacteria, may continue for 2 to 6 weeks PP.

An emergency room nurse is assessing a male client who has sustained a blunt injury to the chest wall. Which of these signs would indicate the presence of a pneumothorax in this client? A. A low respiratory rate B. Diminished breath sounds C. The presence of a barrel chest D. A sucking sound at the site of injury

B. Diminished breath sounds

The nurse is planning care for an 18 month-old child. Which of the following should be included the in the child's care? A. Hold and cuddle the child often B. Encourage the child to feed himself finger food C. Allow the child to walk independently on the nursing unit D. Engage the child in games with other children

B. Encourage the child to feed himself finger food According to Erikson, the toddler is in the stage of autonomy versus shame and doubt. The nurse should encourage increasingly independent activities of daily living.

The nurse is going to suction an adult client with a tracheostomy who has copious amounts of respiratory secretions. Which intervention should the nurse take to perform this procedure safely? A. Set the suction pressure range between 160 to 180 mm Hg. B. Hyper-oxygenate the client using a manual resuscitation bag. C. Apply continuous suction in the airway for up to 20 seconds. D. Occlude the Y-port of the suction catheter while advancing it into the tracheostomy.

B. Hyper-oxygenate the client using a manual resuscitation bag.

The nurse is assessing the lochia on a 1 day PP patient. The nurse notes that the lochia is red and has a foul-smelling odor. The nurse determines that this assessment finding is: A. Normal B. Indicates the presence of infection C. Indicates the need for increasing oral fluids D. Indicates the need for increasing ambulation

B. Indicates the presence of infection Lochia, the discharge present after birth, is red for the first 1 to 3 days and gradually decreases in amount. Normal lochia has a fleshy odor. Foul smelling or purulent lochia usually indicates infection, and these findings are not normal. Encouraging the woman to drink fluids or increase ambulation is not an accurate nursing intervention.

A nurse is preparing to perform a fundal assessment on a postpartum client. The initial nursing action in performing this assessment is which of the following? A. Ask the client to turn on her side B. Ask the client to lie flat on her back with the knees and legs flat and straight C. Ask the mother to urinate and empty her bladder D. Massage the fundus gently before determining the level of the fundus.

C. Ask the mother to urinate and empty her bladder Before starting the fundal assessment, the nurse should ask the mother to empty her bladder so that an accurate assessment can be done. When the nurse is performing fundal assessment, the nurse asks the woman to lie flat on her back with the knees flexed. Massaging the fundus is not appropriate unless the fundus is boggy and soft, and then it should be massaged gently until firm.

The nurse is assessing a client who is 6 hours PP after delivering a full-term healthy infant. The client complains to the nurse of feelings of faintness and dizziness. Which of the following nursing actions would be most appropriate? A. Obtain hemoglobin and hematocrit levels B. Instruct the mother to request help when getting out of bed C. Elevate the mother's legs D. Inform the nursery room nurse to avoid bringing the newborn infant to the mother until the feelings of lightheadedness and dizziness have subsided

B. Instruct the mother to request help when getting out of bed Orthostatic hypotension may be evident during the first 8 hours after birth. Feelings of faintness or dizziness are signs that should caution the nurse to be aware of the client's safety. The nurse should advise the mother to get help the first few times the mother gets out of bed. Obtaining an H/H requires a physicians order.

The nurse is caring for a client who is receiving immunosuppressant therapy, including corticosteroids, after a renal transplant. The nurse should plan to carefully monitor which laboratory result for this client? A. Potassium B. Magnesium C. Blood glucose D. Serum albumin

C. Blood glucose

A document that lists the medical treatment a person chooses to refuse if unable to make decisions is the: A. Durable power of attorney B. Living will C. Advance directive D. Informed consent

C. Advance directive

A client has 2 chest tubes inserted into the right pleural space after thoracic surgery; the tubes are attached to chest drainage systems. To promote optimal respiratory functioning, which intervention should the nurse include when developing a plan of care? A. Milk and strip the chest tubes once a shift. B. Position the client only on the back and on the right side. C. Encourage the client to cough and deep breathe every hour. D. Maintain the client on bedrest until the chest tubes are removed.

C. Encourage the client to cough and deep breathe every hour.

The home care nurse is making follow-up visits to a client after renal transplant. The nurse should assess the client for which manifestations of acute graft rejection? A. Hypotension, graft tenderness, and anemia B. Hypertension, oliguria, thirst, and hypothermia C. Fever, hypertension, graft tenderness, and malaise D. Fever, vomiting, hypotension, and copious amounts of dilute urine output

C. Fever, hypertension, graft tenderness, and malaise

You are preparing to discharge a client whose calcium level was low but is now just slightly within the normal range (9-10.5 mg/dL). Which statement by the client indicates the need for additional teaching? A. "I will avoid dairy products, broccoli, and spinach when I eat." B. "I will call my doctor if I experience muscle twitching or seizures." C. "I will take my calcium pill every morning before breakfast." D. "I will make sure to take my vitamin D with my calcium each day."

A. "I will avoid dairy products, broccoli, and spinach when I eat." Clients with low calcium levels should be encouraged to consume dairy products, seafood, nuts, broccoli, and spinach. Which are all good sources of dietary calcium.

A client tells the nurse that he has seen many articles in the health care section of the newspaper about case management. The client asks the nurse what this means. Which response should the nurse make to the client? A. "It represents an interdisciplinary health care delivery system." B. "One nurse takes care of one client and is responsible for that client." C. "One nurse supervises all of the other employees when they care for clients." D. "A single case manager plans the care for all of the clients in the nursing unit."

A. "It represents an interdisciplinary health care delivery system."

A PP client is being treated for DVT. The nurse understands that the client's response to treatment will be evaluated by regularly assessing the client for: A. Dysuria, ecchymosis, and vertigo B. Epistaxis, hematuria, and dysuria C. Hematuria, ecchymosis, and epistaxis D. Hematuria, ecchymosis, and vertigo

C. Hematuria, ecchymosis, and epistaxis The treatment for DVT is anticoagulant therapy. The nurse assesses for bleeding, which is an adverse effect of anticoagulants. This includes hematuria, ecchymosis, and epistaxis. Dysuria and vertigo are not associated specifically with bleeding.

Which of the following interventions would be helpful to a breastfeeding mother who is experiencing engorged breasts? A. Applying ice B. Applying a breast binder C. Teaching how to express her breasts in a warm shower D. Administering bromocriptine (Parlodel)

C. Teaching how to express her breasts in a warm shower Teaching the client how to express her breasts in a warm shower aids with let-down and will give temporary relief. Ice can promote comfort by vasoconstriction, numbing, and discouraging further letdown of milk.

The nurse is caring for a client newly diagnosed with chronic kidney disease who has recently begun hemodialysis. The nurse determines that the client has not tolerated the procedure optimally if the client experiences which symptoms that represent disequilibrium syndrome? A. Hypertension, tachycardia, and fever B. Hypotension, bradycardia, and hypothermia C. Restlessness, irritability, and generalized weakness D. Headache, deteriorating level of consciousness, and seizures

D. Headache, deteriorating level of consciousness, and seizures Disequilibrium syndrome is characterized by headache, mental confusion, decreasing level of consciousness, nausea, vomiting, twitching, and possible seizure activity. It results from the rapid removal of solutes from the body during hemodialysis. The blood-brain barrier interferes with equally efficient removal of wastes from brain tissue. As a result, water goes into cerebral cells because of the osmotic gradient, causing brain swelling and onset of symptoms. It most often occurs in clients who are new to dialysis, and it is prevented by dialyzing for shorter times or at reduced blood flow rates.

A nurse is assisting a physician with the removal of a chest tube. The nurse should instruct the client to: A. Exhale slowly B. Stay very still C. Inhale and exhale quickly D. Perform the Valsalva maneuver

D. Perform the Valsalva maneuver

A nurse is developing a plan of care for a PP woman with a small vulvar hematoma. The nurse includes which specific intervention in the plan during the first 12 hours following the delivery of this client? A. Assess vital signs every 4 hours B. Inform health care provider of assessment findings C. Measure fundal height every 4 hours D. Prepare an ice pack for application to the area.

D. Prepare an ice pack for application to the area. Application of ice will reduce swelling caused by hematoma formation in the vulvar area. The other options are not interventions that are specific to the plan of care for a client with a small vulvar hematoma.

When performing a PP assessment on a client, the nurse notes the presence of clots in the lochia. The nurse examines the clots and notes that they are larger than 1 cm. Which of the following nursing actions is most appropriate? A. Document the findings B. Notify the physician C. Reassess the client in 2 hours D. Encourage increased intake of fluids

B. Notify the physician Normally, one may find a few small clots in the first 1 to 2 days after birth from pooling of blood in the vagina. Clots larger than 1 cm are considered abnormal. The cause of these clots, such as uterine atony or retained placental fragments, needs to be determined and treated to prevent further blood loss. Although the findings would be documented, the most appropriate action is to notify the physician.

The clinical nurse educator is conducting an educational session for new nursing graduates and is discussing standards of care. The nurse educator determines that a graduate understands the purpose of standards of care when the graduate makes which statement regarding standards of care? A. They provide excellent care based on current medical research. B. They identify methods of treatment based on the most current technology. C. They include providing competent levels of care based on current practice. D. They include providing care based on specialty guidelines for the client's condition.

C. They include providing competent levels of care based on current practice.

A nurse prepares to administer a vitamin K injection to a newborn infant. The mother asks the nurse why her newborn infant needs the injection. The best response by the nurse would be: A. "Newborn infants are deficient in vitamin K, and this injection prevents your infant from abnormal bleeding." B. "You infant needs vitamin K to develop immunity." C. "The vitamin K will protect your infant from being jaundiced." D. "Newborn infants have sterile bowels, and vitamin K promotes the growth of bacteria in the bowel."

A. "Newborn infants are deficient in vitamin K, and this injection prevents your infant from abnormal bleeding." Vitamin K is necessary for the body to synthesize coagulation factors. Vitamin K is administered to the newborn infant to prevent abnormal bleeding. Newborn infants are vitamin K deficient because the bowel does not have the bacteria necessary for synthesizing fat-soluble vitamin K. The infant's bowel does not have support the production of vitamin K until bacteria adequately colonizes it by food ingestion.

The nurse prepares to administer digoxin (Lanoxin) to a newborn with a diagnosis of heart failure. The nurse notes that the apical rate is 140 beats per minute. Which nursing action is appropriate? A. Administer the digoxin because the apical rate is within normal limits. B. Recheck the apical rate in 1 hour, and administer the medication at that time. C. Notify the health care provider because the apical rate is lower than the normal rate. D. Hold the medication because the apical rate is normal, indicating that the medication is not needed.

A. Administer the digoxin because the apical rate is within normal limits. Rationale: The normal apical rate for a newborn is 120 to 160 beats per minute. Because the apical rate is within normal range, options 2 and 3 are inappropriate. The nurse should hold Digoxin is the infant's apical rate is less than 90 beats per minute. Digoxin is not administered on an as-needed basis, which makes option 4 incorrect.

A nurse performs an assessment on a client who is 4 hours PP. The nurse notes that the client has cool, clammy skin and is restless and excessively thirsty. The nurse prepares immediately to: A. Assess for hypovolemia and notify the health care provider B. Begin hourly pad counts and reassure the client C. Begin fundal massage and start oxygen by mask D. Elevate the head of the bed and assess vital signs

A. Assess for hypovolemia and notify the health care provider Symptoms of hypovolemia include cool, clammy, pale skin, sensations of anxiety or impending doom, restlessness, and thirst. When these symptoms are present, the nurse should further assess for hypovolemia and notify the health care provider.

When performing an assessment on a neonate, which assessment finding is most suggestive of hypothermia? A. Bradycardia B. Hyperglycemia C. Metabolic alkalosis D. Shivering

A. Bradycardia Hypothermic neonates become bradycardic proportional to the degree of core temperature. Hypoglycemia is seen in hypothermic neonates.

Normal lochial findings in the first 24 hours post-delivery include: A. Bright red blood B. Large clots or tissue fragments C. Pinkish-brown blood D. The complete absence of lochia

A. Bright red blood

You are admitting an elderly client to the medical unit. Which factor indicates that this client has a risk for acid-base imbalances? A. Chronic renal insufficiency B. Shortness of breath with extreme exertion C. Myocardial infarction 1 year ago D. Occasional use of antacids

A. Chronic renal insufficiency Risk factors for acid-base imbalances in the older adult include chronic renal disease and pulmonary disease. Occasional antacid use will not cause imbalances, although antacid abuse is a risk factor for metabolic alkalosis

Which of the following is an example of nursing malpractice? A. The nurse administers penicillin to a patient with a documented history of allergy to the drug. The patient experiences an allergic reaction and has cerebral damage resulting from anoxia. B. The nurse applies a hot water bottle or a heating pad to the abdomen of a patient with abdominal cramping. C. The nurse assists a patient out of bed with the bed locked in position; the patient slips and fractures his right humerus. D. The nurse administers the wrong medication to a patient and the patient vomits. This information is documented and reported to the physician and the nursing supervisor.

A. The nurse administers penicillin to a patient with a documented history of allergy to the drug. The patient experiences an allergic reaction and has cerebral damage resulting from anoxia. -Option A: The three elements necessary to establish a nursing malpractice are nursing error (administering penicillin to a patient with a documented allergy to the drug), injury (cerebral damage), and proximal cause (administering the penicillin caused the cerebral damage). -Option B: Applying a hot water bottle or heating pad to a patient without a physician's order does not include the three required components. -Option C: Assisting a patient out of bed with the bed locked in position is the correct nursing practice; therefore, the fracture was not the result of malpractice. -Option D: Administering an incorrect medication is a nursing error; however, if such action resulted in a serious illness or chronic problem, the nurse could be sued for malpractice.

The nurse is developing an educational session on client advocacy for the nursing staff. The nurse should plan to tell the nursing staff that which interventions are examples of the nurse acting as a client advocate? Select all that apply. A. Obtaining an informed consent for a surgical procedure B. Providing information necessary for a client to make informed decisions C. Providing assistance in asserting the client's human and legal rights if the need arises D. Ignoring the client's religious or cultural beliefs when assisting the client in making an informed decision E. Defending the client's rights by speaking out against policies or actions that might endanger the client's well-being

B, C, E -In the role of client advocate, the nurse protects the client's human and legal rights and provides assistance in asserting those rights if the need arises. -The nurse advocates for the client by providing information needed so that the client can make an informed decision. -The nurse also defends clients' rights in a general way by speaking out against policies or actions that might endanger the client's well-being or conflict with his or her rights. -Informed consent is part of the health care provider-client relationship; in most situations, obtaining the client's informed consent does not fall within the nursing duty. Even though the nurse assumes the responsibility for witnessing the client's signature on the consent form, the nurse does not legally assume the duty of obtaining informed consent. -The nurse needs to consider the client's religion and culture when functioning as an advocate and when providing care. The nurse would not ignore the client's religious or cultural beliefs in discussions about treatment plans, so that an informed decision can be made.

An elderly client was admitted to hospital in a coma. Analysis of the arterial blood gave the following values: PCO2 16 mm Hg, HCO3- 5 mmol/L and pH 7.1. As a well-rounded nurse, you know that a normal value for HCO3 is: A. 29 mmol/L B. 24 mmol/L C. 20 mmol/L D. 31 mmol/L

B. 24 mmol/L

The nurse admits a newborn to the nursery. On assessment of the newborn, the nurse palpates the anterior fontanel and notes that it feels soft. The nurse determines that this finding indicates which condition? A. Dehydration B. A normal finding C. Increased intracranial pressure D. Decreased intracranial pressure

B. A normal finding

A client tells the home care nurse of a personal decision to refuse external cardiac resuscitation measures. Which is the most appropriate initial nursing action? A. Discuss the client's request with the client's family. B. Notify the health care provider (HCP) of the client's request. C. Document the client's request in the home care nursing care plan. D. Conduct a client conference with the home care staff to share the client's request.

B. Notify the health care provider (HCP) of the client's request. -External cardiac resuscitation is a life-saving treatment that a client may refuse. The most appropriate initial nursing action is to notify the HCP because a written "do not resuscitate" (DNR) prescription from the HCP is needed to ensure that the client's wishes are followed. -The DNR prescription must be reviewed or renewed on a regular basis per agency policy. -Although options A, C, and D may be appropriate, remember that obtaining a written health care provider's DNR prescription must be completed first.

A nurse is suctioning fluids from a male client via a tracheostomy tube. When suctioning, the nurse must limit the suctioning time to a maximum of: A. 1 minute B. 5 seconds C. 10 seconds D. 30 seconds

C. 10 seconds

The nurse is handling a client with a chest tube. Suddenly, the chest drainage system is accidentally disconnected, what is the most appropriate action for the nurse to take? A. Secure the chest tube using a tape. B. Clamp the chest tube immediately. C. Place the end of the chest tube in a container of normal sterile saline. D. Apply an occlusive dressing and notify the physician

C. Place the end of the chest tube in a container of normal sterile saline. If a chest drainage system is disconnected, the nurse can place the end of the chest tube in a container of normal sterile saline to prevent air from entering the chest tube, thereby preventing negative respiratory pressure. Option A: The nurse should tape the chest tube securely to prevent it from being disconnected, rather than taping it after it has been disconnected. Option B: The nurse should not clamp the chest tube because doing so increases the risk of tension pneumothorax. Option D: The nurse should apply an occlusive dressing if the chest tube is pulled out and not if the system is disconnected

A client diagnosed with leukemia asks the nurse questions about preparing a living will. Which recommendation from the nurse should be the best method of preparing this document? A. Talk to the hospital chaplain. B. Obtain advice from an attorney. C. Consult the American Cancer Society. D. Discuss the request with the health care provider (HCP)

D. Discuss the request with the health care provider (HCP). Living wills are legal documents known as advance directives wherein the client delineates the withdrawal or withholding of treatment when the client is incompetent. Living wills should not be confused with a will that bequeaths personal property and specifies other actions at the time of the client's death. The client starts the process of writing a living will by discussing treatment options and other related issues with the HCP. In addition, the client should discuss this issue with the family. Although options 1 and 2 may be helpful, contacting them is not the initial step because both professionals lack the medical information the client needs to make an informed decision; however, the lawyer may be involved after discussion with the HCP and family. The American Cancer Society may have pertinent information on living wills; however, the information is not individualized to the client's needs.

While assessing a 2-hour old neonate, the nurse observes the neonate to have acrocyanosis. Which of the following nursing actions should be performed initially? A. Notify the physician of the need for a cardiac consult B. Immediately take the newborn's temperature according to hospital policy C. Activate the code blue or emergency system D. Do nothing because acrocyanosis is normal in the neonate

D. Do nothing because acrocyanosis is normal in the neonate Acrocyanosis, or bluish discoloration of the hands and feet in the neonate (also called peripheral cyanosis), is a normal finding and shouldn't last more than 24 hours after birth.

The home health nurse visits the Cox family 2 weeks after hospital discharge. She observes that the umbilical cord has dried and fallen off. The area appears healed with no drainage or erythema present. The mother can be instructed to: A. cover the umbilicus with a band-aid. B. continue to clean the stump with alcohol for one week. C. apply an antibiotic ointment to the stump D. give him a bath in an infant tub now

D. Give him a bath in an infant tub now

A client having a mild panic attack has the following arterial blood gas (ABG) results: pH 7.49, Pco2 31 mm Hg, Pao2 97 mm Hg, HCO3 22 mEq/L. The nurse reviews the results and determines that the client has which acid-base disturbance? A. Metabolic acidosis B. Metabolic alkalosis C. Respiratory acidosis D. Respiratory alkalosis

D. Respiratory alkalosis

The nursing assistant reports to you that a client seems very anxious and that vital signs included a respiratory rate of 38 per minute. Which acid-base imbalance should you suspect? A. Respiratory acidosis B. Metabolic alkalosis C. Metabolic acidosis D. Respiratory alkalosis

D. Respiratory alkalosis The client is most likely hyperventilating and blowing off CO2. This decrease in CO2 will lead to an increase in pH, causing respiratory alkalosis. Respiratory acidosis results from respiratory depression and retained CO2. Metabolic acidosis and alkalosis result from problems related to renal acid-base control.